This document provides an overview of brain anatomy and imaging techniques used to interpret brain CT and MRI scans. It describes the layers covering the brain, lobes, structures beneath the cerebrum, cerebral circulation, and the ventricular system. Common abnormalities that can be seen on CT and MRI are also outlined, along with the appropriate uses and limitations of each imaging modality. Interpreting radiographic images and systematically approaching a read is discussed.
This document provides an overview of brain anatomy and imaging techniques used to interpret brain CT and MRI scans. It describes the layers covering the brain, lobes, structures beneath the cerebrum, cerebral circulation, and the ventricular system. Common abnormalities that can be seen on CT and MRI are also outlined, along with the appropriate uses and limitations of each imaging modality. Interpreting radiographic images and systematically approaching a read is discussed.
This document provides an overview of brain anatomy and imaging techniques used to interpret brain CT and MRI scans. It describes the layers covering the brain, lobes, structures beneath the cerebrum, cerebral circulation, and the ventricular system. Common abnormalities that can be seen on CT and MRI are also outlined, along with the appropriate uses and limitations of each imaging modality. Interpreting radiographic images and systematically approaching a read is discussed.
Angela Nelson, MSN, RN, CCRN, ACNP-BC Department of Neurosurgery I have no current affiliation or financial arrangement with any grantor or commercial interest that might have direct interest in the subject matter of this CE Program 9.4.79 Objectives Identification of normal brain anatomy on both CT and MRI imaging Identification of common CNS abnormalities on both CT and MRI imaging Identification of appropriate radiographic studies to be obtained for the more common suspected CNS abnormalities Brain Anatomy Layers covering the Brain Skin Periosteum Bone Craniumepidural space is between dura mater and the bone. Superior Sagittal Sinus lies here Dura Mater hard mother (leather like) Subdural space lies between dura and arachnoid Arachnoid Membrane spider (spider web) Subarachnoid spaces lies between the arachnoid and pia Pia Gentle Mother(thin layer adhering closely to brain) Cerebrum 4 Lobes: Frontal, Temporal, Parietal and Occipital Falx Cerebri Separates the 2 hemispheres Tentorium Cerebelli Separates the cerebellum from the Cerebrum Gyri Rounded ridges on surface of brain Sulci Shallow groves separating the gyri Fissure Deeper groves Gray Matter Unmylinated Nerve Fibers White Matter Mylinated Nerve Fibers 9.4.79 Review of Lobes Frontal-Personality, judgment, abstract reasoning, social behavior, language expression and movement Temporal-Hearing, language expression, storage and recall of memory Parietal-Interprets and Integrates sensations including pain, temperature, touch, size, shape, distance and texture Occipital-Interprets visual stimuli Right and Left-Cerebral Hemispheres connected by Corpus Collosum Right Emotion Prosopagnosia Music Spatial Relationship Left Logic Brain Speech Math Science 9.4.79 Falx Cerebri 9.4.79 Primitive Structures Beneath the Cerebrum. . . . Diencephalon-Thalmus/Hypothalmus/RAS/Internal Capsule Thalmus Relays sensory stimuli to cerebral cortex Primitive awareness of pain Screening of incoming stimuli and focusing of attention Hypothalmus Controls body temperature, appetite, water balance, pituitary secretions, emotions and autonomic functions including sleep and wake cycles Internal Capsule Motor Tracts Limbic SystemInitiating basic drives; hunger, aggression, emotional and sexual arousal Reticular Activating System Arousal, Sleep and Wakefulness Screens all incoming sensory information 9.4.79 Basal Ganglia Corpus StriatumCaudate Nucleus Lentiform Nucleus Putamen and Globus Pallidus Interconnected nuclear masses deep within cerebral hemispheres involved in the initiation of voluntary movements, controls of postural adjustments associated with voluntary movements 9.4.79 White/Gray Matter White Matter Consists mostly of myelinated axons (surrounded by a fatty sheath containing myelin) that connect various gray areas of the brain to each other Gray Matter Contains cell bodies as well as fibers of unmylinated neurons Gray matter includes the basal ganglia (caudate nucleus, putamine, globus pallidus), thalmus, hypothalmus, subthalmus, and cerebellar nuclei Cerebellum Maintains muscle tone, coordinate muscle movement and controls balance A disorder of this area may cause dizziness, nausea, balance and coordination problems 9.4.79 Cerebellum Brain Stem Composed of Medulla Oblongato, Pons, and Midbrain Medulla Autonomic Function (HR, RR, BP) Pons Arousal Respiratory Midbrain Controls sensory response Produces autonomic behavior necessary for survival Pathways for nerve fibers between higher and lower neural centers Origin for 10 of 12 pairs of cranial nerves 9.4.79 Medulla Pons Ventricular System Contains the CSF Composed of lateral ventricles, foramina of Monro, the third ventricle, aqueduct of Sylvius, and the forth ventricle Choroid Plexus located throughout the system makes the CSF CSF leaves the ventricles through the foramina of Magendie and Lushka to reach the subarachnoid space 9.4.79 Lateral Ventricles Foramen of Monroe Third Ventricle 9.4.79 Aquaduct of Sylvius 4 th Ventricle Cerebral Circulation 9.4.79 Cerebral Circulation MR Angiography Internal Carotid Artery 9.4.79 Middle Cerebral Artery Anterior Cerebral Artery 9.4.79 Venous Drainage Venous Sinus Drainage MR Venography 9.4.79 Computed Tomography Nobel Prize Winner Sir Godfrey Hounsfield developed CT for clinical use in 1972-1973 The first company to introduce the CT scanner was EMI (English Musical Instruments)-the same company that distributed the Beatles on the Apple label Grossman, R.I. and Yousem, D.M. The Requistes. Neuroradiology. Second Edition. Philadelphia, PA, 2003 Computed Tomography Physics Uses a highly collimated x-ray beam Photons that pass through the patient are collected by CT detectors which show a differential rate of intensity on a gray scale The beam is rotated across the patient at many angles so as to get a differential rate of absorption Grossman, R.I. and Yousen, D.M. The Requistes. Neuroradiology. Second Edition, Philadelphia, PA, 2003 Indications of Use of CT First line in evaluation of a change in mental status Test of choice for those with implantable devices Shows acute and sub acute blood (ICH/SAH, SDH) Bony abnormalities, i.e. Trauma or fracture Edema/Mass effect Abnormalities in size and shape of structures i.e. brain tissue atrophy, gyri effacement with swelling Hydrocephalus Hemorrhagic stroke Add contrast if looking for tumor, abscess, or cerebral arteries and veins 9.4.79 Disadvantages of Computer Tomography Poor imaging for demyelinating disease Poor resolution in the posterior fossa of the brain primarily due to streak artifact from the bones Density gradients on CT Bone Calcification Contrast material Clotted blood Some tumors with densely packed cells Grey matter White matter Edema Pus Necrotic Cavities CSF Fat Air How things appear on a CT? Acute Blood/Calcifications-White Chronic Blood Collection-Low density black to gray as increasing density CSF/Air-Black White Matter-Less dense than gray matter and therefore will be darker Ischemia-Lower density and therefore will be darker and may not appear for 12 hours 9.4.79 Radiographic Images What is on the left side of the picture represents the right side of the patients brain Axial-top to bottom or bottom to top Radiographic Images Sagittal-Side to side T1 Radiographic Imaging Coronal-Front to back or back to front 9.4.79 Orbit Spenoid Temporal Mastoid Air Auditory Cerebellum Frontal Lobe SylvianFissure Temporal Lobe Supracellar Cistern Midbrain 4th Ventricle Cerebellum 9.4.79 FalxCerebri Frontal Lobe Anterior Horn 3rd Ventricle Quadrigeminal Cistern Cerebellum Radiology Atlas.exe Caudate Ant HornLat Ventricle Internal Capsule Putamen/Globus Pallidus 3rd Ventricle Quadrigeminal Cistern Vermis Occipital Lobe FalxCerebri Frontal Lobe Bodyof Lateral Ventricles Corpus Callosum Parietal Lobe Occipital Lobe Superior Sagittal Sinus 9.4.79 FalxCerebri Superior Sagittal Sinus 9.4.79 How to Approach a Read View the Subdural windows for bony defects, fractures Are the sinuses opacified Bony Windows Soft Tissues (brain window) View the lateral, 3 rd and 4 th ventricles Are they enlarged, compressed, distorted, diplaced Is there anything in them other than choroid plexus Look for blood or debris especially in the dependent portions 9.4.79 Brain Window Is there a focal density abnormality in the brain? Is there something that is not symmetrical? Is it mass producing or volume losing? Are midline structures midline? Are the sulci symmetrical or effaced? Are the lateral ventricles symmetrical? Brain Window Is the gray/white junction seen around both cerebral hemispheres? Is the insular ribbon seen? Are the basal ganglia distinct from the internal and external capsule? Spinal Cord 9.4.79 9.4.79 Sinuses Orbits 9.4.79 External Auditory Canal Mastoid Air Cells Medulla 9.4.79 Cerebellum Temporal Lobe 4 th Ventricle 4 th Ventricle Basilar Artery Pons 9.4.79 Basilar Artery Supracellar Cistern Sylvian Fiisure 9.4.79 Frontal Lobe Parietal Lobe Quadgeminal Cistern Anterior Horn Lateral Ventricle Third Ventricle Vermis of Cerebellum 9.4.79 Occipital Horns Occipital Horns Caudate Head Choroid Plexus 9.4.79 Body of Lateral Ventricles 9.4.79 White Matter Faux Cerebri 9.4.79 Central Sulcus Pre Central Gyrus Post Central Gyrus Intraparietal Sulcus Cental Sulcus 9.4.79 9.4.79 9.4.79 Hemorrhagic Contusion Often due to impaction of the brain against the skull on the opposite side of the injury Contusion in the right frontal lobe with surrounding low density infarction or edema CT Chronic Subdural Hematoma Note the left sided low density collection of this chronic subdural hematoma CT Acute Subdural Hematoma/CT 9.4.79 Meningioma/CT Epidural Hematoma/CT Glioblastoma/CT 9.4.79 Hypertensive Cerebellar Bleed/CT Coagulopathic Bleed/CT Chronic Subdural Hematoma/CT 9.4.79 MCA Infarction/CT Melanoma Hydrocephalus 9.4.79 Indications for Use of MRI Use with caution with people with claustrophobia, implantable devices or programmable shunts Provides better soft tissue differentiation than CT Tumors Abscess Vascular Anomalies of the Brain Stroke Trauma Chronic Central Nervous System Disorders Stereotactic Surgical Planning MRI Sequences Diffusion Magnectic Susceptibility (gradient echo, hemoflash) Blood, calcium and calcified lesions Flair (Fluid Attenuation Inversion Recovery) Good at identifying abnormalities adjacent to CSF T1 T1 Post T2 Types of MRI Gadolinium Enhancement-Tumor/Infection/Inflammation T1T2-Vascular structures appear brighter on T1 and darker on T2 Diffusion (DWI)-Can assess an acute infarct within the last 2 weeks MRV-Assess patency, stenosis or occlusion of the venous system MRA-Assess patency, stenosis or occlusion of arterial system and vascular malformations. Multiple viewing angles Flair/Echo Gradient-Similar studies however an echo gradient may see a smaller bleed clearer. Flair can improve image quality of lesions adjacent to CSF Functional MRI-Asked to do sensory, motor and cognitive tasks. Shows increasing signals with cerebral activity 9.4.79 Diffusion MRI Diffusion Weighted Imaging (DWI) Determines the ease of water diffusion Can determine cerebral ischemia within minutes of irreversible damage Most sensitive way of determining an acute infarction Good in differentiating vasogenic edema (generally tracks along white matter and spares the gray matter) Appears as dark CSF, bright Fat and Lesions DWI Apparent Diffusion Coefficient (ADC) Measures the brownian motion of protons High ADC will be seen in CSF where there protons can freely move Low ADC will be found with new strokes and tumors where they are more tightly packed together 9.4.79 T1 Pre and Post contrast CSF appears black Subcutaneous tissue (beneath the skull) appears white Blood appears white White matter brighter than gray matter Lesion will appear dark Shows blood clearer *Note-T1 post- sinus/nasal terbinates, choroid plexus bright T2 MRI CSF appears white Subcutaneous tissue appears black Blood appear white White matter darker than gray matter Shows older changes and microvascular More accurate for brain pathology Flair/Echo Gradient 9.4.79 Tonsils Vertebral Artery Falx Cerebelli 9.4.79 Vermis Medulla, Verebral Artery, 4 th ventricle 9.4.79 9.4.79 9.4.79 9.4.79 9.4.79 9.4.79 9.4.79 9.4.79 9.4.79 Subarachnoid Hemmorhage Primary causes include Aneurysm, AVM and head trauma Worst headacheof my life 30% survive without major disability Outcome is associated with neurological status at time of Presentation 10-30 % die before getting medical attention SAH/CT SAH/CT with contrast 9.4.79 Diffuse Axonal Injury Frequent result of traumatic deceleration injuries resulting in shearing of axons and small blood vessels Frequent cause of persistent vegetative state Usually occur at gray/white matter junction DAI suggestive in any pt who demonstrates clinical symptoms disproportionate to imaging findings Up to 90% of these patients remain in a persistent vegetative state, rarely die DAI/Diffusion Glioblastoma Average age of diagnosis 50-70 Occur more commonly in men Most patients die within 8-18 months Clinical presentation depends on location of the tumor; stroke like symptoms, focal neurological deficits, headache, change in behavior, seizure 9.4.79 GBM/T1/T2 Meniogioma 15% of all brain tumors More common in women Usually occur in 3 rd to 6 th decade of life Discrete well defined dural masses Can remain clinically asymptomatic for years as they grow slow Common symptoms include focal defecits, seizures, headaches and psycho organic syndrome Meningioma/T1/T2 9.4.79 STROKE CT is preferred for intracranial hemmorhage For non hemorrhagic stroke a CT can be negative for 24-36 hours Flair/T2 MRI can detect in 6-12 hours Diffusion MRI can detect within minutes STROKE/Ct/T1 T1 T2 Flair DWI 9.4.79 Metastatic Tumor 66 year old right handed female with PMH mestatic lung cancer, s/p Right Lobectomy with radiation and Right masectomy 1-2 months of slurred speech, word finding difficulty and lethargy Exam: Mild right upper extremity drift, mild right dysmetria Found to have left temporal lesions Patient started on Anti-convulsants and lesion resected 9.4.79 Post op Blood products and air Skull Based Meniogioma 61 year old, left handed male with PMH of HTN, A fib (on coumadin), and Hypercholesterolemia 3 week history of worsening vision and sinus headaches with he attributed to his sinuses Initially sent by his cardiologist to an Optomotrist, then Opthomologist and finally a Neuroopthomologist who prompty admitted him Stated on IV steroids on admission and anti- convulsants INR on admission 3.59. Given FFP and Vitamin K Exam remarkable for Right Homonymous, left eye 20/200 and right unable to visualize anything but the chart Tumor measured 5.4 x 4.8 cm extending into the optic canals and suprasellar cistern Taken to OR 2 days after admission after INR <1.4 for a Bifrontal Craniotomy Pre Op 9.4.79 Presumed Metastatic Lesions 72 year old right handed male with Prior history of CABG, AAA, Cardiac Stent, and recently Mylodysplastic Syndrome with a 4 day history of dizziness and headaches, now with confusion and receptive and expressive dysphagia Exam significant for right sided weakness, right drift, right facial droop, inability to follow commands Anticonvulsants and IV steroids initiated Platelet count 6 Hematology consult-found to have high grade Mylodysplasia Transfused multiple units of platelets in an attempt to >150 before OR Patient developed Aspiration Pneumonia and surgery was delayed Continued to deteriorate CT Hemmorhagic Lesion Large Left MCA Infarction 58 year old man with history of tobacco use, HTN, BPH who was in process or being worked up for a transient decreased sensation in right arm At work with sudden right sided weakness, right facial droop and aphasia Found to have occulsion of the left internal carotid artery and M1 segment left MCA thrombus Given TPA without improvement 9.4.79 Pituitary Macroadenoma 39 year old right handed male with no PMH. Developed fatigue 3 years ago, treated for depression, started on Lexapro Past 2 years noted a decrease in the amount of facial and leg hair Low testostone, Low LH Visual fields normal 2.2 cm tumor Underwent Endoscopic TSSH approach Resection of Mass 9.4.79 Pituitary Tumor/Normal Pituitary Glioblastoma 48 year old right handed man with no PMH 8 week history of congestion, head feeling heavy and full Began to develop nausea/vomiting with headaches 3-4 times per day Treated with 2 courses of antibiotics and steroids for presumed sinusitis Symptoms improved with steroids but then returned when tapered off Treated with Maxol for migranes ENT with negative CT of Sinuses Finally MRI with large right temporal lesion Stated on IV Steroids and Anticonvulsants Exam grossly intact Underwent Craniotomy for Removal Of Lesion Now undergoing radiation and chemotherpy for an aggressive growing lesion 9.4.79 Mystery Lesions 49 year old right handed male with PMH of HIV, AIDS, and Stoke presents with a 3 week history of headaches particularly severe for the last 3 days Exam significant for dysarthric speech, bilateral dysmetria, left foot drop Patient underwent craniotomy with pathology sent however no cultures were sent. Path inconclusive Pathology inconclusive Lesions/Old Infarctions 9.4.79 Arteriovenous Malformation 21 year old right handed male presents with an acute onset on BLE numbness Had a warm sensation throughout his body, felt dizzy and faint with a headache which progressed to complete left sided weakness Exam significant for left sided weakness although A/O x3 Angiogram Right frontal AVM Underwent pre op Angio/Embolization of Lesion AVM resected with post op Angio done POD #6 developed headaches and CT revealed right frontal epidural hematoma and pt emergently taken to OR 9.4.79 Acute Cerebral Infarction of Pre-Central Gyrus 63 year old right handed, male with sudden onset of tingling in right check, inability to speak and could not properly use right hand T2 Acute Infarction 9.4.79 Communicating Hydrocephalus CSF circulation blocked at level of arachnoid granulations Multiple Sclerosis/Flair Age of onset 10-59, with peak between 20-40 Demyelinating disease of white matter affecting the cerebrum, optic nerves and spinal cord Typically has exacerbations and remissions Common symptoms visual disturbances, spastic paraparesis and bladder dysturbances Infarction with Hemicraniectomy Pre op Post op 9.4.79 Trauma Subdural Intraparenchymal SAH Epidural Cerebellar Hemangioblastoma 9.4.79 DWI Infarction ADC Melonoma withhemmorhage XXXXXXXXXX 9.4.79 Angela.Nelson@nyumc.org http://www.imaios.com/en/e-Anatomy/Brain- neuroanatomy-MR http://www.med.harvard.edu/AANLIB/home.htm http://www.healthsystem.virginia.edu/courses/ra d/headct/index.html http://brighamrad.harvard.edu/cgi-bin/rc- report/query.py http://spinwarp.ucsd.edu/NeuroWeb/Anatomy/br ain/brain-anat.html http://www.strokecenter.org/images/ 9.4.79