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Neuroimaging of Common Neurological Conditions
Neuroimaging of Common Neurological Conditions
Introduction
In routine clinical practice, neuroimaging aims differentiating normal and
pathological nervous tissue by demonstrating nonspecific macroscopic physical
changes with a variety of radiological techniques, mostly magnetic resonance
imaging (MRI) and CT Scan. Increasingly, and with major gains in specifity, imaging
can demonstrate physiological or metabolic differences between normal and
abnormal tissue. Examples inclide :
1) Diffusion- weighted imaging (DWI) with very high specifity in acute stroke,
brain abcess, and certain tumors
2) Perfusion techniques (CT or MRI) used to triage acute stroke to allow the
delivery of hyperacute thrombolytic therapy and to accurately separate tumor
reccurence rom radiaton injury
3) Magnetic resonance spectroscopy (MRS), which shows patholognomonic
findings in brain tumors and certain dysmyelinating and degenerative
conditions
4) Function MRI (fMRI), which allows real time assessment of eloquent cortex
in the live patient.
5) Radiobuclide techniques like single photonemission SPECT and positron
emission tomography (PET), used in epilepsy, neuro- oncology, and stroke
neurology. Current recommendations for neuroimaging of common
neurologicaldisease are herein discussed according to clinical presentation.
The benefits of medical imaging are great, but one should always be warry of
the risks. Lionizing radiation from standard X-Ray imaging, including CT,
has negligible risk,, but exposure should be justifiable and limited. Lodinated
contrast is nephrotoxic in patients with poor renal function. Recently,
gadolinium contrast has been linked to nephrogenic systemic fibrosis (NSF), a
rare scleroderma-like syndrome in patients with poor renal failure. Current
recommendations are to avoid gadolinium contrast in patients in moderate or
severe renal failure; if medically necessary, patients should be informed of the
risk of developing NSF.
I.
HEADACHES
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cavities ( the temporal horns and the third ventricle are early reliable indicators of
hydrocephalus). Cerebral tumors and infections may be evaluated with postcontrast
CT (although contrast-enhanced MRI is superior), showing as enhancing masses,
possibly in a ring- enhancing pattern, with a chronic CSF leak, is a common reasin
for headaches causing recurrent ER visits, postcontrast MRI (particularly in the
coronal plane is diagnostic, showing thickened and densely enhancing meninges.
c. Chronic headaches. Unruptured AVMs, temporal arteritis, vasculitides,
intrascranial colloid cysts ogf the third ventricle, and cervical spondylosis are all
possible causes of chronic headaches, in addition to migraine, cluster headaches, and
chronic sinusitis. MRI currently has the best yield in screening patients with a
suspected intracranial anomaly.
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II.
SEIZURES
A. New onset adult seizures. MRI is currently and by far the preffered
initial maging metod to investigate new onset adult seizures, owing to
its superior contrast resolution and multiplanar capability. Magnetoencephalography (MEG) is a new technique that measures magnetic
fields due to neuronal activity, with a spatial resolutions of a few
millimeters and a temporal resolution of miliseconds; as of 2007, 30
MEG systems are installed in the Unitade States, 70% in intitutions
with a level 4 epilepsy program. MRI uses MEG in combination with
MRI in the same machine, and has currently the highest yield to detect
epiloptogenicfoci. Spect and PET imaging have extremely high
specifity if obtained duraing and ictus, but have limited use in clinical
practice. New onset adult seizures may be caused by brain tumors
(primary or metastatic), AVMs, inflammatory conditions, vasculitides,
ischemic lesions, gliotic scars from prior injury (both penetrating and
mild), again all conditions in which MRI has significant priority over
CT.
In oatients with temporal lobe epilepsy, coronal MRI (FLAIR
and T2) has a high overall detection rate (up to 80%) for
hippocampal sclerosis (FIG. 32.4), showing an atrophic
hippocamous with high t2 signal, and indirect signs like a
dilated choroidal fissure and forniceal atrophy. Anterior
temporal lobectomy is recommended and may be curative in
DEMENTIA
Cognitive decline may be related to
1)
2)
3)
4)
Depression
Structural lesion (cerebral tumor, subdural hematoma, hydrocephalus)
Chronic cerebral ischemia
Primary dementing onditions, the most common of which Alzheimer/s
disease (AD). A thorough clinical evaluation plays a major role in
these patients who are often in the older are group. Neuroimaging
detects correctable causes of dementia, found in about 5% of patients
with progressive cognitive decline. CT is adequate is conditions like
severe hydrocephalus and chronic subdural hematomas. However,
MRI is overall superior CT in the vast majority of patients, although
unfortunately corrective theraphy is only available in few conditions .
for example assessment of generalized cerebral and focal hippocampal
atrophy in AD is more easily done with MRI, including computerized
volumetric measurement of the hippocampus, considered promising
V.
basilar artery thrombosis, diagnosed with DWI MRI, axial MRI and MR
angiography (MRA), hypertensive encephalopathy, and posterior reversible
encephalopathy syndrome )PRES), which show characteristic T2 and FLAIR
subcortical lesions, diffuse in hypertensive encephalopathy, predominantly
occipital in PRES.
CEREBRAL ISCHEMIA
Arterial supply to the brain may be acutely interrupted (acute stroke) or
chronically decreased with intermittent, usually progressively worsening
symptoms. Thorough clinical evaluation usually allows one to localize the
involved part of the brain. Venous ischemia results from occlusion of major
venous drainage channels, which can cause severe deficits culminating in
coma in diencephalic involvement from internal cerebral vein thrombosis.
A. Acute stroke. Acute stroke is an extreme emergency (time is brain).
There is a 3 hour window within stroke onset or the delivery of
intravenous tissue plasminogen activator (t-PA), the only currently
FDA-approved therapy for hyperacute management of ischemic
stroke. Past that, and up to 6 hours in the carotid circulation (possibly
longer in the vertebrobasilar circulation), intraarteial thrombolysis may
be offered in specialixed centers. An acceptable algorithm for the
emergency evaluation of acute stroke, currently technically attainable
in any medical institution, is to first obtain a plain CT, followed (if no
hemorrhage) by a contrast CTA and CT perfusion study to elevaluate
the perusion deficit (FIG.32.5). this is not only diagnostic , but also
prognostic as to the territory at risk, allowing to adjust hemodynamic
management. In some specialized centers, MRI,MRA (fig.32.6), and
MR perfusion are the standard protocol in acute stroke patients.
Diffusion weighted imaging (DWI) is positive for acute strokes as
early as 30 minutes and up to 10 day of the onset, and is therefore
particularly well suited to differentiate acute and subacute from
chronic events. Mismatch (size difference) between DWI and
perfusion deficits (especially a comparatively small DWI deficit)
requires special attention, prompting immediate thrombolysis (if
feasible) and hemodynamic support.
B. Dural sinus and cortical vein thrombosis. The venous intracranial
circulation should always be thoroughly evaluated, particularly if the
patients neurological deficit is accompanied by headache. Recent
thrombus within a dural sinus may be difficult to identify on plain CT
(although possibly seen as a spontaneously hyperdense filling
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XII. MYELOPATHIES
Mri is the preffered imaging method in myelopathies, both aute and chronic,
providing direct mutiplanar imaging, superior cintrast between normal and abnormal
spinal cord, CSF, fat and bony structures. Gating techniques help reduce artifacts
from breathing and CSF, cardiac and vascular pulsations. Patients with acute
myelopathy and major contraindications to MRI (pacemakers) may be evaluated with
plain CT or CT myelography.
Nontraumatic acute myelopathy most often results from spinal cord
compression by a retripulsed neoplastic vertebral compression fractures, usually in an
elderly patient with an unknown (or known) cancer, best evaluated by noncintrast
whole spine MRI. Acute inflammatory myelopathy due to transverse myelitis or
demyelinating conditions is also best evaluated with MRI (Fig.32,8), with the
addition of contrast. Less commonly, acute myelopathy is due to spontaneous
epidural (or rare subdural ) hematomas. Traumatic cord contusions are best
evaluated by MRI using T2, STIR, and gradient echo sequences.
Causes of chronic myelopathy include spinal cord tumors. Degenerative
disease and disc herniations syringomyelia, congenital anomalies, that is,
diastematomyelia and tethere cord with or without associated lipomas, inflammatory
and demyelinating disease, and spinal dural arterovenous fistulae (Fig.32.9). initial
evaluation of these patients is also best undertaken with pre and postcontrast MRI.
CT myelography should be reserved for the rare patient with a major contraindication
MRI.