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BasicRadiology,2e>

Chapter12.BrainandItsCoverings
MichaelE.Zapadka,DOMichelleS.Bradbury,MD,PhDDanielW.WilliamsIII,MD

BrainandItsCoverings:Introduction
Technologicaladvancesinradiologyduringthepast30yearshavevastlyimprovedourabilitytodiagnose
neurologicdiseases.Priortotheintroductionofcomputedtomography(CT)in1974,neuroradiologic
examinationsofthebrainconsistedprimarilyofplainfilmsoftheskull,cerebralarteriography,
pneumoencephalography,andconventionalnuclearmedicinestudies.Unfortunately,thesetechniques,forthe
mostpart,providedonlyindirectinformationaboutsuspectedintracranialprocesses,wereinsensitivein
detectingsubtleorearlybrainlesions,orwerepotentiallyharmfultothepatient.Computedtomography
revolutionizedtheradiologicworkupofcentralnervoussystem(CNS)abnormalitiesbecauseforthefirsttime
normalandabnormalstructurescouldbedirectlyvisualizedwithminimalrisktothepatient.

Inthelate1980s,itbecameapparentthatmagneticresonance(MR)imagingwouldbecometheprocedureof
choiceforevaluatingmanyneurologicdisorders,aswellasfordemonstratingvascularflowphenomena.Since
then,therehavebeenmanytechnologicaladvancesassociatedwiththismodality.Theseincludeimprovements
inmagnetandcoildesign,decreaseinimagingtime,andthedevelopmentofnewpulsesequences.Inadditionto
advancesinconventionalanatomicimaging,therehasalsobeensubstantialgrowthofphysiologicMR
imagingincludingMRspectroscopy(MRS),diffusionweighted(DW)andperfusionweighted(PW)MR
imaging,andfunctionalMRimaging(fMRI),amongothers.Theseimagingmodalitiesprovidefunctional
informationaboutthebrainandhavethepotentialtogreatlyextendourunderstandingofneuropathology
beyondstructurealone.

RevolutionarybreakthroughsinCTscanningtechnologyduringthe1990sfacilitatedthedevelopmentof
advancedCTapplications,namely,dynamiccontrastenhancedCTangiography(CTA)andCTperfusion(CTP).
Thesetechniques,whichallowhighspatialresolutionimagingofthecervicalandintracranialvasculature,are
currentlybeingusedintheevaluationoftheacutestrokepatientinmanymedicalcenters.Furthermore,recent
technologicadvancesinCTimaginghavemarkedlydecreasedscantimesandhaveallowedevaluationofvery
tinyanatomicstructuresbecauseofimprovementinspatialresolution.

Recentadvancesinnuclearmedicinefunctionalimagingtechniques,includingsinglephotonemissioncomputed
tomography(SPECT)andpositronemissiontomography(PET),improvementsinconventionalangiographic
methods,andexpansionofcatheterbasedtherapeuticprocedureshaveprovidedtheneuroradiologisttodaywith
anevengreatervarietyofstrategiesfordiagnosingandtreatingneurologicabnormalities.

Themainpurposeofthischapteristoacquaintthereaderwiththemajorradiologictechniquesusedcurrentlyto
evaluatethebrainanditscoverings.Thestrengthsandweaknessesofthesetechniquesarediscussed.Imaging
anatomyofthebrainanditscoveringsisbrieflyreviewed.Basicguidelinespertainingtotechniqueselectionfor
evaluatingcommonneurologicconditionsareprovided.Finally,examplesofcommonbrainabnormalitiesare
presented.Itisassumedthatreadershaveabasicunderstandingofneuroanatomyandneuropathology.

Althoughthischaptermaygivesomeinsightintoneuroradiologicstudyinterpretation,thatisnotitsprimary
goal.Rather,readersshouldexpecttobecomereasonablyfamiliarwiththevarioustechniquesemployedto

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examinethebrainandshouldgainsomeideaabouttheappropriateorderingofexaminationsinspecificclinical
situations.

Techniques
Radiologicmodalitiesusefulinevaluatingthebrainanditscoveringscanbedividedintotwomajorgroups:
anatomicmodalitiesandfunctionalmodalities.Anatomicmodalities,whichprovideinformationmostlyofa
structuralnature,includeplainfilmsoftheskull,CT,MRimaging,cerebralarteriography(CA),and
ultrasonography(US).Ontheotherhand,SPECTandPETimaging,CTperfusion,DWandPWMRimaging,
fMRI,andMRSareprimarilyfunctionalmodalities,whichgiveinformationaboutbrainperfusionor
metabolism.Sometechniquesprovidebothanatomicandfunctionalinformation.Forexample,cerebral
arteriographydepictsbloodvesselssupplyingthebrainbutalsoallowsustoestimatebraincirculationtime.
Ultrasoundofthecarotidbifurcationisanothermodalitythatprovidesbothanatomicandfunctional
information.Aroutinesonogramofthecarotidbifurcationgivesanatomicdatathat,whencombinedwith
Dopplerdata,readilyprovidesinformationaboutbloodflow.

Thefollowingdiscussionofcurrentneuroradiologictechniquesemphasizesrelativeexaminationcostand
patientrisk,alongwiththeadvantagesanddisadvantagesofeachtechnique.Thenormalimagingappearanceof
thebrainanditscoveringsisalsoillustrated.

PlainRadiographs
Plainradiographsoftheskullareobtainedbyplacingapatient'sheadbetweenanxraysourceandarecording
device(ie,xrayfilm).Whereasbonesoftheskullattenuatealargenumberofxraystocreateanimage,soft
tissuessuchasscalporbrainarepoorlyvisualized,ifatall.Anotherdifficultyinplainfilminterpretationresults
fromthesphericalshapeoftheskull,leadingtomultiplesuperimposedstructures.Theresultantskullradiograph
primarilygivesinformationaboutthebonesoftheskull,butnodirectinformationabouttheintracranial
contents.Indirectinformationaboutintracranialabnormalitiescansometimesbeobtainedfromtheskullplain
radiograph,althoughthisinformationcanbequitesubtle,eveninthesettingofadvanceddisease.Skullplain
radiographshavebeenlargelyreplacedtodaybymoresensitivetechniquessuchasCTorMRimaging.Evenin
thesettingofsuspectedskullfracture,plainradiographsarerarelyindicated,becauseCTscansalsoshowthe
fracture,aswellasanyintracranialabnormalitythatmightrequiretreatment.Currently,plainradiographsofthe
skullserveaverylimitedroleinroutineneuroimagingandareonlybrieflydiscussed.

ComputedTomography

CTscansconsistofcomputergeneratedcrosssectionalimagesobtainedfromarotatingxraybeamanddetector
system.Advancesinscanningtechnologynowpermitsimultaneousacquisitionofmultipleimagesduringa
singlerotationofthexraytube(eg,currentlyupto256slices)duringabreathhold.Theresultantimages,
unlikeplainfilms,exquisitelydepictanddifferentiatebetweensofttissues,thusallowingdirectvisualizationof
intracranialcontentsandabnormalitiesassociatedwithneurologicdiseases.Thecontrastorbrightness
(windoworlevel,respectively)oftheseimagescanbeadjustedtohighlightparticulartissues.

Typically,aheadCTconsistsofimagesadjustedtoemphasizesofttissuedetail(softtissuewindows)aswellas
imagesadjustedtovisualizebonydetail(bonewindows)(Figure121).Asstatedearlier,CTimagegenerationis
dependentonvariableattenuationofthexraybeambasedonthedensityofstructuresitpassesthrough(eg,
bonesoftheskullbaseareverydenseandattenuatealargepercentageofthexraybeam).Therefore,cortical
boneappearswhite(hasahighattenuationvalueorHounsfieldunit),whereasairwithintheparanasalsinuses
appearsblack(hasalowattenuationvalue)(Figure121).CerebralwhitematterhasaslightlylowerHounsfield
numberthandoescerebralgraymatterandconsequentlyappearsslightlydarkerthangraymatteronaheadCT
scan(Figure121A).Intracranialpathologicconditionscanbeeitherdark(lowattenuation)orbright(high
attenuation),dependingontheparticularabnormality.Forexample,acuteintracranialhemorrhageistypically

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verybright,whereasanacutecerebralinfarctiondemonstrateslowattenuationwhencomparedtothe
surroundingnormalbrainbecauseofthepresenceofedema.

Figure121.

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NormalaxialheadCTimages.Appropriatewindowselectionallowsvisualizationofbothintracranialcontents
(A)andbonycalvarium(B).Notedifferencesinattenuationamonggraymatter(leftthalamus,doubleblack
arrows),rightinternalcapsule(singleblackarrow),cerebrospinalfluid(CSFfrontalhornoftheleftlateral
ventricle,whitearrow),andbone(skull,arrowheads).

TheCTtechnologistcanchangetheslicethicknessandangulation,amongothertechnicalfactors,toalterthe
wayanimageappears.Imagesaretypicallyobtainedaxiallyinhelicalfashion,withacquisitionofavolumetric
dataset.Currentscannertechnologyallowstheaxialdatasettobereformattedincoronal,sagittal,oroblique
planesorasa3Dimage,withlittle,ifany,lossofresolution.CTexaminationsmaybeperformedafter
intravenousadministrationofaniodinatedcontrastagent,especiallywhenMRIiscontraindicatedor
unavailable.Theseagentslightuporenhancenormalbloodvesselsandduralsinuses,aswellasintracranial
structuresthatlackabloodbrainbarrier(BBB),suchasthepituitarygland,choroidplexus,orpinealgland.
PathologicconditionsthatinterrupttheBBB(suchasneoplasm,infection,orcerebralinfarction)also
demonstrateenhancementaftercontrastmaterialadministration.Forthisreason,lesionsthatmaybeinvisibleon
anoncontraststudyareoftenobviousonthecontrastenhancedscan.

Theintravenousadministrationofacontrastboluscanbeappropriatelytimedtomaximizevascular
opacificationofthearterialorvenouscirculation(CTAorCTV,respectively).Thesehighspatialresolution3D
CTAimages(Figure122)ofthecervicalandintracranialvasculatureareroutinelyemployedtoquantifyvessel
stenosisduetoatheroscleroticdisease,toassessforvascularinjuryrelatedtotrauma,ortodetectcerebral
aneurysminthepatientwithsubarachnoidhemorrhage.

Figure122.

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NormalCTangiogramwith3Dvolumerendering.Imageisorientedslightlyobliquewiththesuperior
calvariumcutaway.Majorvesselsdemonstratedincludetheanteriorcerebralartery(ACA),middlecerebral
artery(MCA),basilarartery(BA),andposteriorcerebralartery(PCA).

Inparticular,CTAhasbecomeastandardcomponentofevaluatingtheacutestrokepatient.CTAaccurately
identifiesthelocationandextentoflargevesselocclusionsandcanbesupplementedbyamoredetailed,
quantitativeevaluationofthecerebralmicrovascularhemodynamics(CTperfusion)duringtheearlyphaseof
boluspassage.SoftwareanalysisofthistailoredCTAdataproducesmapsofcapillarylevelcerebralperfusion,
typicallymeasuredbymeantransittime(MTT),cerebralbloodflow(CBF),andcerebralbloodvolume(CBV).
Inthesettingofcerebralinfarction,theseparameterscanhelpinterprettheinfarctcore(CBV)versusthe
ischemicpenumbra(MTTandCBF).Evaluationofpotentialmismatchbetweentheinfarctcoreand
surroundingpenumbraservesastherationaleforinstitutingvariousreperfusiontechniques.

AnotherrecentapplicationofCTAisinthescreeningevaluationofbluntcerebrovascularinjury,including
closedheadinjuries,seatbeltabrasion(orothersofttissueinjury)oftheanteriorneck,basilarskullfracture
extendingthroughthecarotidcanal,andcervicalvertebralbodyfracture.Itisanaccuratetechniquefor
detectinginternalcarotidartery(ICA)dissectionsandforassessingstenoses,althoughevaluationisdifficultin
areasofsurroundingdenseboneasaresultofassociatedstreakartifact.However,thisnoninvasive,relatively
shortimagingprocedurerivalsconventionalangiographicmethods,asitrequiresnopatienttransferandcan
sensitivelyidentifyvascularinjuryinrelationtootherassociatedbraininsults,cervicalspineinjury,orfacialor
basilarskullfractures.

Highresolutiondataacquisitionduringthevenousphasefollowingintravenouscontrastadministration(CT
venography)canbeusedtoidentifyduralsinusesandcerebralveins,evaluateforduralvenoussinus
thrombosis,anddistinguishpartialsinusobstructionfromvenousocclusioninthesettingofadjacentbrain
masses.CTvenographycanalsodifferentiateslowflowfromthrombosis,whichmayoccasionallybedifficult
withMRtechniques.
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ThemajoradvantagesofCTarethatitisinexpensive,iswidelyavailable,canbeusedinpatientswithMR
incompatiblehardware,andallowsarelativelyquickassessmentofintracranialcontentsinthesettingofa
neurologicaldeficit.Theimagesobtainedareverysensitivetothepresenceofacutehemorrhageand
calcification,andimagesrevealingexquisitebonydetailoftheskullandskullbasecanbeacquired.Becauseof
theconfigurationofthescanner,patientsarereasonablyaccessibleformonitoringduringtheexamination.

CTscannersdohaveanumberofdisadvantages,however.Patientsareexposedtoionizingradiationandiodine
basedcontrastagents(althoughlowerdosesofcontrastareneededwithnewermultidetectorscanners).Imaging
artifactscaninterferewithaccurateinterpretation.Inparticular,imagesofthebrainstemandposteriorfossaare
oftendegradedbystreakartifactsfromdensebone(Figure123).Streakartifactsfrommetallicobjects(eg,
fillings,braces,surgicalclips)canalsoobscureabnormalities.Imagescanbeseverelydegradedbypatient
motion.Fortunately,unlikeMRscans,individualCTimagesdegradedbymotioncanberapidlyreacquired.

Figure123.

Streakartifacts(arrows)commonlyobscureportionsofthebrainstem,posteriorfossa,andtemporallobeson
routineheadCTscans.

MagneticResonanceImaging
Oneofthemostexcitingdevelopmentsinradiologyduringthepast30yearshasbeenthegrowthofmagnetic
resonanceimaging(MRI),whichiscurrentlythemainstayofclinicalneuroimaging.Theconceptofnuclear
magneticresonance(NMR),initiallyusedforprobingthephysiochemicalstructureofmolecules,wasfirst

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describedinthe1930s,butittookmorethan40yearsbeforethetranslationofNMRphenomenacouldbeused
forclinicalimaging.

MRexaminations,likeCTscans,consistofcomputerreconstructedcrosssectionalimages(Figure124).In
MRimaging,however,unlikeCTscansorplainradiographs,theinformationcollectedisnotxraybeam
attenuation.TheMRimageisavisualdisplayofNMRdatacollectedprincipallyfromnucleiwithinbody
tissuesespeciallyhydrogennucleiwithinwaterandfatmolecules.Intrinsictissuerelaxationoccursbytwo
majorpathways,calledlongitudinal,orT1,andtransverse,orT2,decay.MRimagingsequencesthatemphasize
T1decayarecommonlyreferredtoasT1weightedsequencesthataccentuateT2relaxationpropertiesare
calledT2weighted(Figure124).MostMRscansofthebrainusebothofthesesequences,becausecertain
abnormalitiesmayonlybeobviousononeortheother.T2weightedimagesareusuallyeasytoidentifybecause
fluid(eg,cerebrospinal,globevitreous)isverybrightfluidonaT1weightedscanisusuallydark.Fatisbright
onT1weightedscans,butdarkeronT2weightedimages.Ontheotherhand,bothcorticalboneandairarevery
darkonallimagingsequences.Braintissuehasintermediateintensityvesselscanhavealmostanysignal,
dependingonthevelocityofflowingblood.

Figure124.

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NormalheadMRimages.SagittalT1weighted(A),axialT1weighted(B),andaxialT2weighted(C)images.
Notedifferencesinsignalbetweengraymatter(largearrows),whitematter(curvedarrows),CSF(small
arrowheads),fat(smallarrows),andcorticalbone(largearrowheads)ondifferentpulsesequences.Normal
structuresincludethegenu(g)andspleniurn(s)ofthecorpuscallosum(cc),fornix(f),opticchiasm(oc),
pituitarygland(pit),midbrain(mb),pons(p),medulla(m),cerebellarvermis(Cb),straightsinus(SS),caudate
head(c),putamen(pt),andthalamus(T).

ThemostcommonlyusedclinicallyapprovedcontrastagentforMRimagingisgadopentetatedimeglumineor
GdDTPA,whichisverywelltoleratedandgenerallysafe,althoughcautionmustbeusedinpatientswithrenal
impairmentbecauseoftheassociatedriskofdevelopingnephrogenicsystemicsclerosis(refertoChapter1).Its
majoruseintheCNSistoimprovelesiondetectabilitybylightinguppathologicconditionsthateitherlacka
BBBorhaveadisruptedBBB.

ConventionalMRimagingdepictsexcellentsofttissuecontrast.Traditionally,longimageacquisitiontimes,
imageartifactsrelatedtopatientmotion,andtheincreasedcostofscanningduetolimitedpatientthroughput
havehamperedtheclinicalutilityofMRimaging.Overthepast15years,technicaladvancesingradient
technology,coildesign,imagereconstructionalgorithms,contrastadministrationprotocols,anddataacquisition
strategieshaveacceleratedthedevelopmentandimplementationoffastimagingmethods.Thesetechniques,
includingfastgradientechoimaging,fastspinechoimaging,FLAIR(fluidattenuatedinversionrecovery),and
echoplanarimaging,haveenabledsubstantialreductionsinimagingtime.Imagesmaybeacquiredduringa
singlebreathholdonaclinicalscanner,eliminatingrespiratoryandmotionartifacts.Vesselconspicuitycanbe
enhancedbyapplicationoffatsuppressionsequences,whicheliminateunwantedsignalfrombackground
tissues.Theseimprovementshaveledtoavastrangeofapplicationsthatwerepreviouslyimpractical,including
highresolutionMRA,DWandPWMRimaging,MRS,fMRI,andrealtimemonitoringofinterventional
procedures.
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Sinceitsfirstclinicalapplicationnearly15yearsago,MRAhasproventobeausefultoolforevaluationofthe
cervicalorintracranialcarotidvasculature.MRArepresentsaclassoftechniquesthatutilizetheMRscannerto
noninvasivelygeneratethreedimensionalimagesofthecarotidorvertebralbasilarcirculations.Althougha
detaileddiscussionofthesetechniquesisbeyondthescopeofthischapter,severalcommentsarenoteworthy.
Thesemethodspermitdistinctionbetweenbloodflowandadjacentsofttissue,withorwithoutadministrationof
intravenouscontrast.Asnotedearlier,revolutionarydevelopmentshavepermittedMRAimagestoberapidly
acquiredwitheverimprovingtemporalandspatialresolution.

Presently,MRAservesasoneofthefirstlinestudiesforevaluationofarterialocclusivediseaseandfor
screeningofintracranialaneurysms.Thesemethodshavelargelyreplacedconventionalarteriographicstudies
forevaluationofatheroscleroticdisease,exceptincasesofcriticalstenosis(>70%).Intheseinstances,the
degreeofluminalnarrowingmaybeoverestimatedbyMRAandmayrequireverificationwithCTA,catheter
basedstudy,orDopplerultrasound.Moreover,aneurysmsdetectedonanintracranialMRAtypicallyrequirea
catheterbasedstudyfordetailinganeurysmsizeandorientation,forestablishingthelocationofadjacentvessels
andcollateralflow,andforconfirmingsuspiciousvasculardilatation,aswellasfordetectingthepresenceof
vasospasmoradditionalaneurysmsthatmaynotbereadilyapparentontheMRAstudy.Inanincreasingnumber
ofcases,catheterbasedstudieswilladditionallybeperformedforcoilembolization(obliteration)ofdetected
aneurysms,ratherthansurgicalclipping.

Moleculardiffusion,therandomtranslationalmovementofwaterandothersmallmoleculesintissue,is
thermallydrivenandisreferredtoasBrownianmotion.Overagiventimeperiod,theserandommotions,
expressedasmoleculardisplacements,canbedetectedusingspecificallydesigneddiffusionsensitiveMR
sequences.Acommonapplicationofdiffusionimagingisthedetectionofearlyischemicinfarction,wherethe
infarctedtissuelightsupbecauseofarestricteddiffusionstatewithintheintracellularcompartment.Other
applicationsofdiffusionsensitivesequencesincludedifferentiatingcystsfromsolidtumors,aswellas
evaluatinginflammatory/infectiousconditions(encephalitis,abscess)orwhitematterabnormalities
(hypertensiveencephalopathy).

PerfusionMRimagingmeasurescerebralbloodflowatthecapillarylevelofanorganortissueregion.
PerfusionweightedMRimaginghasapplicationsintheevaluationofanumberofdiseasestates,including
cerebralischemiaandreperfusion,braintumors(Figure125),epilepsy,andbloodflowdeficitsinAlzheimer's
disease.Inaddition,theclosespatialcouplingbetweenbrainactivityandCBFpermitstheapplicationof
perfusionMRtechniquestoimagingbrainfunction.MRperfusionimagingistechnicallycomplexandrequires
advancedscannerandpostprocessingsoftwareforimagegeneration.Variousmethodscanbeemployed
includingcontrastbolustechnique(analogoustoCTperfusion)orarterialspinlabeling(ASL).ASLusesa
radiofrequencypulsetolabelprotonsflowinginthecervicalarteriesandthatsignalissubsequentlyimagedas
thoseprotonsflowintothecerebrum.OneofthemajoradvantagesofASListhatitrequiresnocontrast
administration,whichisofgreatbenefitinpatientswithrenalimpairment.

Figure125.

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MRimagesofanewlydiagnosedhighgradeglioma.(A)AxialpostcontrastT1imageshowsaperipherally
enhancing,centrallynecroticmassintherightfrontallobe(blackarrow)aswellassurroundinghypointenseT1
signalconsistentwithvasogenicedema(whitearrow).(B)Cerebralbloodflowimage(pulsedarterialspin
labelingtechnique)showsincreasedperfusion(arrow)alongtheperipheralaspectofthemass.

FunctionalMRimagingisanimportantbrainmappingtechniquethatusesfastimagingtechniquestodepict
regionalcorticalbloodflowchangesinspaceandtimeduringperformanceofaparticulartask(eg,flexionofthe
indexfinger).Theutilizationofthistechniquetolocalizebrainactivityishistoricallybasedonmeasurable
increasesincerebralbloodflow(andbloodvolume)withincreasedneuralactivity,referredtoasneurovascular
coupling.Thehemodynamicresponsetoastimulusisnotinstantaneous,butontheorderofafewseconds.
Consequently,fMRItechniquesareconsideredanindirectapproachtoimagingbrainfunction,butprovide
excellentspatialresolutionandcanbepreciselymatchedwithanatomicstructures.Changesinblood
oxygenationandperfusioncanbeimagedusingfMRItechniques,whichhasbecomethemostwidelyused
modalityfordepictingregionalbrainactivationinresponsetosensorimotororcognitivetasks.

AnimportantclinicalapplicationoffMRIispresurgicalmapping,wherebyeloquentbraincortexcanbedefined
inrelationtomasslesions(Figure126).Thisallowsforthejudiciousselectionofanappropriatemanagement
strategy(surgicalversusnonsurgical)accordingtothefunctionalnatureoftheadjacentbraintissue.Asecond
applicationinvolvesdeterminationofthecerebralhemisphereresponsibleforlanguageandmemorytasksina
patientwithcomplexpartialseizures,priortoundergoingtemporallobectomy.Additionally,severalgroupshave
reportedsuccessfulfunctionalactivationstudiesforlateralizinglanguagepreoperativelyutilizingfMRI.

Figure126.

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FunctionalMRimageforpreoperativeplanningrevealslefthandmotoractivation(largearrows)adjacentto,
butseparatefromtherightfrontallobemassandsurroundingedema(smallarrow).

MRspectroscopy(MRS)providesqualitativeandquantitativeinformationaboutbrainmetabolismandtissue
composition.Thisfunctionalanalysisisbasedondetectingvariationsintheprecessionfrequenciesofspinning
protonsinamagneticfield.Onefactorinfluencingtheprecessionorresonancefrequencyisthechemical
environmentoftheindividualproton.Protonsindifferentcerebralmetabolitescanbesensitivelydiscriminated
onthisbasis,andthepositionofthesemetabolitescanbedisplayedasaspectrum.Thexaxispositionofagiven
metabolitereflectsthedegreeofchemicalshiftofthemetabolitewithrespecttoadesignatedreference
metaboliteandisexpressedinunitsofpartspermillion(orppm).Theareaunderthepeakisdeterminedbythe
numberofprotonsthatcontributetotheMRsignal.

ThemajormetabolitesdetectedintheCNSareNacetylaspartate(NAA),aneuronalmarkercholine,amarker
forcellularityandcellmembraneturnovercreatine,amarkerforenergymetabolismandlactate,amarkerfor
anaerobicmetabolism.Inadditiontothesemetabolites,othershavebeenassessed,includingalanine,glutamine,
myoinositol,andsuccinate,usingvariousMRstrategies.Presently,MRSisbeingusedinclinicalpracticeto
providefunctionalinformationregardingmanyCNSabnormalities,andcomplementstheconventionalMR
imagingstudy.Acommonapplicationrelatestothepreandposttreatmentevaluationofbraintumors,with
MRSplayinganimportantroleinassessingforresidualorrecurrenttumorfollowingsurgicalresection.

MRimagingoffersanumberofadvantagesoverCTintheworkupofpatientswithneurologicdisease.Itssoft
tissuecontrastresolutionissuperiortothatofCT,andlesionsthatmaybesubtleorinvisibleonCTare
frequentlyobviousonMRimaging.MRimagingalsoallowsacquisitionofmultiplanarviewsinthesagittal,
axial,coronal,andobliqueprojectionsthatmaybeimpossibletoobtainwithCT.Furthermore,MRimaging
givesinformationaboutbloodflowwithouttheneedforacontrastagent,andbonystreakartifactsthatobscure

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lesionsofthebrainstemandcerebellumonCTscansarenotpresentonMRimages.Finally,MRimagingdoes
notexposethepatienttoionizingradiation.

CerebralArteriography
Cerebralarteriographyinvolvestheinjectionofwatersolublecontrastmaterialintoacarotidorvertebralartery.
Contrastmaterialisinjectedintothedesiredvesselviaasmallcatheter,whichhasbeenintroducedintothebody
throughthefemoralorbrachialartery.Informationaboutthearterial,capillary,orvenouscirculationofthebrain
isrecordedonserialplainfilmsor,mostcommonly,digitizedforviewingonamonitororforstoragewithina
computer(Figure127).

Figure127.

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Normalcerebralarteriogram.(A)Lateralviewofthecervicalcarotidartery.Catheterislocatedwithinthe
commoncarotidartery,andcontrastmaterialfillsinternal(arrows)andexternal(arrowheads)carotidarteries.
(B)Lateralviewoftheheadafterinjectionofthecarotidartery(arrow).Noteanteriorcerebral(A),ophthalmic
(O),posteriorcommunicating(PC),andmiddlecerebral(M)branches.

Cerebralarteriogramsareexpensive(twotothreetimesasmuchasMRexaminations)andarerelativelymore
riskyproceduresthanothernoninvasiveneuroradiologicstudies.Themajorriskoftheprocedureisstroke,
whichmayoccurinoneofevery1,000patients.Strokeduringcerebralarteriographyoccurseitherfroman
embolicevent(eg,inadvertentinjectionofair,thrombusformationonthecathetertip,atheroscleroticplaque
dislodgedbycathetermanipulation)orfromcatheterrelatedlocalvesseltrauma(eg,dissectionsorocclusions).

AlthoughCTangiographyhaslargelyreplacedcatheterangiographyformostroutinediagnosticevaluations,
catheterangiographyisinvaluableintheworkupofvasculardiseasesaffectingtheCNS.Specifically,itremains
thegoldstandardforassessingvasculitisandisindispensableinevaluatingandtreatingcerebralaneurysmsand
certainintracranialvascularmalformationsorfistulas.Itisausefuladjuncttocrosssectionalimaging(CTA,
MRA,orUS)toassessvascularstenosisaswellascarotidorvertebralarteryintegrityaftertraumatotheneck,
especiallyinthesettingofacuteneurologicaldeficit.Finally,itisunsurpassedforshowingvascularanatomyof
thebrainandis,therefore,usefulasapreoperativeroadmap.

Thefieldofinterventionalneuroradiologycontinuestogrowandexertconsiderableimpactonthediagnosisand
treatmentofcertainCNSdiseases.Newcatheterdesignsandmaterials,recentlydevelopedendovasculardevices
(extracranial/intracranialstents),andanincreasingnumberoftrainedspecialistsperformingendovascular
procedureshaveledtonoveltherapeuticapplicationsandapproachesformanagingpreviouslyuntreatable
conditions.Endovasculardiagnosticandtherapeuticprocedures,basedonfundamentalcerebralarteriography
principles,havegainedwidespreadacceptanceand,insomecases,rivaltraditionalneurosurgicalapproachesin
termsofcomplicationrates,clinicaloutcomes,andlongtermsurvivalbenefit.Althoughafulldiscussionof
thesetechniquesisbeyondthescopeofthischapter,theyincludepharmacologicandmechanicalthrombolysis
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ofintracranialclotinthesettingofacuteinfarctionorduralsinusthrombosisembolization(obliteration)of
intracranialaneurysmsusingthrombosingmaterial(ie,coils)carotidarteryangioplastyand/orstentplacement
forcriticalstenoticnarrowingorradiationinducedarterialstricturepreoperativeordefinitivedevascularization
ofahypervascularmassorarteriovenousmalformationembolizationofsmall,bleedingexternalcarotidartery
branchesinepistaxisballoonocclusiontestsofthecarotidarteryandendovasculartreatmentofvasospasm.
Embolizationmaterialsincludeparticulateemboli,liquidadhesiveglues,andvariouscoils.

Ultrasonography
Ultrasonographyisthediagnosticapplicationofultrasoundtothehumanbody.Majorapplicationsof
ultrasonographyinCNSdiseaseincludegrayscaleimagingandDopplerevaluationofcarotidarterypatency
andflowinthesettingofatherosclerosis,assessmentofvasospasminthesettingofsubarachnoidhemorrhage
usingtranscranialDoppler,screeningevaluationofintracranialabnormalitiesinthenewbornandyounginfant
(Figure128),anddetectionofintracranialhemorrhageinprematureinfantspriortoextracorporealmembrane
oxygenationtherapy.Ultrasoundhasalsobeenusedintraoperativelytodemonstratethespinalcordand
surroundingstructuresduringspinesurgeryandtodefinetumorandcystmarginsduringcraniotomies.

Figure128.

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Coronal(A)andsagittal(B)headultrasoundofaneonate.Normalstructuresincludethecorpuscallosum(CC),
lateralventricle(LV),cavumseptumpellucidum(CS),sylvianfissure(SF),thirdventricle(3V),fourthventricle
(4V),temporallobe(TL),frontallobe(FR),occipitallobe(OCC),cerebellum(CER),andthalamus(TH).

TranscranialDopplerisarecentlydevelopedtoolintheevaluationofcerebrovasculardisorders.Ituseslow
frequencysoundwavestoadequatelypenetratetheskullandproducesspectralwaveformsofthemajor
intracranialvesselsforevaluationofflowvelocity,direction,amplitude,andpulsatility.Presentclinical
applicationsincludediagnosisofcerebralvasospasm,evaluationofstrokeandtransientischemicattack,
detectionofintracranialemboli,serialmonitoringofvasculitisinchildrenwithsicklecelldisease,and
assessmentofintracranialpressureandcerebralbloodflowchangesinpatientswithheadinjuryormasslesions.

Ultrasoundexaminations,althoughmoderatelyexpensive,arevirtuallyriskfreetothepatient,involveno
ionizingradiation,andareportable(ie,canbeperformedatthebedside).However,examinationqualityand
thereforediagnosticaccuracyareoperatordependent.Also,theheavyrelianceofultrasonographyonthe
presenceofanadequateacousticwindowthroughwhichanexaminationcanbeperformeddiminishesits
usefulnessinexaminingthebrainafterthefontanellescloseininfancy.Finally,totheuntrainedeye,anatomic
structuresandpathologicprocessesasdepictedbyUSarenotasreadilyapparentastheyareonCTorMR
images.

SinglePhotonEmissionComputedTomography
SPECTusesarotatinggammacameratoreconstructcrosssectionalimagesofthedistributionofaradioactive
pharmaceuticalthathasbeenadministeredtoapatient(usuallyintravenously).Forbrainimaging,radioactive
iodine(123I)ortechnetium(99mTc)iscombinedwithacompoundthatrapidlycrossestheBBBandlocalizes

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withinbraintissueinproportiontoregionalbloodflow.Therotatinggammacameradetectsgammaraysemitted
bytheradiopharmaceuticalandproducescrosssectionalimagesofthebrainthatarereallyamapofbrain
perfusion(Figure129).SPECTimagingalsogivesindirectinformationaboutbrainmetabolism,because
perfusionisusuallyhighesttopartsofthebrainwithhighmetabolicactivityandlowesttoareaswithlow
metabolicdemand.NormalSPECTexaminationsdemonstrateactivityconcentratedprimarilyinareasofhigh
perfusion/metabolism,suchasthecorticalanddeepgraymatter(Figure129).

Figure129.

AxialSPECTimageofnormalcerebralperfusion.Notethatperfusionisgreatesttograymatterstructures,
includingthecerebralcortex(arrows)anddeepgraynuclei(arrowheads).Whitematterandventriclesarenearly
invisiblebecauseoflowornoperfusion.

SPECTstudiesaremoderatelyexpensive(asmuchasormorethanbrainMRimaging),and,asexpected,they
providelimitedanatomicinformation.SPECTalsoexposespatientstoionizingradiation.Becausepatients
rarelyhaveallergicreactionstotheradiopharmaceuticalsused,theexaminationisoflowrisk.AlthoughSPECT
providescriticalinformationregardingregionalcerebralperfusion,particularlyinthesettingofstroke,this
informationcanbemorereadilyobtainedduringCTA/CTperfusionorMRperfusionacquisitions.SPECThas
alsobeenusedwithvaryingdegreesofsuccessintheworkupofpatientswithepilepsyordementia.

PositronEmissionTomography
PETscansconsistofcomputergeneratedcrosssectionalimagesofthedistributionandlocalconcentrationofa
radiopharmaceutical.ThistechniqueisverysimilartoSPECTimaginghowever,therearedifferencesinthe

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typeofcameraandradiopharmaceuticalsused.PETstudiesuseradiopharmaceuticalslabeledwithacyclotron
producedpositronemitter,whichareveryexpensivetoproduceandhaveaveryshorthalflife(ontheorderof
secondstominutes).Themostwidelyusedradiotraceris18Fdeoxyglucose.PETscanningwiththisagentgives
ameasurementofbrainglucosemetabolism.Areasofhighmetabolicactivity(ie,cerebralcortex,deepgray
nuclei)demonstrategreaterradiopharmaceuticaluptakethandoareasoflowmetabolicactivity,suchaswhite
matterorcerebrospinalfluid(Figure1210).Thebonesoftheskullandscalpsofttissuesare,forthemostpart,
invisible.Otheragentsareusefulinassessingregionalcerebralbloodflow,neuroreceptorfunction,andthelike.

Figure1210.

NormalaxialimageofbrainPETscan.AsintheSPECTstudy(Figure1210),areasofhighactivitycorrespond
tometabolicallyactivegraymatter(arrows),especiallythevisualcortex(arrowheads).

Sincethepreviousedition,PETscanshavebecomemuchmorewidelyavailable,althoughtheyremain
expensive.Theexpense,inlargepart,isrelatedtothecostofimagingequipmentandintheproductionor
deliveryofradiopharmaceuticals.AlthoughpatientsundergoingPETexaminationsareexposedtoionizing
radiation,theoverallrisktothepatientislow.Anatomicresolution,althoughnotasgoodaswithCTorMR
imaging,isbetterthanwithSPECTimaging.ThemajoradvantageofPETimagingisthatitisextremely
versatile,providinginvivoinformationaboutbrainperfusion,glucosemetabolism,receptordensityand,
ultimately,brainfunction.

PETprovidesusefulinformationinthesettingofstroke,epilepsy,dementia,andtumors.Atpresent,thetwo
mainindicationsareintheworkupofpatientswithcomplexpartialseizuresandinidentifyingtumorrecurrence
inpatientswhohaveundergonesurgery,radiationtherapy,orboth,forbraintumors.

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TechniqueSelection
Theprimarygoalofaradiologicexaminationistoprovideusefulinformationfordiseasemanagement.
Radiologicstudiescanprovideadiagnosisorcangiveinformationaboutdiseaseextentorresponsetotreatment.
Inthepresentmedicalclimate,ithasalsobecomeimperativethatradiologicworkupsbeperformedefficiently
andinacosteffectivemanner.Thisrequirementpresentsaproblemforclinicianstryingtodecidewhichtestto
orderinagivenclinicalsituation.

Themajorstrengthsandweaknessesofneuroradiologicexaminationshavebeendiscussedearlierinthischapter.
Thefollowingbriefdiscussionconcernstheappropriateorderingofexaminationsinclinicalsituations.Several
pointsshouldbeemphasized.First,althougharecommendedmodalitymayclearlybesuperiortoanotherin
evaluatingaparticularneurologiccondition,thechoiceofexaminationisnotalwaysobviousbeforethe
diagnosisisestablished.Forexample,inpatientswithnonfocalheadache,MRscansaremoresensitivethanCT
scansfordetectingmostintracranialabnormalities.However,iftheheadacheisproducedbysubarachnoid
hemorrhage,CTwouldbeamuchbetterexaminationthanMRimaging,becausesubarachnoidhemorrhageis
nearlyinvisibleonMRimages.Choiceofexaminationsmayalsobelimitedbywhatislocallyavailable.IfMR
imagingisunavailable,oriftheMRscannerisofpoorqualityortheinterpretingradiologistisinadequately
trainedinMRimageinterpretation,thenCTwouldbeanexcellentexaminationforevaluatingmostneurologic
disorders.

Next,itisimportanttorealizethattheleastexpensiveexaminationisnotalwaysthebestfirstchoice,evenin
thiscostconsciousage.Forexample,mostsuspectedskullfracturesshouldbeevaluatedwithCTscanningand
notwithplainfilms,despitethesignificantcostdifferential,becausewhatisreallyimportantinmanagement
decisionsisnotthefractureitselfbutthepotentialunderlyingbraininjury.Someneurologicdiseasesrequire
multipleradiologicstudiesforaccurateevaluation.Complexpartialseizuresrefractorytomedicalmanagement
frequentlyrequiremultipleexaminationstolocalizetheseizurefocuspriortotemporallobectomy.Sucha
workupnormallyincludesMRimagingandictal/interictalSPECTand/orPETscanningofthebrain,aswellasa
cerebralarteriogramtoidentifycerebraldominance.

Finally,certainexaminationsarecontraindicatedincertainpatients,andanalternativetestmustsuffice.Patients
withferromagneticcerebralaneurysmclipsorpacemakersshouldnotundergoMRimaging.Patientswitha
stronghistoryofallergicreactiontoiodinatedcontrastmediashouldnotroutinelyundergocontrastenhanced
CTscanning,unlesstheyarepretreatedwithantiinflammatoryagents(ie,steroids).MRscanningisfrequently
unsuccessfulinclaustrophobicoruncooperativepatientsunlesstheyaresedated.

CongenitalAnomalies
CongenitalanomaliesofthebrainarebestevaluatedbyMRimaging.MRimagingisthebestexaminationfor
demonstratingintracranialanatomy.Itprovidesexcellentdiscriminationbetweengraymatterandwhitematter,
superbviewsoftheposteriorfossaandcraniocervicaljunction,and,mostimportantly,theabilitytoviewthe
braininanyplane.MRimaginghas,forallpracticalpurposes,completelyreplacedCTforthisindication.The
oneexceptionisinevaluationofosseousstructuresincludingvariouscraniofacialanomaliesandinsuspected
prematurefusionofthecranialsutures.

CraniocerebralTrauma

CTisthepreferredmodalityforstudyingpracticallyallacuteheadinjuries.Examinationtimesareshort,
intracranialhemorrhageiswelldemonstrated,andskullfracturesarereadilyapparent.Unstablepatientscanalso
beeasilymonitored.Intravenousadministrationofcontrastagentsisunnecessaryintheusualtraumasetting.
CTAandoccasionallyMRAareutilizedwithincreasingfrequencytoassessforvascularinjuryassociatedwith
bluntorpenetratingtrauma.CTAistypicallythefirstlineevaluationfordissectionorlaceration,particularly
whenadisplacedfracturecrossesavascularforamenorinthecaseofpenetratingvesselinjury.Occasionally,

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cerebralarteriographyisperformedtolookforcarotidorvertebralarteryinjury,particularlywhenCTAorMRA
areinconclusiveorwhenthereisananticipatedendovasculartreatmentoftheinjuredvessel.

AlthoughMRimagingisnotroutinelyperformedintheacutetraumasetting,itmaysometimesbehelpfulin
patientswithneurologicdeficitsunexplainedbyaheadCTexamination.Forexample,traumaticbrainstem
hemorrhagesareoftendifficulttoseeonCTscansbutareusuallyquiteobviousonMRimages.MRimagingis
alsousefulindemonstratingtinyshearlesionswithinthebrainindiffuseaxonalinjuryandinassessingthebrain
inremoteheadtrauma.

IntracranialHemorrhage
ThebestexaminationtoperforminmostcasesofsuspectedacuteintracranialhemorrhageisaheadCTscan.CT
scanscanbeobtainedquickly,allowingrapidinitiationoftreatment,andtheyareverygoodatdemonstratingall
typesofintracranialhemorrhage,includingsubarachnoidblood.Becausemostnontraumaticsubarachnoid
hemorrhage(SAH)issecondarytoarupturedcerebralaneurysm,CTAisnowperformedroutinelyfollowinga
conventionalheadCTdemonstratingSAH.Inmostcases,theCTAisadequateforaneurysmdetectionand
characterizationpriortosurgicalorendovasculartreatment.MRimagingtakesmuchlongertoperformina
potentiallyunstablepatient,andsubarachnoidhemorrhagemaybedifficulttosee.However,MRimagingis
moreusefulinthesubacuteorchronicsetting,especiallybecauseitgivesinformationaboutwhenahemorrhagic
eventoccurred.Thisinformationmightbeusefulinsuchsettingsasnonaccidentalheadtrauma(eg,child
abuse).MRimagingisalsoverysensitivetopetechialhemorrhagethatfrequentlyaccompaniesacerebral
infarctionandcouldpotentiallyhelptoidentifyanunderlyingcauseforanintracranialhemorrhage(eg,tumor,
arteriovenousmalformation,occludedduralsinus).Cerebralarteriographyisgenerallyreservedwhenthe
etiologyofhemorrhageisnotdiscernablebyCTA/MRA,whenitisnecessarytoevaluatetheflowdynamicsofa
vascularlesionorforplanningendovasculartreatment.

Aneurysms

Althoughcerebralarteriographyhastraditionallybeenconsideredthegoldstandardforcerebralaneurysm
evaluation,CTAhassupplantedcatheterarteriographyasthefirstlineimagingmodalityforaneurysmdetection.
Thecurrentliteraturevariesslightlyhowever,CTAisreportedtohaveexcellentsensitivity(greaterthan95%
foraneurysmsmeasuring4mmorlarger)aswellashighspecificity.Inmostcases,CTAisadequateforsurgical
orendovasculartreatmentplanning.IfCTAfailstoidentifyasuspectedaneurysmfollowingSAH,cerebral
arteriographywilltypicallybeperformed.Cerebralarteriographynotonlyallowsaneurysmidentification,but
alsoprovidesothercriticalpreoperativeinformationsuchasaneurysmorientation,presenceofvasospasm,
locationofadjacentvessels,andcollateralintracranialcirculation.Arteriographyalsohelpstodeterminewhich
aneurysmhasbledwhenmorethanoneaneurysmispresent.Asmentionedpreviously,interventional
neuroradiologistscantreataneurysms,usuallyinnonsurgicalpatients,byplacingthrombosingmaterial(ie,
coils)withintheaneurysmitselfviaanendovascularapproach.

Althoughmostpatientswithsymptomaticcerebralaneurysmspresentwithsubarachnoidhemorrhage,some
aneurysmsactlikeintracranialmasses.ThesesituationsusuallywarrantevaluationbyMRimagingasafirst
examination.Thesameissometimestruewithposteriorcommunicatingarteryaneurysms(whichcanproduce
symptomsrelatedtotheadjacentthirdcranialnerve)orwithaneurysmsarisingfromtheinternalcarotidartery
asitcoursesthroughthecavernoussinus(whichcanaffectanyofthecranialnervesthatliewithinthisstructure,
includingcranialnervesIII,IV,V,orVI).

VascularMalformations
Patientswithavascularmalformation(eg,arteriovenousmalformation,cavernousangioma,venousangioma,or
capillarytelangiectasia)oftenseekmedicalattentionafteranintracranialhemorrhageoraseizure.Inthissetting,
thefirsttestthatshouldbeperformediseitheraCTexamination(tolookforintracranialhemorrhage)orMR
imaging.AlthoughanintracranialhemorrhageisusuallyveryobviousonaCTscan,thevascularmalformation
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itselfmaybedifficult,ifnotimpossible,toseeunlessintravenouscontrastmaterialisadministered.MR
imaging,ontheotherhand,isquitesensitivefordetectingvascularmalformations,whethertheyhavebledor
not.Thechoiceoftheinitialexaminationforevaluationofavascularmalformationcanbedifficult.Usually,
patientsundergononcontrastheadCTscanningtolookforintracranialhemorrhagewhentheycometothe
emergencydepartment.ThisisusuallyfollowedbyCTA,particularlyifanarteriovenousmalformation(AVM)
issuspected.Otherwise,theheadCTisfollowedbygadoliniumenhancedMRimagingtofurthercharacterize
theCTfindings.Ifatruehighflowarteriovenousmalformationissuspected,eitherclinicallyorfromacross
sectionalimagingstudy,thencerebralarteriographyisperformed.Incontrasttocerebralaneurysms,catheter
angiographyisstillperformedroutinelytoevaluateAVMs.Thisisdonebecausecatheterangiographyprovides
detailsofflowdynamicswithintheAVManddemonstratescertainanatomicfeaturesthatarenecessaryto
elucidatepriortoinitiationoftreatment.Asspatialresolutionanddynamicsequencesimprove,CTorMR
angiographymaysomedayreplaceconventionalarteriographyintheworkupoftheselesions,aswith
aneurysms.

Infarction
Today,mostpatientswithsuspectedcerebralinfarctionundergoCTscanningintheacutesetting,eventhough
infarctionsaredemonstratedearlierandaremoreobviousonMRimaging.SowhyisCTusuallyperformed
first?Theansweristhatclinicianswhomanagestrokepatientsarenotsointerestedinseeingtheinfarctitself.
Infarctlocationisusuallysuspectedfromthephysicalexamination,andacuteinfarctsmaynotevenbevisible
onCTscansfor12to24hoursafteronsetofstrokesymptoms.Cliniciansareveryinterested,though,toknowif
astrokeissecondarytosomethingbesidesaninfarct(eg,intracranialhemorrhage,braintumor),orifaninfarct
ishemorrhagic,becausethrombolyticagentswouldbecontraindicatedinthissetting.CTcanquicklyanswer
bothofthesequestions.MRimaging,specificallydiffusionweightedimaging,cansensitivelydetectacute
infarctionsandistypicallyorderedincasesofhighclinicalsuspicion,whentheinitialCTstudyisnondiagnostic
orwhenbrainstemorposteriorfossainfarctsaresuspected.

Theunderlyingcauseofmostcerebralinfarctionsisthromboembolismrelatedtoatherosclerosis.ACT/CTAor
MR/MRA(includingDWandPWMRimaging)studymayprovideapositiveimagingdiagnosisofbrain
infarction,revealtheextentandlocationofvesselocclusion,demonstratethevolumeandseverityofischemic
tissue,andpredictfinalinfarctsizeandclinicalprognosis.CTandMRperfusioncanidentifyareasofcompleted
infarct(ie,infarctcore)andpotentiallysalvageablesurroundingbrainparenchymaatriskofinfarction(ie,
ischemicpenumbra).Ultrasonographyandcerebralarteriographycanalsobeperformedinthesettingofstroke
ortransientischemicattacktoidentifyvascularstenosesorocclusionstheseexaminationsareusuallyreserved
forpatientswhomightbecandidatesforcarotidendarterectomy.Functionalexaminations(SPECTandPET)
havealsobeenusedinpatientswithstrokelikesymptomstoidentifyregionsofthebrainatriskforinfarction.
Thesestudiesarenotwidelyavailableandthereforedonotenterintotheimagingalgorithmformoststroke
patients.

BrainTumorsandTumorLikeConditions

ThebestexaminationtoorderinthesettingofsuspectedbraintumorisacontrastenhancedMRscan.Thisis
trueforprimaryneoplasmsaswellasformetastaticdisease.MRimagingisespeciallyusefulinidentifying
tumorsofthepituitaryregion,brainstem,andposteriorfossa,includingthecerebellopontineangle.

AlthoughMRimagingisthepreferredexaminationforintracranialneoplasms,itisoccasionallysupplemented
byaCTscan,whichcangiveimportantpretreatmentinformationnotprovidedbyMRimages.Forexample,CT
candemonstratetumorcalcification,occasionallyausefulfactorindifferentiatingbetweentypesofneoplasms.
Also,CTisveryusefulinidentifyingbonedestructioninskullbaselesions.

Inmostmedicalcenters,MRimagingisperformedtoassessbraintumorresponsetotreatment.Anatomic
imagingisoftensupplementedwithsometypeofphysiologicimagingincludingMRperfusion,MR
spectroscopy,andPETscanning.PerfusionMRI,MRS,andPETscanningcanfrequentlydifferentiaterecurrent
tumorfrompostradiationtissuenecrosis,whichcanmimictumoronanMRoraCTscan.MRperfusion
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imagingalsoprovidesfunctionalinformationregardingthevasculardensity(ie,neovascularity)ofatumor,
whichmayhelptopredicttumorgradeorhelpguideapotentialbiopsysite.

Today,cerebralarteriographyisrarelyperformedforbraintumorevaluationexcepttomapthebloodsupplyof
veryvasculartumors(ie,juvenileangiofibromas,paragangliomas)preoperatively.Suchlesionscanalsobe
embolizedpriortosurgeryinordertominimizeintraoperativebloodlossbyinjectingvariousmaterialsinto
feedingvesselstooccludethem.

Infection
IntracranialinfectionsarebestevaluatedbycontrastenhancedMRimaging.Abscesses,cerebritis,subdural
empyemas,andotherinfectiousorinflammatoryprocessesareallverywelldemonstrated.MRimagingis
especiallyusefulinassessingpatientswithacquiredimmunodeficiencysyndrome(AIDS).Notonlydoesit
allowidentificationofsecondaryinfections(eg,toxoplasmosis,cryptococcosis,progressivemultifocal
leukoencephalopathy),butitisalsoexquisitelysensitivetothewhitematterchangesproducedbythehuman
immunodeficiencyvirusitself.CTscanningislesssensitivethanMRimaginginthedetectionofintracranial
infectionsandshouldbereservedforpatientsinwhomMRimagingiscontraindicated.Cerebralarteriographyis
onlyusefulinoneparticularsituation,suspectedvasculitis.Involvementofbrainarteriesandarteriolesinthis
conditionrequiresarteriographyfordiagnosticconfirmation.

InheritedandAcquiredMetabolic,WhiteMatter,andNeurodegenerativeDiseases

Aswithsuspectedintracranialinfections,thislargeanddiversegroupofdiseasesisbestevaluatedwithMR
imaging,whichsensitivelydetectswhitematterabnormalities.Infact,oneoftheveryfirstclearindicationsfor
MRimagingwasintheworkupofsuspectedmultiplesclerosis.Althoughbrainabnormalitiesinthese
conditionsmaybequiteobviousonMRimaging,thereisoneproblem:manyoftheseconditionsappearvery
similar,andanexactdiagnosismaynotbepossible.Inpatientswithdementiaandsuspectedneurodegenerative
disease,PETimagingiscurrentlytheprocedureofchoicefordiagnosticevaluation.

SeizureandEpilepsy
Seizureisacommonclinicalindicationforimagingthebrain,particularlyintheemergencysetting.CTisthe
bestmodalitytoscreenformultipleunderlyingcausesofseizureincludinghemorrhage,masslesion,orvascular
malformation.CTisalsoveryusefultoassessforsecondarytraumathatmayoccurduringaseizure.MRIis
oftensubsequentlyperformeddependingonvariousfactorsincludingthepatient'sage,clinicalpresentation,and
typeofseizure,orinthecaseofepilepsy.MRIissuperiortoCTinevaluatingfinecerebralanatomybecauseof
itsexcellentsofttissuecontrastandtheabsenceofbeamhardeningartifact,aswellasitsmultiplanarcapability.
ParticularMRprotocolsareutilizedtodiscriminatethehippocampalstructuresandtodetectotherepileptogenic
foci,includingvariouscorticalmalformations,neoplasms,andvascularmalformations.

Inthecaseofmedicallyrefractoryepilepsy,patientsmaypursuesurgeryformoredefinitivetreatment.During
surgicalplanning,additionalfunctionalimagingperformedincludesictalSPECTandinterictalPET.These
studieshelpconfirmasuspectedepileptogenicfocus,whichdemonstratesincreasedactivityduringor
immediatelyfollowingaseizure(SPECT)versusdecreasedmetabolicactivitybetweenseizures(PET).Cerebral
arteriographyisoftenperformedpriortoepilepsysurgeryinordertoestablishcerebraldominanceby
intracarotidsodiumamytalinjection(Wadatest).Followingcatheterinjectionofamytalintotheinternalcarotid
artery,functionwithinthecorrespondingcerebralhemisphereistemporarilydepressed,allowingfor
neurologicaltestingofmemoryandlanguageinthecontralateralhemisphere.

Exercise121.CongenitalAnomalies
121.InCase121,whatisthemajorabnormality(Figure1211A,B)?

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A.Enlargedventricles

B.Cystintheposteriorfossa

C.Lackofbraincleavageintotwohemispheres

D.Herniationofintracranialcontentsthroughaskulldefect

E.Abnormalmigrationofgraymatter

Figure1211.

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Case121.Sagittal(A)andcoronal(B)T1weightedMRimagingofthebrainina2dayoldmaleinfantwho
presentswithmultiplecraniofacialdeformities,includingmicrocephalyandafleshymassonthebridgeofthe
nose.

122.InCase122,whatistheetiologyofthepatient'sseizures(Figure1212A,B)?

A.Braintumor

B.Graymatterinthewrongplace(ie,heterotopicgraymatter)

C.Congenitalinfection

D.Nodulesalongventriclesinapatientwithtuberoussclerosis

E.Infarctionofperiventricularwhitematter

Figure1212.

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(A,B)Case122.AxialT1andT2weightedMRimagesina15montholdfemaleinfantwhopresentswith
newonsetofseizures.

RadiologicFindings
121.Inthiscase,thecorpuscallosum(curvedarrow)isabsentonthesagittalT1MRimage(Figure1211A).
Alsonoteothermidlineabnormalities,includingabnormaltissueatthebridgeofthenose(largearrow)anda
posteriorcyst(smallarrows).CoronalT1weightedMRimage(Figure1211B)demonstratesamonoventricle
(smallarrows)andthalamicfusion(curvedarrow).Alsonotethelackofseparationofthetwohemispheres
(largearrow)(CisthecorrectanswertoQuestion121).

122.Inthiscase,T1weighted(Figure1212A)andT2weighted(Figure1212B)MRimagesshowabnormal
tissueliningthelateralventricle(arrows).Signalofthistissuefollowsthatofnormalgraymatter(arrowheads)
onbothT1andT2weightedimages(BisthecorrectanswertoQuestion122).

Discussion

TwocommonreasonsforperformingMRscansinyounginfantsareillustratedbythecasesinthissection.
InfantswithcraniofacialanomaliesfrequentlyhaveunderlyingcongenitalmalformationsoftheCNS.Seizures,
too,maybethefirstsignofanunderlyingbrainmalformation.Asdiscussedinthesectionontechnique
selection,wheneveracongenitalbrainanomalyissuspected,MRimagingisthebestexaminationtoperform.

Insultstothedevelopingbrainleadtopredictablealterationsofbrainmorphology.Byanalyzingpatternsof
alteredbrainmorphology,wecanoftendeterminewhichstageofCNSdevelopmenthasbeendisrupted.This
analysis,combinedwithknowledgeofneuroembryology,hasallowedforthedevelopmentofsystemstoclassify
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congenitalanomaliesoftheCNS.Onesimplifiedclassificationsystemdividescongenitalmalformationsinto
disordersoforganogenesis(whichincludeabnormalitiesofneuraltubeclosure,diverticulation/cleavage,
sulcation/cellularmigration,andsize,aswellasdestructivelesionsacquiredinutero),disordersofhistogenesis
(ie,neurocutaneoussyndromes),anddisordersofcytogenesis(ie,congenitalneoplasms).Readersarereferredto
thesuggestedreadingsattheendofthischapterforfurtherinformationonthistopic.

ThepatientinCase121hasalobarholoprosencephaly,aclassicexampleofdisorderedventralinduction.Inthis
condition,thereiscomplete(alobar)orpartial(semilobar,lobar)failureofseparationoftheforebrain
(prosencephalon)intotwohemispheres.Inalobarholoprosencephaly,themostsevereformofthisdisorder,
thereisnoseparationofthetwohemispheresatall.Thethalamiarefused,acentralmonoventricleispresent,
andthereisnocorpuscallosum.Infantswiththisformofholoprosencephalyfrequentlyhaveseverefacial
anomalies.

InCase122,thepatienthasheterotopicgraymatterliningthelateralventricles.Thiscongenitalanomalyisone
typeofdisorderedcellularmigration.Neuronsthatmakeupthegraymatterofthecerebralcortexactually
developalongtheedgesofthelateralandthirdventricleswithinthesocalledgerminalmatrixzone.Theythen
migrateoutwardtotheirfinalcorticallocation.Ifthisnormalneuronalmigrationisdisrupted,anormalcortex
maynotdevelop,andfociofgraymattermaybepresentinabnormallocationsalongthemigrationroute.
Collectionsofthesenormalneuronsinabnormallocationsarecalledgraymatterheterotopias.

Severaldifferenttypesofheterotopiashavebeendescribed.Thecasepresentedinthissectiondemonstratesa
focalnodulargraymatterheterotopiainvolvingthesubependymalregionattheedgeofthelateralventricles.
Seizuresfrequentlyoccurinpatientswiththiscondition,asinthepatientinCase122.BecauseMRimaging
usuallyprovidesanexactdiagnosisofthiscondition,biopsiesofCNStissueareunnecessary.

Incontrasttofocalnodularheterotopias,diffuse(orlaminar)heterotopiasarecommonlyseenwithinoradjacent
tothecortex,whilebandtypeheterotopiasarelocateddeeptothenormalcortex,inasubcorticallocation,
separatedbyathininterfaceofwhitematter(Figure1213).Bandtypeheterotopiasarewelldefined,with
smoothmargins,demonstratingsignalintensitiesidenticaltothoseofnormalgraymatter.Masseffectonthe
underlyingwhitematterordeepgraystructuresmaybeseen,andthesulcationpatternofthebrainsuperficialto
theheterotopiamaybeabnormal.AssociatedCNSanomaliesmaybepresent,suchasagenesisofthecorpus
callosum,holoprosencephaly,orherniationofbraintissue(encephaloceles).Althoughatfirstglancethecortex
mayappeartobemarkedlythickened,closerexaminationwillrevealanadditionalbandofgraymatterina
subcorticallocation,whichmayormaynotdemonstrateincreased18FFDGactivityonaPETscan.Thisband
ofheterotopiaisknowntobeassociatedwithintractableseizures,occurringearlierthaninthefocaltype,aswell
asseveredevelopmentaldelay.

Figure1213.

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(A)PostcontrastcoronalT1weightedimagesofthebrainina32yearoldwithintractableseizures.An
additionalcircumferentialbandofgraymatterisseen(arrows)deeptothenormalgraymatterwithinthe
occipitalregion.Thisfindingwasnotedtobediffuselypresentthroughouttheremainingbrainparenchyma(not
shown).(B)ThecorrespondingPETimageinthesamepatientrevealsincreasedactivityofthebandheterotopia
relativetotheadjacentnormalcortex(arrows),ofunclearsignificance.

SeveraltypesofChiarimalformationswereinitiallydescribedbytheGermanpathologistHansChiari,who
classifiedthesecongenitalhindbrainanomaliesintothreetypes.Ineachcase,abnormaldescentofcerebellar
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tissueintothecervicalcanalisdemonstrated.AChiariImalformationisassociatedwitharelativelysmall
posteriorfossaandanormalsizedcerebellum.Consequently,elongatedpeglikecerebellartonsilsextendbelow
theforamenmagnumwitheffacementofthecorrespondingCSFspaces.Thereisoftendorsaltiltingofthedens,
whichmayindentthebrainstem.ThereisnoassociationbetweenChiariImalformationsandneuraltube
defectshowever,thespineshouldbeimagedbecauseofthecommoncoexistenceofasyrinx.

IncontrasttoChiariI,theChiariIImalformationisveryhighlyassociatedwithmyelomeningoceleand
generallysupratentorialabnormalities.Theposteriorfossaissmallwithherniationofcerebellartonsils,vermis,
andmedullabelowtheforamenmagnum.Becausethecervicalcordissomewhatfixedinpositionbythedentate
ligaments,thisdownwarddisplacementresultsinacharacteristiccervicomedullarykink.Thefourthventricleis
lowlyingandelongatedaswell,withdistortionofthecerebralaqueductandtectum(socalledtectalbeaking),
oftenresultinginhydrocephalus.Thesuperiorcerebellumtowerssuperiorlythroughawidenedtentorium
incisura,withtheremainderofthecerebellumwrappingaroundthebrainstem.Supratentorialabnormalities
includeagenesisorhypoplasiaofthecorpuscallosum,enlargedmassaintermedia,deficiencyofthefalx
resultingininterdigitationofcorticalgyriacrossthemidline,andenlargedoccipitalhorns(colpocephaly)
(Figure1214).ChiariIIImalformationsareassociatedwithoccipitalorhighcervicalencephaloceles,
containingcerebellartissue,withorwithoutbrainstem.

Figure1214.

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UninfusedsagittalT1weighted(A)andcoronalT1postcontrast(B)imagingina30yearoldpatientwitha
ChiariIImalformation.(A)Asmallposteriorfossaispresent,resultingincerebellartonsillarectopia(long
arrow),toweringofthecerebellum(shortarrow),beakingofthetectum(curvedarrow),andcompressionofthe
fourthventricle(arrowhead)withresultinghydrocephalus.Partialagenesisoftherostrumandspleniumofthe
corpuscallosumisnoted.(B)Cerebellartonsillarectopiaintotheforamenmagnumisdemonstrated
(arrowheads).

Disordersofhistogenesisincludetheneurocutaneoussyndromes,whichareaheterogeneousgroupofdisorders
withCNSand,forthemostpart,cutaneousmanifestations.Visceralandconnectivetissueabnormalitiesmaybe
prominent.CommondisorderswithinthisgroupincludeneurofibromatosistypesIandII,tuberoussclerosis,
vonHippelLindaudisease,andSturgeWebersyndrome,wheretheabnormallesionscorrespondingtothese
entitiesareneurogenictumors,tubers,hemangioblastomas,andangiomas,respectively.

Neurofibromatosistype1isthemostcommonofalltheneurocutaneoussyndromes,accountingfor90%ofall
neurofibromatosiscases,andistheonlyentitydiscussedhere.Itistransmittedonthelongarmofchromosome
17andisadiseaseofchildhood.Autosomaldominanttransmissionoccursin50%,andtheremainderappear
sporadicallyasnewmutationsinapatientwithnoknownfamilyhistoryofthedisease.Thediagnosisis
establishedwhentwoormoreofthefollowingcriteriaarepresent:(1)sixormorecafaulaitspots(brownskin
pigmentation),(2)twoormoreLischnodules(hamartomas)oftheiris,(3)twoormoreneurofibromas,(4)one
ormoreplexiformneurofibromas,(5)axillaryfreckling,(6)oneormorebonedysplasias(ie,dysplasiaofthe
greatersphenoidwing),(7)opticnerveglioma,or(8)firstdegreerelativewithneurofibromatosistype1.

Theopticpathwaygliomasaregenerallynonaggressive(lowgrade)pilocyticastrocytomas,whichpresentin
childhoodandmaynotaffectvisionuntilgreatlyincreasedinsize(Figure1215A).Cerebellar,brainstem,and
cerebralastrocytomasmayadditionallybeseen.HighT2signalintensityfocimaybeidentifiedwithinthe

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pedunclesordeepgraymatterofthecerebellum,brainstem,basalganglia(particularlytheglobuspallidus),and
supratentorialwhitematter(Figure1215B).Thenatureoftheselesionsremainsunresolved.

Figure1215.

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NoncontrastparasagittalT1weighted(A)andcoronalT2weighted(B)imagesina4yearoldmalewith
neurofibromatosis.(A)Bulbousenlargementoftheopticchiasmispresent(arrow),suggestinganopticglioma.
(B)FociofincreasedT2signalabnormalityaredemonstratedwithintheglobuspalladi(arrows).

Exercise122.Stroke
123.InCase123,whatisthemostlikelydiagnosis(Figure1216A,B)?

A.Intracranialabscess

B.Arachnoidcyst

C.Metastaticbraintumor

D.Primarybraintumor

E.Cerebralinfarction

Figure1216.

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(A,B)Case123.AxialnoncontrastheadCTimagesina56yearoldmalewithhistoryofhypertensionand
diabeteswhopresentstotheemergencydepartmentwithlefthemiparesis.

124.InCase124,whatisthelikelycauseofthepatient'sproblem(Figure1217A,B)?

A.Brainsteminfarction

B.Brainstemcompressionfromcerebellarinfarction

C.Brainstemtumor

D.Cerebellarastrocytoma

E.Posteriorfossahemorrhage

Figure1217.

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(A,B)Case124.AxialT2weighted(A)andsagittalT1weighted(B)imagesina66yearoldwomanwho
presentswithgradualonsetofnausea,dizziness,andataxia.Thepatientbecamecomatose24hoursafterthe
onsetofsymptoms.

125.InCase125,whatisthemostlikelydiagnosis(Figure1218)?

A.Thalamicglioma

B.Subarachnoidhemorrhage

C.Metastaticdisease

D.Hypertensivehemorrhageinthebasalganglia

E.Cerebralcontusion

Figure1218.

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Case125.AsingleaxialimagefromanoncontrastheadCTina68yearoldfemalepatientuncontrolled
hypertensionwhowasfoundunresponsive.

RadiologicFindings
123.Inthiscase,theaxialCTimage(Figure1216A)demonstratesawelldefinedareaofhypodensity(white
arrows)intherightmiddlecerebralartery(MCA)territory.Thereissecondarymasseffectonthesurrounding
brainparenchymawitheffacementofthecorticalsulci.Inamoreinferioraxialimage(Figure1216B),notethe
brightrightMCA(arrowhead)correspondingtoanacutethrombusinthemaintrunkofthisvessel(Eisthe
correctanswertoQuestion123).

124.Inthiscase,theaxialT2weightedMRimage(Figure1217A)showsareasofincreasedT2signal
(arrows)correspondingtoedemawithinthecerebellum.AsagittalT1weightedimage(Figure1217B)showsa
swollencerebellum,aswellasupwardtranstentorial(arrowhead)anddownwardtonsillar(curvedarrow)
herniationofcerebellartissue.Alsonotecompressionofthebrainstem(smallarrows)andfourthventricle
(asterisk).Thesechangesarecompatiblewitharecentcerebellarinfarctionwithbrainstemcompressioncaused
bytheswollencerebellum(BisthecorrectanswertoQuestion124).

125.Inthiscase,anaxialCTscan(Figure1218)demonstratesalarge,hyperdenseintraparenchymal
hemorrhagecenteredintherightbasalganglia(blackarrow)withsurroundingedemaandmasseffect(double
whitearrows).Intraventricularextensionofhemorrhageispresent(blackarrowheads)withentrapmentofthe
leftlateralventriclesecondarytomidlineshift(singlewhitearrow).Thisismostlikelysecondarytothepatient's
knownhypertension(DisthecorrectanswertoQuestion125).

Discussion
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Strokeisalaytermforneurologicdysfunction.Theusualimageofastrokepatientisthatofanelderly
individualwithhemiparesis,oftenassociatedwithabnormalspeech.Thereareactuallymanydifferentcausesof
stroke.Theseincludecerebralinfarction,intracerebralhemorrhage,subarachnoidhemorrhage,and
miscellaneouscausessuchasduralsinusocclusionwithassociatedvenousinfarction.Althoughtheseconditions
mayhavesimilarclinicalpresentations,theyhavedifferenttreatmentsandprognoses.

Thevastmajorityofstrokesarecerebralinfarctionsassociatedwithatherosclerosis.Theradiologic
manifestationsofcerebralinfarctionvarywithtime.TheheadCTscanofthepatientinCase123wasobtained
severaldaysaftertheonsetofsymptomsandshowstypicalfindingsofasubacuteinfarctinamajorvascular
territory,inthiscase,therightmiddlecerebralarteryregion.Bythistime,theinfarctisaverywelldefinedarea
oflowattenuationcomparedtonormalsurroundingbrain.Thereisassociatedmasseffectfromtheedematous
tissue.Acuteinfarcts(lessthan24hourssinceonsetofsymptoms)maybedifficulttoidentifyonheadCT
scans,ifatall.However,diffusionweightedMRimagingoftendemonstratesbrainabnormalitieswithinhours
ofsymptomonset.SubtlechangesonheadCTscansinacuteinfarctioncansometimesbeseen,butmaybe
overlookediftheexaminationisnotcloselyscrutinized.SometimestheonlyapparentchangeonCTscansisa
subtlelossofgraymatter/whitematterdifferentiationintheareaofinfarction.CTscanningisperformedin
acutecerebralinfarctionbecausescanscanbequicklyobtained,andCTisaverygoodtestforidentifying
intracranialhemorrhage,animportantfindingformanagementconsiderations.Institutionsthatareinvolvedin
theearlymanagementofstrokeoftenhaveastrokeimagingprotocolwherebynoncontrastCTistypically
obtainedalongwithCTangiography(Figure1219A,B)aswellasCTperfusion.Iftheinfarctisnotobvious
ontheinitialCTscan,anMRscanisusuallyobtainedtoverifyhighclinicalsuspicion.

Figure1219.

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CTangiographicimagescorrespondingtoCase123.(A)3Dvascularrenderingdemonstratingoccludedright
superiorMCAbranch(arrow)and(B)axialCTshowinggeneralizedpoorintravascularcontrastopacificationof
therightMCAterritory(whitearrows)relativetotheleft(blackarrows).Subsequentdiffusionweighted(C)
and(D)axialT2MRimagesdemonstratealargewedgeshapedregionofincreasedsignal(arrows)
correspondingtorightMCAinfarct.PostcontrastaxialT1weighted(E)MRimagerevealsintravascular
enhancementovertherightcerebralcortex(arrows),reflectingslowflowofintravascularcontrast.

Anacuteorsubacuteinfarctionwillexhibitadiffusionsignalabnormalitythatreflectstherestrictedmovement
ofwatermoleculesandtypicallypersistsfor1to2weekswithininfarctedtissue(Figure1219C).T2weighted
imagingdemonstratesincreasedsignalwithintheinfarctedterritoryduetothepresenceofcytotoxicedema
(Figure1219D).Intravascularenhancementextendingintothecorticalsulcimaybeseenintheacutetoearly
subacutephaseofinfarct,generallyrelatedtoprolongedintravascularopacificationfromslowvascularflow
(Figure1219E).Withinseveraldaysofacerebralinfarction,parenchymalenhancementiscommonly
identifiedalongthecortex,whichusuallyhasabandlike,tubular,orgyriformappearanceandmaypersistfor
severalweeks.Solidorringenhancingareas,aswellasmoreamorphousappearingpatternsofenhancement,
canoccasionallyoccur.

Case124illustratesanimportantpointtoconsiderwhendecidingwhichtesttoorderinthesettingofacute
stroke.Inthiscase,thepatient'ssymptomswereworrisomeforabrainstemprocess.CTscanningofthe
brainstemandposteriorfossaisfrequentlydegradedbystreakartifactsemanatingfromthedenseboneofthe
skullbase.Subtle(andsometimesnotsosubtle)abnormalitiesmaynotbeapparent.Therefore,formost
neurologicconditionsthatinvolvethebrainstemorposteriorfossa,MRscansaremuchbetteratdepictingan
abnormality.NoticethatthepatientinCase124didnotinfacthaveabrainsteminfarct,aswassuspected
clinically,butratherhadbrainstemcompressionfromalargecerebellarinfarct.

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Case125illustrateshowessentialanimagingexaminationisinmanagingstrokeasthepatientinitiallyhad
signsofcerebralinfarction.TheCTscandemonstratedanobviousbasalgangliahemorrhage,probably
secondarytothepatient'shypertension.Managementofthesetwoconditionsisconsiderablydifferent.
Hypertensionisthemaincauseofnontraumaticintracranialhemorrhage.Inadults,thesehemorrhagestypically
occurintheputamen/externalcapsule.Otherlocationsforhypertensivehemorrhageincludethethalamus,pons,
cerebellum,and,rarely,subcorticalwhitematter.Acuteparenchymalhematomas,asinthiscase,areusually
hyperdenseonCTscans.Withtimetheselesionsbecomedarkerandeventuallyappearasroundorslitlike
cavities.TheMRimagingappearanceofaparenchymalhematomaiscomplexanddependslargelyonthe
presenceofhemoglobinbreakdownproductswithintheclot.

Exercise123.BrainTumors
126.InCase126,whatisthemostlikelydiagnosis(Figure1220AC)?

A.Extraaxialbraintumor

B.Intraaxialbraintumor

C.Frontalcontusion

D.Subduralhematoma

E.Encephalocele

Figure1220.

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Case126.NoncontrastsagittalT1weighted(A)andaxialT2weighted(B)images,aswellaspostcontrastaxial
T1weightedimage(C)ina33yearoldHispanicmanwhopresentswithasyncopalepisodeandinvoluntary
tremors.

127.InCase127,whatisthemostlikelycauseofthepatient'ssymptoms(Figure1221A,B)?

A.Multiplesclerosis

B.Innerearabnormality

C.Intraventricularmeningioma

D.Hematoma

E.Malignantbraintumor

Figure1221.

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A,B.Case127.InitialcoronalT2FLAIRweighted(A)andaxialcontrastenhancedT1weighted(B)imagesin
a48yearoldwomanwhopresentswithahistoryofheadachesandseizures.

128.InCase128,whatisthemostlikelyexplanationforthepatient'smentalstatuschanges(Figure1222A,
B)?

A.Metastaticdisease

B.Intracranialhemorrhage

C.Smallinfarcts

D.Sarcoidosis

E.Arteriovenousmalformation

Figure1222.

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Case128.AcontrastenhancedaxialCTscan(A)andagadoliniumenhancedaxialT1weightedMRimage(B)
ina58yearoldmanwhopresentswithahistoryoflungcancerandmentalstatuschanges.

RadiologicFindings
126.Inthiscase,thesagittalT1weightedimagebeforecontrastadministrationshowsanextraaxial,left
frontalconvexitymass(Figure1220A,arrows).Thishomogenousappearing,smoothlymarginated,mass
(arrows)isisointensetothenormalgraymatter(Figure1220A),andissometimesdifficulttodifferentiate
fromnormalbraintissueonunenhancedT1images.OnT2weightedimaging,themasshasaheterogeneous
appearance,butispredominantlyisointensetograymatter(Figure1220B).Themassiscircumscribedbya
thinrim(pseudocapsule)ofincreasedT2signal(longarrows),aswellasmarginatedbyamoreperipherally
locatedbandofT2signalhyperintensityalongitsmedialandposteriorborders(shortarrows).Thereis
distortionoftheadjacentbrainparenchyma,withcompressionoftheleftlateralventricle,andamildshiftofthe
midlinestructurestotheright.FollowingintravenousGdDTPAadministration,themassenhancesuniformly
(arrows),andduraltailsareidentified(arrowheads),allowingeasyidentification(Figure1220C).These
featuresarefairlytypicalofameningioma(AisthecorrectanswertoQuestion126).

127.Inthiscase,acoronalT2FLAIRweightedMRimage(Figure1221A)demonstratesalargeareaof
signalhyperintensityinvolvingtheinferiorfrontalregions(largewhitearrows)andrighttemporallobe(small
whitearrow),withextensionintothecorpuscallosum(curvedarrows).Ontheinfusedaxialview,atthelevelof
thebodyofthecorpuscallosum(Figure1221B),subtle,illdefinedenhancementispresentwithintheright
cerebralhemisphere(arrowhead)withpatchyenhancement(arrows)extendingintothebodyofthecorpus
callosum.Thisisoneappearanceofamalignantbraintumor,inthiscase,ananaplasticoligodendroglioma(Eis
thecorrectanswertoQuestion127).

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128.Inthiscase,acontrastenhancedaxialCTscanshowsnodefiniteabnormality(Figure1222A).A
gadoliniumenhancedaxialT1weightedMRimageshowsmultipleenhancinglesions(arrows)withinthebrain
parenchyma(Figure1222B).Inapatientwithknownlungcancer,metastaticdiseaseisthemostlikely
explanationformultipleintracranialenhancinglesions(AisthecorrectanswertoQuestion128).

Discussion
Braintumorscanbeclassifiedinavarietyofways.Thetraditionalclassificationofintracranialneoplasmsis
basedonhistology.Inthissystem,braintumorsareeitherprimary(theyarisefromthebrainanditslinings)or
secondary(theyarisefromsomewhereoutsidetheCNS,ie,metastases).Primarytumors,whichaccountfor
approximatelytwothirdsofallbrainneoplasms,canbesubdividedintoglialandnonglialtumors.Secondary
tumors,especiallyfromlungandbreastcancer,accountfortheremainingonethirdofbrainneoplasms.
Metastasesaremostcommonlyparenchymal,butcanalsoinvolvetheskullandmeninges.

Braintumorscanalsobeclassifiedaccordingtopatientageandgeneraltumorlocation(ie,adultorchild,
supratentorialorinfratentorial).Finally,braintumorscanbeclassifiedaccordingtothespecificanatomicregion
involved.Forexample,wecangeneratelistsofbraintumorsthatspecificallyaffectthepinealorthepituitary
regions.

Case126illustratesausefulprincipleforinterpretingstudiesofpatientswithsuspectedbraintumors.Itisvery
importanttofirstdecidewhetheramassiswithinthebrainparenchyma(intraaxial)oroutsidethebrain(extra
axial).Extraaxialmassesusuallyturnouttobemeningiomas,manyofwhichcanberemovedsurgicallywitha
verylowincidenceofrecurrence.Intraaxialmassesfrequentlyturnouttobeastrocytomas,andtheprognosisis
lessfavorable.

ThepatientinCase126hasanextraaxial,duralbased,frontalconvexitymassthatmarkedlyenhanceswith
GdDTPA.Meningiomascomprise15%to20%ofintracranialtumors,predominantlyoccurinfemales,and
exhibitapeakageincidenceof45years.TheyarethemostcommonnonglialprimaryCNStumors.Theycan
occuranywherewithintheheadbuttypicallyoccuralongtheduralvenoussinuses.Theparasagittalregionand
cerebralconvexitiesarethemostcommonlocations.Anteriorbasalorolfactorygroovemeningiomasaccount
for5%to10%ofintracranialmeningiomas.Anosmiaresultsfrominvolvementoftheolfactorytractsbythe
tumor.Theseexpansilelesionsareslowgrowing,andtheensuingmasseffectontheadjacentbrainparenchyma
isgradual.Theabsenceofreactiveedemainasubsetoftheselesionscanbeseenasaresultoftheirslow
growth.Thesemassesusuallydemonstrateintenseanduniformenhancement,independentoftumorsize.A
layerofthickenedduralenhancement(duraltail)iscommonlyseenextendingawayfromthebaseofthe
meningioma.Inmanycases,thisfindingrepresentsreactivethickeningwithouttumorinvolvement.

Case127demonstratesalarge,infiltrating(aggressiveorhighgrade)gliomainvolvingthemajorityoftheright
frontotemporallobe,withextensionintothecorpuscallosum.AlthoughthereissomeoverlapoftheMR
imagingfeaturescharacteristicallyseenwiththeseinvasiveneoplasmsandtheirlessaggressive(lowergrade)
counterparts,theimagingfeaturesofhighergradeneoplasms,onthewhole,aredistinctlydifferentfromthose
seenwithlowergradelesions.Highgradegliomas,namelyanaplasticastrocytomasandoligodendrogliomas(as
inthiscase),aswellasglioblastomamultiforme(themosthighlymalignantglioma),demonstrateheterogeneous
signalcharacteristics,generallyareflectionofthevariablecellularity,inadditiontothepresenceofnecrosis,
hemorrhage,andcysticfoci.Calcificationandhemorrhagearemorecommoninoligodendrogliomas,often
accompaniedbycystformationandnecrosis.ThespectroscopicfindingsofdecreasedNAAandincreased
cholinesuggestdecreasedneuronal/axonaldensityandincreasedbreakdownofcellmembranes(Figure1223
A,B).

Figure1223.

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ThesamepatientasinFigure1221.(A)Atamoreinferiorlevel,thepatchy,heterogeneousenhancementofthis
masswithintherightinferiorfrontal/temporalregionsisbetterappreciated.Aregionofinterestorvolume
element(ie,voxel)wascenteredwithintheenhancingtumorvolume,andanMRspectrumwasobtained.(B)
MRspectrum.TheNAApeakisabnormallydecreased(shortarrowat2.0),andthecholinesignaliselevated
(longarrowat3.2),supportingthediagnosisofamalignantbraintumor.

Oligodendrogliomasaccountforabout5%ofprimarygliomas,occurringmostfrequentlywithinthefrontallobe
andofteninvolvingthecortex.Themajorityofpatientspresentwithseizures.Ontheotherhand,glioblastoma
multiformeisthemostcommonprimarymalignantbrainneoplasmandoccursmostfrequentlyinpatientsover
50yearsofage.Patientswithglioblastomamultiformepresentwithneurologicdeficitsornewonsetseizures.
Theprognosisintheselattercasesisdismalpostoperativesurvivalaverages8months.

OnT2weightedscans,thesehighgrademassesusuallyexhibitheterogeneoussignalcharacteristics,withareas
ofhighT2signalattributabletotumortissue,necrosis,cysts,andreactiveedema,whereasregionsoflowsignal
mayreflecthemorrhageorcalcification.Thecorrespondingtissuepathologyofthisregionoftenshowstumor
cellsresidingwithinandextendingbeyondthesurroundingedema.Enhancementishighlyvariablewithin
anaplasticoligodendrogliomas.Othertypesofmalignantgliomas,suchasglioblastomamultiforme,typically
demonstrateintenseenhancement.Thecorpuscallosumisofteninvolvedbyahighgradeglialtumor,which
maygrowmediallyfromanadjacenthemisphericsourceormayariseindependentlywithinthisstructure.
Wingsmayextendsymmetricallyorasymmetricallyintobothcerebralhemispheres,exhibitingabutterfly
typeappearance(Figure1224),appropriatelytermedbutterflyglioma.Perfusionstudiesonhighgradegliomas
generallyshowincreasedbloodflowandvolume,reflectingtheincreasedvasculardensityandpermeabilityof
thesetumors.Incontrast,lowgradegliomasmayappearonlyasaregionofamorphoussignalabnormality
(mostobviousonT2weightedimages),oftenwithoutassociatedenhancementorperfusionabnormality.

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Figure1224.

A76yearoldwomanpresentswitha6monthhistoryofprogressivegaitataxiaandfrequentfalling.Coronal
contrastenhancedT1weightedMRimageofaglioblastomamultiformeisshown.Anenhancingmass(white
arrows)extendsthroughthecorpuscallosum(blackarrows)intobothhemispheres.

Case128illustratesaveryimportantpointtorememberwhenworkinguppatientswithsuspectedmetastatic
diseasetothebrain:MRimagingisconsiderablymoresensitivethanCTindetectingmetastases.Thisisnota
trivialpoint,becausesurgicalresectionofsingle,notmultiple,brainlesionsissometimesperformed.
Conversely,thesuccessfulapplicationofradiotherapyprotocolsreliesonsensitivelyandaccuratelydetecting
theentiremetastatictumorburden.Metastaticdiseasetothebrainhasavarietyofmanifestations,themost
commonbeingparenchymalinvolvement.Typicalhematogenousbrainmetastasesdemonstratesolidorringlike
enhancementonCTorMRscans,occurneargraymatter/whitematterjunctions,andareusuallysurroundedby
amarkedamountofedema.Theymostcommonlymetastasizefromlungorbreastprimaries.

Exercise124.IntracranialInfections
129.InCase129,whatisthemostlikelydiagnosis(Figure1225A,B)?

A.Frontalcontusion

B.Aneurysmwithintraventricularhemorrhage

C.Parietallobeabscess

D.Intracraniallymphoma

E.Cerebritis

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Figure1225.

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Case129.PostcontrastaxialT1weighted(A)anddiffusionweightedMR(B)imagesina75yearoldmanwho
presentswithahistoryofrecurrentlymphomacomplicatedbymultipleinfectionsandnewmentalstatus
changes.

1210.InCase1210,thelocationoftheabnormalityispathognomonicforwhichtypeofinfection(Figure12
26A,B)?

A.Toxoplasmosis

B.Tuberculosis

C.Cryptococcus

D.Herpes

E.Staphylococcus

Figure1226.

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Case1210.AxialT2(A)andaxialT1postcontrastimages(B)ina42yearoldfemalewhopresentswith
mentalstatuschanges.

1211.InCase1211,themajordifferentialdiagnosisforthislesionistoxoplasmosisversus(Figure1227)

A.Cryptococcus

B.Intracraniallymphoma

C.Sarcoidosis

D.Metastaticdisease

E.Cytomegalovirus(CMV)

Figure1227.

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Case1211.AnaxialcontrastenhancedT1weightedMRimageina43yearoldmanwhopresentswith
headacheandweakness.

RadiologicFindings
129.Inthiscase,thecontrastenhancedMRscanshowsaringenhancinglesion(arrows)intheleftparietal
lobewithdecreasedsurroundingT1signal(Figure1225A).Adiffusionsignalabnormalityispresentonthe
correspondingdiffusionweightedimage(Figure1225B),withinthecentralaspectofthelesion,andisfound
tobecompatiblewithanareaofrestrictedwatermotion.Thepatient'shistoryiscompatiblewithanintracranial
infection,andthedemonstratedMRimagingfindingsfavoranabscess(CisthecorrectanswertoQuestion12
9.)

1210.Inthiscase,theT2weightedMRimage(Figure1226A)showsincreasedsignalinthemedialand
anterioraspectsoftherighttemporallobe(singlearrow)withsmallfocusofT2hypointensity(doublearrows)
consistentwiththepresenceofbloodproducts.PostcontrastaxialT1(Figure1226B)showsabnormalpatchy
parenchymalandleptomeningealenhancementalongthemedialrighttemporallobe.Thesechangesare
commonlyseeninpatientswithherpesencephalitis(DisthecorrectanswertoQuestion1210).

1211.Inthiscase,multipleenhancinglesionsarepresentwithinthebasalganglia,especiallyontheright
(arrows),onthegadoliniumenhancedT1weightedMRimage(Figure1227).Themostcommonlesionswith
thisappearanceinanimmunocompromisedpatient,suchasapatientwithHIV,aretoxoplasmosisand
intracraniallymphoma(BisthecorrectanswertoQuestion1211).Thepatientmarkedlyimprovedafteranti
toxoplasmosistherapy,andthelesionsshownontheMRimagedisappeared.

Discussion
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Ahostofinfectiousdiseasescaninvolvethebrainanditscoverings.BecausetheCNShasalimitednumberof
waysofrespondingtoaninfectiousagent,manyintracranialinfectionsappearidenticalonneuroimaging
studies.Itis,therefore,veryimportanttocloselycorrelatetheimagingfindingswiththeclinicalpresentation
andotherdiagnostictests,suchaslumbarpunctureorstereotacticbrainaspiration.

Forourpurposes,itisusefultoclassifyCNSinfectionsaccordingtotheintracranialcompartmentinvolved,
especiallybecausethishastreatmentimplications.Intracranialinfectionscanbeeitherparenchymalor
extraparenchymal.Parenchymalmanifestationsincludecerebritis/abscessandencephalitis.Extraparenchymal
diseaseincludesepiduralabscess,subduralempyema,andleptomeningitis.Bacterial,viral,fungal,andparasitic
agentscanallaffecttheCNS.Althoughafewinfectiousagentspreferentiallyinvolveaparticularanatomic
compartmentoftheCNS,mostarenotsitespecific.

Case129demonstratestheclassicringenhancinglesionofanabscess,inthiscase,duetoNocardia.No
specificfeaturesofthisabscessdistinguishitfromatypicalpyogenicabscess.Thediffusionsignalabnormality
hasbeenpostulatedtoarisefromrestrictedwatermotioninthepresenceofviscous,purulentmaterialwithinthe
abscesscavityandcanmimicanareaofacuteischemia.CerebralinfectionbyNocardiausuallyarisesfroma
pulmonaryfocusinanimmunocompromisedhost.Similarly,mostpyogenicabscessesaretheresultof
hematogenousdisseminationfromanonCNSsource.Pyogenicbrainabscessescanalsoresultfromdirect
extensionofaninfectiousprocessfromanadjacentarea(eg,sinusitisormastoiditis)orfromtrauma(eg,
penetratingwoundorsurgery).

Abscessesusuallyoccuratgraymatter/whitematterjunctions,althoughtheycanoccuranywhereinthebrain.
Patientsfrequentlypresentwithseizuresorsymptomsrelatedtointracranialmasseffect.Ifabscessesdevelop
nearthebrainsurface,theymayruptureintothesubarachnoidspace,producingmeningitistheymayalso
produceaventriculitisiftheyruptureintotheventricularsystem.Mostabscessesaretreatedsurgically.

Herpesencephalitis(Case1210)iscausedbytheherpessimplexvirus(HSV).Olderchildrenandadultsare
usuallyinfectedbyHSV1,eitherprimarilyorasaresultofreactivationofalatentvirus.Theensuing
necrotizingencephalitisinthisconditiontypicallyinvolvesthetemporalandinferiorfrontallobes,insular
cortex,andcingulategyrus.Focalabnormalitiesofattenuation(onCT)orsignal(onMR)inthesecharacteristic
locations,oftenwithenhancementaftercontrastadministration,arepracticallypathognomonicofHSV1
encephalitis.Earlydiagnosisofthisconditionisextremelyimportant,becauseantiviraltherapycansignificantly
affectpatientoutcome.

Neonatalherpessimplexinfectiondiffersfrominfectionintheolderchildandadult.Theoffendingorganismis
usuallyHSV2,whichmaybeacquiredinuteroorduringbirthfrommotherswithgenitalherpes.HSV2
infectioncanproduceseveredestructivechangeswithinthedevelopingbrain.UnlikeHSV1infectioninolder
childrenandadults,neonatalherpesencephalitiscaninvolveanyareaofthebrain,havingnopredilectionforthe
temporallobe.

PatientswithAIDS(Case1211)commonlydevelopintracranialinfectionsduringthecourseoftheirdisease.
Humanimmunodeficiencyvirus(HIV)itselfcandirectlyinfecttheCNS,producingencephalopathyinupto
60%ofAIDSpatients.ThemostcommonneuroimagingfindinginHIVencephalopathyiscerebralatrophy,
oftenwithpatchywhitematterhypodensity(onCT)orT2hyperintensity(onMRimaging)fromdemyelination
andgliosis(Figure1228).OthercommonCNSinfectionsintheimmunocompromisedAIDSpatientinclude
toxoplasmosis,cryptococcosis,andprogressivemultifocalleukoencephalopathy(fromapolyomavirus
infection).

Figure1228.

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An8yearoldgirlwithAIDSandnewonsetofseizures.AxialT2weightedimageshowswhitematterhigh
signal(arrows).Alsonotethediffuseprominenceofgyriandsulci(arrowheads)andsylvianfissures(asterisks),
compatiblewithcerebralatrophy.

Toxoplasmosisusuallypresentsasmultiplelesionsofvaryingsizeanddemonstratesringenhancementwith
surroundingedemaonCTorMRimaging.Lesionscommonlyoccurinthebasalgangliaoratthegray
matter/whitematterjunctionwithinthecerebralhemispheres.Individualmassesmayhaveasolidappearanceor
demonstratecentralnecrosisorhemorrhage.Theenhancementpatternisvariablebothrimenhancingandmore
solidlyenhancinglesionscanbeseen.Theirappearanceisalmostidenticaltothatofprimaryintracranial
lymphoma,anothercommonintracranialconditioninAIDS.Metabolicstudies,suchasPETorSPECTscans
(noincreasein18FFDGactivitywithtoxoplasmosis,increasedwithlymphoma),MRspectroscopy(nocholine
elevationintoxoplasmosis,elevatedinlymphoma),andperfusionweightedsequences(lowercerebralblood
volumeintoxoplasmosis)mayassistindistinguishingthesepathologies.

MeningitisisthemostfrequentmanifestationofcryptococcosisinAIDS,althoughparenchymallesions,termed
cryptococcomas,areoccasionallyencountered.Inprogressivemultifocalleukoencephalopathy,extensiveareas
ofwhitematterdemyelinationareshownonMRimaging.Anumberofotherintracranialinfectionscanoccurin
AIDSpatients,andthereaderisreferredtothesuggestedreadingsattheendofthischapterforsourcesof
furtherinformation.

Exercise125.HeadTrauma
1212.InCase1212,whatisthediagnosis(Figure1229A,B)?

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A.Subduralhematoma

B.Cerebralcontusion

C.Epiduralhematoma

D.Meningioma

E.Subduralhygroma

Figure1229.

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Case1212.AxialnoncontrastheadCTwithsofttissue(A)andbonewindows(B)inan18yearoldmalewho
isfoundunconsciousfollowingamotorvehiclecollision.

1213.InCase1213,whatisthemainradiologicfinding(Figure1230)?

A.Subduralhematoma

B.Epiduralhematoma

C.Durethemorrhage

D.Cerebralcontusions

E.Shearinginjuries

Figure1230.

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Case1213.AxialnoncontrastheadCTimageina24yearoldmanwhopresentswithmultiplefacialfractures
andfrontalscalpsofttissueswellingresultingfromamotorvehicleaccident.

RadiologicFindings
1212.Inthiscase,apredominantlyhighdensity,extraaxial,hemorrhagiccollection(blackarrows)is
producingmasseffectontherightfrontallobeonanunenhancedheadCTscan(Figure1229A).Masseffect
resultsinmarkeddistortionoftheunderlyingcortexandleftwardsubfalcineherniation(whitearrow)(Figure
1229A).Alinearnondepressedfractureispresentalongtheanterioraspectoftherightparietalbone(black
arrow)(Figure1229B).Thebiconvexappearanceofthislesionistypicalofanepiduralhematoma,whichis
theacutefindinginthiscase(CisthecorrectanswertoQuestion1212).

1213.Inthiscase,therearemultipleareasofincreasedattenuationwithinthefrontallobes,especiallyonthe
left(arrows)(Figure1230).Theseareascorrespondtomultiplehemorrhagiccontusionsinvolvingthebrain
parenchyma(DisthecorrectanswertoQuestion1213).

Discussion

Intracranialabnormalitiesinheadtraumacanbeclassifiedaseitherprimaryorsecondary.Primarylesionsoccur
atthemomentofinjuryandincludeskullfractures,extracerebralhemorrhage(eg,epiduralorsubdural
hematomas,subarachnoidhemorrhage),andintracerebralhemorrhage(eg,braincontusion,brainsteminjury,
diffuseaxonalinjury).

Thesecondaryeffectsofheadtraumaareactuallycomplicationsoftheprimaryintracranialinjury.Elevated
intracranialpressureandcerebralherniationareresponsibleformostofthesecondaryeffectsofheadtrauma,
whichinmanycasesmaybemoredevastatingtothepatientsthantheinitialinjury.

Epiduralhematomaisusuallyassociatedwithskullfracturesthatlaceratethemiddlemeningealarteryoradural
sinus.Uptoonehalfofpatientswithepiduralhematomashavealucidintervalaftertheheadtraumaoccurs.On
CT,epiduralhematomasusuallyappearasbiconvex,highattenuation,extraaxialmasses.Mostarelocatedin
thetemporoparietalarea.Underlyingskullfracturesarecommon.Intracranialbrainherniationmayalsobea
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prominentfeatureinthiscondition.Oneimportantimagingfeatureinepiduralhematomasisthattheydonot
crossskullsutures,butmaycrossthemidline.

Subduralhematoma,ontheotherhand,isusuallyacrescentshapedextraaxialcollectionthatmaycrosssuture
lines,butisconfinedbytheduralreflections(Figure1231).Theselesionsaremorelethalthanareepidural
hematomasthesubduralhematomamortalityrateisover50%.CTcanusually,butnotalways,distinguish
betweenepiduralhematomasandsubduralhematomas.Subduralhematomasareacommonlyidentified
abnormalityintheabusedchild(nonaccidentaltrauma).CTscansareobtainedtodetectthepresenceofsubdural
hematomas(Figure1232).AbrainMRI,however,canmoresensitivelydelineatesmallextraaxialhematomas,
subduralhematomasofvaryingages,andcoexistingcorticalcontusionsorshearinginjuries.Ashearinginjury
(ordiffuseaxonalinjury)isassociatedwithanoverallpoorprognosisandisrecognizedassmallpetechial
hemorrhagesatthegraywhitejunctionandinthecorpuscallosum.Interhemispheric(paraandintrafalcial)
subduralhematomasmayarisefromtearingofbridgingveinsalongthefalxcerebriinshakinginjuriesandare
nearlypathognomicfornonaccidentaltrauma.Retinalhemorrhagesmaybepresentandarealsosuspicious,
especiallyifbilateral.Inaddition,cerebralischemia/infarctionandmultiple,complex,unexplainedskull
fracturesmaybeassociatedfindings.

Figure1231.

AxialnoncontrastheadCTobtainedona67yearoldmaleafterafall.Alarge,crescentichyperdenseextraaxial
hemorrhagelayersovertheleftcerebralconvexity(blackarrow)andextendsalongtheposteriorfalx(black
arrowhead).Secondarymasseffectontheadjacentbrainparenchymawitheffacementoftheleftlateralventricle
andrightwardshiftofthemidlinestructures(whitearrowhead).

Figure1232.
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NoncontrastaxialCTimages(A,B)ina21dayoldmalefollowingnonaccidentaltrauma.Large,bilateral
subduralhematomaslayeroverthetentoriumcerebelliin(A)(closedarrows)andwithintheinterhemispheric
fissurein(B)(arrow).Inaddition,asmallamountofsubarachnoidhemorrhageisseenwithinthequadrigeminal
platecisternin(A)(openarrows),aswellaswithintheleftlateralventricle(notshown).Lossofthenormal
cerebralgraywhitedifferentiationisdemonstrated.Thesefeaturesarenearlypathognomonicfornonaccidental
traumawithdiffuseanoxicinsult.

Cerebralcontusions(Case1213)arethesecondmostcommonformofbrainparenchymalinjuryinprimary
headtrauma(diffuseaxonalinjuryisthemostcommonparenchymalinjury).Cerebralcontusionscanbethought
ofasbrainbruises.Theyresulteitherfromthebrainstrikingabonyridgeinsidetheskullduringrapid
acceleration/deceleration,asoccursinamotorvehicleaccident,orfromadepressedskullfracture.Theselesions
tendtooccurinparticularanatomiclocations,especiallytheundersurfacesandpolesofthefrontalandtemporal
lobes(Figure1233).CTscansshowareasoflowattenuation(edema)andhemorrhageatthesiteofinjury.
Delayedhemorrhage,1to2daysafteraheadinjury,iscommonwithcontusions.

Figure1233.

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AxialnoncontrastheadCTfollowingahighspeedmotorvehiclecollision.Acutehemorrhageinmultiple
intracranialcompartmentsisahallmarkoftrauma.Hemorrhagiccontusionsaredemonstratedintheinferior
bifrontallobes(largeblackarrows),subarachnoidhemorrhagesintheinterpeduncularcistern(whitearrow)and
Sylvianfissure(doublewhitearrows),subduralhemorrhagealongthetentorialincisura(doubleblackarrows),
andepiduralhemorrhagecrossingtherighttentorium(blackarrowhead),aswellasalargescalphematoma
(whitearrowhead).

Exercise126.IntracranialVascularAbnormalities
1214.InCase1214,whatisthereasonfortheabnormalityontheCTscan(Figure1234AC)?

A.Cerebralaneurysm

B.Arteriovenousmalformation

C.Headtrauma

D.Carotiddissection

E.Vasculitis

Figure1234.

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Case1214.AxialnoncontrastCT(A),axialobliqueCTangiographicimages(B),andcatheterangiogram(C)
ina41yearoldmalewhoisfoundunresponsivewhileatworkaftercomplainingofaheadacheearlier.

1215.InCase1215,whatisthereasonfortheabnormalityontheCTscan(Figure1235AC)?

A.Cerebralaneurysm

B.Arteriovenousmalformation

C.Headtrauma

D.Carotiddissection

E.Vasculitis

Figure1235.

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Case1215.AxialnoncontrastCT(A)andT2weightedMRI(B)andcatheterangiogram(C)ina22yearold
malewhocomplainsofpersistentrightsidedheadache.

RadiologicFindings
1214.Inthiscase,theCTscan(Figure1234A)showsextensivesubarachnoidhemorrhagefillingthebasal
cisterns,morepronouncedontheright(blackarrows),withextensionofhemorrhageintotheinterhemispheric
andSylvianfissures.Enlargementofthetemporalhorns(whitearrows)isindicativeofearlyhydrocephalus.An
obliquecraniocaudalviewfromaCTangiogram(Figure1234B)showsa4mmsaccularaneurysmarising
fromtherightparaclinoidinternalcarotidartery(arrow),mostlikelyposteriorcommunicatingarteryorigin.A
lateralviewtakenfromarightcommoncarotidcatheterangiogram(Figure1234C)confirmsaposterior
communicatingarteryoriginaneurysm(blackarrow)withupwarddistortionofthenormalanteriorcerebral
arteryconfigurationsecondarytohydrocephalus(blackarrowheads).(AisthecorrectanswertoQuestion12
14.)

1215.Inthiscase,thenoncontrastCTscan(Figure1235A)showsalobulated,hyperdensemass(black
arrows)centeredinthemedialrightoccipitallobewitheffacementoftherightoccipitalhorn.Accompanying
axialT2MRI(Figure1235B)revealsanidusoflowsignalvascularflowvoids(whitearrowheads)inthe
occipitallobewithamoreprominentdrainingveinextendingintothequadrigeminalplatecistern(whitearrow).
Asubsequentcatheterangiogram(Figure1235C)oftherightvertebralartery(curvedarrow)confirmsahigh
flowvascularlesionwithatangleofvessels(doubleblackarrows)andearlyvenousopacification(arrowhead)
characteristicofanarteriovenousmalformation.(BisthecorrectanswertoQuestion1215.)

Discussion
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Cerebrovasculardisorders(strokes)werediscussedinExercise122,whichdealtmainlywithcerebralinfarction
secondarytoatherosclerosis.Forinformationonothercausesofcerebralinfarction,thereaderisreferredtothe
suggestedreadingsattheendofthischapter.Thissectionaddressestwoothercommonvascularconditions
affectingtheCNS:aneurysmsandvascularmalformations.

Mostcerebralaneurysms,suchasCase1214,aresaccularorberryaneurysms.Thesefocalarterialdilatations
tendtooccuratcerebralarterialbranchpoints.Theyhavetraditionallybeenthoughttodevelopatcongenitally
weakareasofabloodvesselwall.Recentevidence,however,hasquestionedthisview,andmanynowbelieve
thatsaccularaneurysmsareprobablyacquiredlesionsfromabnormalhemodynamicstressesthatdamagethe
arterialwall.

Intracranialaneurysmsareusuallyasymptomaticuntiltheyrupture,atwhichtimethepatienttypicallypresents
withasevereheadacheresultingfromsubarachnoidhemorrhage.ThevastmajorityofnontraumaticSAHsoccur
asaresultofaneurysmrupture.CTisverygoodatdemonstratingSAH.PatientsusuallyundergoCT
angiographywhenevernontraumaticSAHisdetected,andoccasionallycerebralarteriography.

Commonlocationsforintracranialaneurysmsincludetheanteriorcommunicatingartery,theinternalcarotid
arteryattheoriginoftheposteriorcommunicatingartery,andthemiddlecerebralarterytrifurcation.Posterior
fossaaneurysmsarelesscommontheymakeuponlyaround10%ofallintracranialaneurysmsandtypically
arisefromthebasilararterytip.

Vascularmalformationscanbedividedintofourmajortypes:truearteriovenousmalformations(asdemonstrated
inCase1215),cavernoushemangiomas,venousangiomas,andcapillarytelangiectasias.AVMsarecongenital
lesionsconsistingofatangleofabnormalbloodvessels,usuallywithinthebrainparenchyma,thatarefedby
enlargedcerebralarteriesanddrainedbydilated,tortuousveins.Becausethereisnonormalinterveningbrain
parenchymaforthebloodtoflowthrough,bloodisrapidlyshuntedfromthearterialtothevenousside.This
shuntingisdramaticallydemonstratedoncerebralarteriography.PatientswithAVMsusuallypresentwith
intracranialhemorrhageorseizures.MRimagingorcontrastenhancedCTcandemonstratethetortuous
vascularchannelsofmostAVMs,althoughcerebralarteriographyisthedefinitivestudyinthiscondition.

TheotherintracranialvascularmalformationshaveverycharacteristicappearancesonMRimaging,although
theyarefrequentlyinvisibleoncerebralarteriography.Patientswiththeselowpressuremalformationscan
presentwithheadaches,seizures,or,rarely,intracranialhemorrhage.Manyoftheselesions,however,are
incidentallydiscoveredonMRscansperformedforotherreasons.

Exercise127.WhiteMatterDiseases
1216.InCase1216,whatisthemostlikelydiagnosis(Figure1236A,B)?

A.Pseudotumorcerebri

B.Metastaticdisease

C.Septicemboli

D.Radiationnecrosis

E.Multiplesclerosis

Figure1236.

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A,B.Case1216.T1weightedparasagittal(A)andaxialT2FLAIRimages(B)ina48yearoldfemalewho
presentswithahistoryofweaknessandvisualchanges.

1217.InCase1217,whatismostlikelyresponsiblefortheabnormalitiesseenontheMRimage(Figure1237
A,B)?

A.Cardiacarrhythmia

B.Chronichypertension

C.Remotetrauma

D.Hepaticfailure

E.Carbonmonoxidepoisoning

Figure1237.

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A,B.Case1217.AxialT2(A)andcoronalT2FLAIRsequences(B)inan83yearoldfemalewhohasa
historyofhypertension,diabetesandworseningdementia.

RadiologicFindings
1216.Inthiscase,sagittalT1weightedandaxialFLAIRMRimages(Figure1236A,B)showmultiplefociof
abnormalsignalwithintheperiventricularwhitematter(arrows).Theselesionsarequitecharacteristicof
multiplesclerosis(EisthecorrectanswertoQuestion1216).Thepatient'svisualdifficultieswereduetooptic
neuritis,acommonabnormalityinmultiplesclerosis.

1217.Inthiscase,therearepatchyareasofincreasedT2signal(arrows)withintheperiventricularwhitematter
(Figure1237).Usuallyseeninelderlyhypertensivepatients,theselesionscorrespondtofocalareasof
demyelinationsecondarytodeepwhitematterischemia(BisthecorrectanswertoQuestion1217).

Discussion

Diseasesthatprimarilyaffectthecerebralwhitematterhaveahostofcauses.Unfortunately,veryfewofthese
conditionshavespecificappearancesonCTorMRscans.Neuroimagingisusuallyperformedtodetermine
whethertherearechangeswithinthebrainthatarecompatiblewithoneofthewhitematterdiseasesandtorule
outotherconditionsthatmightmimicwhitematterdisease.

Whitematterdiseasesincludebothinheritedandacquiredconditions.Theycanbefurthersubdividedinto
demyelinatingconditions(destructionorinjuryofnormallyformedmyelin)anddysmyelinatingconditions
(abnormalformationormaintenanceofmyelin,usuallybecauseofanenzymedeficiency).Thedysmyelinating
conditionsarerareand,forthemostpart,includetheleukodystrophies,suchasadrenoleukodystrophyand
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metachromaticleukodystrophy.AlthoughtheMRappearancecanbestrikinginsomeofthesediseases,itis
oftennonspecific.Theseconditionsarenotdiscussedhere.

Multiplesclerosis(MS)(Case1216)isthemostcommondemyelinatingdisease.Becausethereisnogenerally
acceptedetiologyforMS,itisalsoreferredtoasaprimarydemyelinatingdisease.Secondarydemyelinating
conditionsarethosecausedbyaknownagentorevent.MSusuallyoccursinyoungadultsandmoreoftenin
womenthanmen(approximately2:1).Thediseaseischaracterizedbyarelapsingandremittingcourseandby
varyingneurologicsymptoms,dependingonthelocationofthelesionwithintheCNS.Althoughdiagnosisof
MSisusuallybasedonclinicalcriteria,MRimagingcanbeaveryhelpfulconfirmatorytest.TypicalMS
plaquesappearasovoid,T2signalhyperintensitieswithintheperiventricularanddeepwhitematter.Lesionsare
alsocommonwithinthecorpuscallosum,brainstem,cerebellarpeduncles,spinalcord,andopticnerves.MS
plaqueenhancementongadoliniuminfusedMRimagessuggestsactivedisease(ie,breakdownoftheBBB).
ConfluentareasofT2signalabnormalityintheperiventricularwhitematterarecommoninseverecases.

Ischemicdemyelination(Case1217)isusuallyseeninpatientswithsmallvesseldisease(suchasfromlong
standinghypertension).Thiscondition,alsocalledleukoaraiosis(whitemattersoftening),occursbecauseof
hypertensioninducedarteriolarsclerosisofpenetratingmedullaryarteriesthatsupplythedeepwhitematterof
thebrain.Thisleadstoareductioninwhitematterbloodflowwithaccompanyingischemicdemyelination.This
conditionoccursmostcommonlyinolderpatientsandisassociatedwithsmallvesselbraininfarcts(lacunar
infarcts).MRimagingusuallydemonstratespatchyareasofincreasedT2signalinthedeepwhitematter.The
lesionsareoftenbilaterallysymmetricandperiventricularindistribution.

Exercise128.SeizureandEpilepsy
1218.InCase1218,whatisthemostlikelydiagnosis(Figure1238AC)?

A.Alzheimer'sdementia

B.Graymatterheterotopia

C.Hemimegalencephaly

D.Mesialtemporalsclerosis

E.Multiplesclerosis

Figure1238.

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Case1218.Coronalfastmultiplanarinversionrecovery(FMPIR)MRI(A),axialictalSPECT(B).andcoronal
interictalPETimages(C)ina34yearoldfemalewithalongstandinghistoryofmedicalrefractoryepilepsy
whopresentswithincreasingseizurefrequency.

RadiologicFindings
1218.CoronalFMPIRMRI(Figure1238A)demonstratesmarkedatrophyofthelefthippocampuswithloss
ofnormallaminararchitecture(whitearrowhead).IctalSPECT(Figure1238B)showsincreasedradiotracer
uptakeintheleftmedialtemporallobe(doublearrows),whereastheinterictalPET(Figure1238C)
demonstratesdiminishedmetabolicactivityinthelefttemporallobe(blackarrow).Theconstellationoffindings
ishighlysuggestiveofmesialtemporalsclerosis(DisthecorrectanswertoQuestion1218).Pronounced
cerebellaratrophy(Figure1238A)inthiscaseistheresultoflongstandingantiepilepticmedication(white
arrows).

Discussion

Althoughacomprehensivereviewofseizureandepilepsyclassificationisbeyondthescopeofthissection,itis
importanttonotethecentralrolethatimagingservesintheevaluationandmanagementofthesepatients.The
etiologyofseizurevariessignificantlywithpatientage.Inyoungchildren(3monthsto5years),feveristhe
mostcommonprecipitantofseizure.Theexactpathophysiologyisnotfullyunderstoodhowever,thereislikely
arelationshiptoaninflammatorycascadeaswellasalowseizurethresholdinyoungchildren.Imagingis
generallynotperformedinthesettingofasimplefebrileseizure(seizuresthatlastlessthan15minutes,are
generalized,anddonotrecurina24hourperiod).Febrileseizuresthatdonotmeetthesecriteriaareclassified
ascomplexandimplyamoreseriousunderlyingabnormalityincludingmeningitis,abscess,orencephalitis,for

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whichimagingmaybeindicated.Otherpotentialcausesofseizureinyoungchildrenincludecerebralanoxia,
metabolicabnormalities,corticalmalformations(refertoCase122),infection,orinheritedneurocutaneous
diseasessuchastuberoussclerosis.

Inolderchildrenandadults,commoncausesofseizureincludevascularmalformations,cerebralinjurydueto
priortraumaorischemia,orunderlyingtumor,amongothers.Noteworthytumorsassociatedwithintractable
seizureincludeganglioglioma,dysembryoplasticneuroepithelialtumor(DNET),andpleomorphic
xanthoastrocytomathesegenerallyoccurinchildhoodorinyoungadulthood.

Themostcommoncauseofmedicallyrefractoryepilepsyismesialtemporal(hippocampal)sclerosis.Although
thisentityismostcommonlyseeninadultpatients,thereislikelyalinktofebrileseizuresearlierinchildhood
orotherremotecerebralinsultsuchastraumaorinfection.OnMRimaging,thereischaracteristicatrophyand
gliosisofthehippocampus,oftenwithdilationoftheipsilateraltemporalhornduetovolumeloss.Theremaybe
atrophyandgliosisofipsilateralfornixandmammillarybodyaswell.Thesepatientsarepotentialcandidatesfor
temporallobectomy,andadditionalimagingwithictalSPECTandinterictalPETisgenerallyperformedas
describedearlier.

SuggestedReading
1.AtlasSW.MagneticResonanceImagingoftheBrainandSpine.4thed.Philadelphia:LippincottWilliams&
Wilkins2009.
2.GrossmanRI,YousemDM.Neuroradiology:TheRequisites.2nded.St.Louis,Mo:Mosby2003.
3.YockDH.MagneticResonanceImagingofCNSDisease.St.Louis,Mo:Mosby2002.
4.BarkovichAJ.PediatricNeuroimaging.4thed.Philadelphia:LippincottWilliams&Wilkins2005.
5.CullenSP,SymonsSP,HunterG,etal.Dynamiccontrastenhancedcomputedtomographyofacuteischemic
stroke:CTAandCTperfusion.SeminRoentgenol.200237:192205.[PubMed:12226898]
6.AksoyFG,LevMH.Dynamiccontrastenhancedbrainperfusionimaging:techniqueandclinical
applications.SeminUltrasoundCTMRI.200021:462467.[PubMed:11138635]
7.PhilipsCD,BubashLA.CTAandMRAintheevaluationofextracranialcarotidvasculardisease.RadiolClin
NorthAm.200240:783798.
8.LiuH,HallWA,MartinAJ,MaxwellRE,TruwitCL.MRguidedandMRmonitoredneurosurgical
proceduresat1.5T.JComputAssistTomogr.200024:909918.[PubMed:11105712]
9.McKinneyAM,PalmerCS,TruwitCL,KaragulleA,TeksamM.Detectionofaneurysmsby64section
multidetectorCTangiographyinpatientsacutelysuspectedofhavinganintracranialaneurysmandcomparison
withdigitalsubtractionand3Drotationalangiography.AmJNeuroradiol.200829:594602.[PubMed:
18065510]

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AccessProvidedby:PelitaHarapanUniversity

Silverchair

NormalaxialheadCTimages.Appropriatewindowselectionallowsvisualizationofbothintracranialcontents
(A)andbonycalvarium(B).Notedifferencesinattenuationamonggraymatter(leftthalamus,doubleblack
arrows),rightinternalcapsule(singleblackarrow),cerebrospinalfluid(CSFfrontalhornoftheleftlateral
ventricle,whitearrow),andbone(skull,arrowheads).

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NormalCTangiogramwith3Dvolumerendering.Imageisorientedslightlyobliquewiththesuperior
calvariumcutaway.Majorvesselsdemonstratedincludetheanteriorcerebralartery(ACA),middlecerebral
artery(MCA),basilarartery(BA),andposteriorcerebralartery(PCA).

Streakartifacts(arrows)commonlyobscureportionsofthebrainstem,posteriorfossa,andtemporallobeson
routineheadCTscans.

NormalheadMRimages.SagittalT1weighted(A),axialT1weighted(B),andaxialT2weighted(C)images.
Notedifferencesinsignalbetweengraymatter(largearrows),whitematter(curvedarrows),CSF(small
arrowheads),fat(smallarrows),andcorticalbone(largearrowheads)ondifferentpulsesequences.Normal
structuresincludethegenu(g)andspleniurn(s)ofthecorpuscallosum(cc),fornix(f),opticchiasm(oc),
pituitarygland(pit),midbrain(mb),pons(p),medulla(m),cerebellarvermis(Cb),straightsinus(SS),caudate
head(c),putamen(pt),andthalamus(T).

MRimagesofanewlydiagnosedhighgradeglioma.(A)AxialpostcontrastT1imageshowsaperipherally
enhancing,centrallynecroticmassintherightfrontallobe(blackarrow)aswellassurroundinghypointenseT1
signalconsistentwithvasogenicedema(whitearrow).(B)Cerebralbloodflowimage(pulsedarterialspin
labelingtechnique)showsincreasedperfusion(arrow)alongtheperipheralaspectofthemass.

FunctionalMRimageforpreoperativeplanningrevealslefthandmotoractivation(largearrows)adjacentto,
butseparatefromtherightfrontallobemassandsurroundingedema(smallarrow).

Normalcerebralarteriogram.(A)Lateralviewofthecervicalcarotidartery.Catheterislocatedwithinthe
commoncarotidartery,andcontrastmaterialfillsinternal(arrows)andexternal(arrowheads)carotidarteries.
(B)Lateralviewoftheheadafterinjectionofthecarotidartery(arrow).Noteanteriorcerebral(A),ophthalmic
(O),posteriorcommunicating(PC),andmiddlecerebral(M)branches.

Coronal(A)andsagittal(B)headultrasoundofaneonate.Normalstructuresincludethecorpuscallosum(CC),
lateralventricle(LV),cavumseptumpellucidum(CS),sylvianfissure(SF),thirdventricle(3V),fourthventricle
(4V),temporallobe(TL),frontallobe(FR),occipitallobe(OCC),cerebellum(CER),andthalamus(TH).

AxialSPECTimageofnormalcerebralperfusion.Notethatperfusionisgreatesttograymatterstructures,
includingthecerebralcortex(arrows)anddeepgraynuclei(arrowheads).Whitematterandventriclesarenearly
invisiblebecauseoflowornoperfusion.

NormalaxialimageofbrainPETscan.AsintheSPECTstudy(Figure1210),areasofhighactivitycorrespond
tometabolicallyactivegraymatter(arrows),especiallythevisualcortex(arrowheads).

Case121.Sagittal(A)andcoronal(B)T1weightedMRimagingofthebrainina2dayoldmaleinfantwho
presentswithmultiplecraniofacialdeformities,includingmicrocephalyandafleshymassonthebridgeofthe
nose.

(A,B)Case122.AxialT1andT2weightedMRimagesina15montholdfemaleinfantwhopresentswith
newonsetofseizures.

(A)PostcontrastcoronalT1weightedimagesofthebrainina32yearoldwithintractableseizures.An
additionalcircumferentialbandofgraymatterisseen(arrows)deeptothenormalgraymatterwithinthe
occipitalregion.Thisfindingwasnotedtobediffuselypresentthroughouttheremainingbrainparenchyma(not
shown).(B)ThecorrespondingPETimageinthesamepatientrevealsincreasedactivityofthebandheterotopia
relativetotheadjacentnormalcortex(arrows),ofunclearsignificance.

UninfusedsagittalT1weighted(A)andcoronalT1postcontrast(B)imagingina30yearoldpatientwitha
ChiariIImalformation.(A)Asmallposteriorfossaispresent,resultingincerebellartonsillarectopia(long
arrow),toweringofthecerebellum(shortarrow),beakingofthetectum(curvedarrow),andcompressionofthe
fourthventricle(arrowhead)withresultinghydrocephalus.Partialagenesisoftherostrumandspleniumofthe
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corpuscallosumisnoted.(B)Cerebellartonsillarectopiaintotheforamenmagnumisdemonstrated
(arrowheads).

NoncontrastparasagittalT1weighted(A)andcoronalT2weighted(B)imagesina4yearoldmalewith
neurofibromatosis.(A)Bulbousenlargementoftheopticchiasmispresent(arrow),suggestinganopticglioma.
(B)FociofincreasedT2signalabnormalityaredemonstratedwithintheglobuspalladi(arrows).

(A,B)Case123.AxialnoncontrastheadCTimagesina56yearoldmalewithhistoryofhypertensionand
diabeteswhopresentstotheemergencydepartmentwithlefthemiparesis.

(A,B)Case124.AxialT2weighted(A)andsagittalT1weighted(B)imagesina66yearoldwomanwho
presentswithgradualonsetofnausea,dizziness,andataxia.Thepatientbecamecomatose24hoursafterthe
onsetofsymptoms.

Case125.AsingleaxialimagefromanoncontrastheadCTina68yearoldfemalepatientuncontrolled
hypertensionwhowasfoundunresponsive.

CTangiographicimagescorrespondingtoCase123.(A)3Dvascularrenderingdemonstratingoccludedright
superiorMCAbranch(arrow)and(B)axialCTshowinggeneralizedpoorintravascularcontrastopacificationof
therightMCAterritory(whitearrows)relativetotheleft(blackarrows).Subsequentdiffusionweighted(C)
and(D)axialT2MRimagesdemonstratealargewedgeshapedregionofincreasedsignal(arrows)
correspondingtorightMCAinfarct.PostcontrastaxialT1weighted(E)MRimagerevealsintravascular
enhancementovertherightcerebralcortex(arrows),reflectingslowflowofintravascularcontrast.

Case126.NoncontrastsagittalT1weighted(A)andaxialT2weighted(B)images,aswellaspostcontrastaxial
T1weightedimage(C)ina33yearoldHispanicmanwhopresentswithasyncopalepisodeandinvoluntary
tremors.

A,B.Case127.InitialcoronalT2FLAIRweighted(A)andaxialcontrastenhancedT1weighted(B)imagesin
a48yearoldwomanwhopresentswithahistoryofheadachesandseizures.

Case128.AcontrastenhancedaxialCTscan(A)andagadoliniumenhancedaxialT1weightedMRimage(B)
ina58yearoldmanwhopresentswithahistoryoflungcancerandmentalstatuschanges.

ThesamepatientasinFigure1221.(A)Atamoreinferiorlevel,thepatchy,heterogeneousenhancementofthis
masswithintherightinferiorfrontal/temporalregionsisbetterappreciated.Aregionofinterestorvolume
element(ie,voxel)wascenteredwithintheenhancingtumorvolume,andanMRspectrumwasobtained.(B)
MRspectrum.TheNAApeakisabnormallydecreased(shortarrowat2.0),andthecholinesignaliselevated
(longarrowat3.2),supportingthediagnosisofamalignantbraintumor.

A76yearoldwomanpresentswitha6monthhistoryofprogressivegaitataxiaandfrequentfalling.Coronal
contrastenhancedT1weightedMRimageofaglioblastomamultiformeisshown.Anenhancingmass(white
arrows)extendsthroughthecorpuscallosum(blackarrows)intobothhemispheres.

Case129.PostcontrastaxialT1weighted(A)anddiffusionweightedMR(B)imagesina75yearoldmanwho
presentswithahistoryofrecurrentlymphomacomplicatedbymultipleinfectionsandnewmentalstatus
changes.

Case1210.AxialT2(A)andaxialT1postcontrastimages(B)ina42yearoldfemalewhopresentswith
mentalstatuschanges.

Case1211.AnaxialcontrastenhancedT1weightedMRimageina43yearoldmanwhopresentswith
headacheandweakness.

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An8yearoldgirlwithAIDSandnewonsetofseizures.AxialT2weightedimageshowswhitematterhigh
signal(arrows).Alsonotethediffuseprominenceofgyriandsulci(arrowheads)andsylvianfissures(asterisks),
compatiblewithcerebralatrophy.

Case1212.AxialnoncontrastheadCTwithsofttissue(A)andbonewindows(B)inan18yearoldmalewho
isfoundunconsciousfollowingamotorvehiclecollision.

Case1213.AxialnoncontrastheadCTimageina24yearoldmanwhopresentswithmultiplefacialfractures
andfrontalscalpsofttissueswellingresultingfromamotorvehicleaccident.

AxialnoncontrastheadCTobtainedona67yearoldmaleafterafall.Alarge,crescentichyperdenseextraaxial
hemorrhagelayersovertheleftcerebralconvexity(blackarrow)andextendsalongtheposteriorfalx(black
arrowhead).Secondarymasseffectontheadjacentbrainparenchymawitheffacementoftheleftlateralventricle
andrightwardshiftofthemidlinestructures(whitearrowhead).

NoncontrastaxialCTimages(A,B)ina21dayoldmalefollowingnonaccidentaltrauma.Large,bilateral
subduralhematomaslayeroverthetentoriumcerebelliin(A)(closedarrows)andwithintheinterhemispheric
fissurein(B)(arrow).Inaddition,asmallamountofsubarachnoidhemorrhageisseenwithinthequadrigeminal
platecisternin(A)(openarrows),aswellaswithintheleftlateralventricle(notshown).Lossofthenormal
cerebralgraywhitedifferentiationisdemonstrated.Thesefeaturesarenearlypathognomonicfornonaccidental
traumawithdiffuseanoxicinsult.

AxialnoncontrastheadCTfollowingahighspeedmotorvehiclecollision.Acutehemorrhageinmultiple
intracranialcompartmentsisahallmarkoftrauma.Hemorrhagiccontusionsaredemonstratedintheinferior
bifrontallobes(largeblackarrows),subarachnoidhemorrhagesintheinterpeduncularcistern(whitearrow)and
Sylvianfissure(doublewhitearrows),subduralhemorrhagealongthetentorialincisura(doubleblackarrows),
andepiduralhemorrhagecrossingtherighttentorium(blackarrowhead),aswellasalargescalphematoma
(whitearrowhead).

Case1214.AxialnoncontrastCT(A),axialobliqueCTangiographicimages(B),andcatheterangiogram(C)
ina41yearoldmalewhoisfoundunresponsivewhileatworkaftercomplainingofaheadacheearlier.

Case1215.AxialnoncontrastCT(A)andT2weightedMRI(B)andcatheterangiogram(C)ina22yearold
malewhocomplainsofpersistentrightsidedheadache.

A,B.Case1216.T1weightedparasagittal(A)andaxialT2FLAIRimages(B)ina48yearoldfemalewho
presentswithahistoryofweaknessandvisualchanges.

A,B.Case1217.AxialT2(A)andcoronalT2FLAIRsequences(B)inan83yearoldfemalewhohasa
historyofhypertension,diabetesandworseningdementia.

Case1218.Coronalfastmultiplanarinversionrecovery(FMPIR)MRI(A),axialictalSPECT(B).andcoronal
interictalPETimages(C)ina34yearoldfemalewithalongstandinghistoryofmedicalrefractoryepilepsy
whopresentswithincreasingseizurefrequency.

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