NEURODIAGNOSTICS II:

NEURORADIOLOGY
 OBJECTIVES
• To discuss the current neuroimaging options in
the diagnosis of the diseases
 CURRENT NEUROIMAGING
OPTIONS
Proton MR Spectroscopy
• distribution of brain metabolites based upon the
chemical shift of the protons within them, which is
a property determined by the chemical
environment of the protons in question
 3 Most Interesting Normal Metabolites
1. choline, which is a marker for cell membranes and
hence a marker for cellular turnover
2. N -acetyl aspartate (NAA), which is a compound
found only in neurons and therefore a marker of
neuronal density
3. creatine, which is evenly distributed in many types
of cells and serves as a reference standard
• Lactate and lipids are markers of anaerobic
metabolic metabolism and necrosis
PICTURE OF Proton MR Spectroscopy

• Normal
• Abnormal
 CT Angiography
• CTA depends upon the bolus injection of iodinated
contrast
• rapid imaging with a multidetector spiral CT
• data post processing to produce clinically useful
images of the cerebral vessels.
Two major classes of images are produced with these
studies
• relatively thick cross-sectional images
• maximum intensity projection (MIP) and shaded
three-dimensional surface renderings
 CT angiography of the cerebral arteries
• CT angiography of the cerebral arteries (also
known as a CTA carotids or an arch to vertex
angiogram) is a noninvasive technique allows
visualization of the internal & external carotid
arteries & vertebral arteries & can include just
the intracranial compartment or also extend
down to the arch of the aorta
 Preparation for a CTA of the Coronary
Arteries?

• patient should not eat for 4 hours prior to their

scheduled appointment and should not drink or
eat caffeinated products for 12 hours prior to
their appointment
• patient should not exercise on the day of the
exam
 Indications
• CTA of the cerebral arteries is indicated in a wide
variety of clinical scenarios including:
• Ischemic stroke to detect occlusion & thrombosis
• TIA to detect carotid artery stenosis
• SAH for detection of aneurysms
• cerebral parenchymal hemorrhage to assess for the
presence of a vascular malformation or ongoing
bleeding (spot sign)
Contraindications
• previous severe reactions to iodinated contrast
• non-compliance
 Contraindications
• previous severe reactions to radiographic contrast
agents, & uncooperative or pregnant patients
• usual precautions for the use of intravenous
contrast agents also apply
• vessels adjacent to metal prostheses, such as joint
replacements, are not well visualized because of CT
artifacts
CT angiography (CTA)
 MRA
• Magnetic resonance angiography (usually
shortened to MR angiography or MRA) is an
alternative to conventional angiography &
CT angiography, eliminating the need for ionizing
radiation & iodinated contrast media, &
sometimes contrast media altogether
• it has evolved into several techniques with different
advantages and applications:
• Contrast enhanced MR angiography (MRA)
• Non-contrast enhanced MR angiography (MRA)
 Indications
• identify abnormalities, such as aneurysms, in the aorta,
both in the chest and abdomen, or in other arteries
• detect atherosclerotic (plaque) disease in the carotid
artery of the neck, which may limit blood flow to the brain
& cause a stroke
• identify a small aneurysm or arteriovenous malformation
(AVM)—an abnormal connection between blood vessels—
inside the brain or elsewhere
• detect plaque disease that has narrowed the arteries to
the legs and help prepare for endovascular intervention or
surgery
• detect disease in the arteries to the kidneys or visualize
blood flow to help prepare for a kidney transplant or stent
placement.
 Indications
• detect injury to one or more arteries in the neck, chest, abdomen,
pelvis or limbs after trauma
• evaluate arteries feeding a tumor prior to surgery or other
procedures such as chemoembolization or selective internal radiation
therapy
• Identify dissection or splitting in the aorta in the chest or abdomen or
its major branches
• show the extent & severity of coronary artery disease and its effects
& plan for an intervention, such as a coronary bypass & stenting
• examine pulmonary arteries in the lungs to detect pulmonary
embolism (blood clots, such as those traveling from leg veins) or
pulmonary AVMs
• look at congenital abnormalities in blood vessels, especially arteries
in children (e.g., malformations in the heart or other blood vessels
due to congenital heart disease).
• evaluate stenosis & obstructions of vessels
• screen individuals for arterial disease, especially patients with a
family history of it
Stroke
 Diffusion-Weighted Imaging
• enhanced the ability of MRI to diagnose cerebral
infarct early & accurately
• this technique exploits the phenomenon of
diffusion, which is related to Brownian motion at
the molecular level
DWI
 Diffusion Tensor Imaging (DTI)
• diffusion phenomenon has also been exploited in
MRI to map white matter tracts for surgical
treatment planning & other purposes

• Diffusion Tensor Imaging (DTI) is an MRI-based

neuroimaging technique which makes it possible to
estimate the location, orientation, & anisotropy of
the brain's white matter tracts
 Diffusion tensor imaging (DTI)
• is an MRI technique that uses anisotropic diffusion
to estimate the axonal (white matter) organization
of the brain

Fiber tractography (FT)

• is a 3D reconstruction technique to assess neural
tracts using data collected by diffusion tensor
imaging
 Clinical applications
• diffusion tensor imaging is synonymous with MR imaging of
the CNS
Applications
• assessment of the deformation of white matter by tumors -
deviation, infiltration, destruction of white matter
• delineation of the anatomy of immature brains
• pre-surgical planning
• Alzheimer Disease- detection of early disease
• Schizophrenia
• Focal cortical dysplasia
• Multiple sclerosis- plaque assessment
• early identification of musculoskeletal & peripheral nerve
pathology
 Comparison of conventional T1- (A) and T2- (B) weighted images, and DTI-derived
mean diffusivity (MD) (C), fractional anisotropy (FA) (D), and color-coded orientation
(E) maps
 Functional MR Imaging (FMRI)
• studies of the brain using blood oxygen level–
dependent imaging (BOLD)
• measures brain activity by detecting changes
associated with blood flow
• this technique relies on the fact that cerebral blood
flow & neuronal activation are coupled
• when an area of the brain is in use, blood flow to
that region also increases
 Functional MR Imaging (FMRI)
• by comparing images captured during sensory
stimulation, motor activity, or higher cortical tasks
with those obtained while the patient is in a resting
or control condition, one can create images
highlighting the area or areas of the brain that are
responsible for the brain function in question
 Positron emission tomography (PET)
• modern non-invasive imaging technique for
quantification of radioactivity in vivo
• it involves the intravenous injection of a positron-
emitting radiopharmaceutical, waiting to allow for
systemic distribution, & then scanning for
detection and quantification of patterns of
radiopharmaceutical accumulation in the body
 Procedure
• fasting for 4-6 hours
• blood glucose level <150 mg/dL
• avoid strenuous activity 24 hours prior to imaging
• avoid speech 20 minutes prior to imaging
• scan is carried out 60 minutes post-injection of FDG
• in cases of fusion imaging such as PET-CT, the whole
body CT scan is conducted first, followed by the
whole-body PET scan and subsequently the two sets
of images are co-registered
• A standard uptake value (SUV) is calculated at the end
of the study i.e. ratio of activity per unit mass tissue to
injected dose per unit body mass
 Limitations
• motion artifacts result in an inaccurate anatomical
coregistration of the CT and PET studies
• distance (2-3 mm) the positron travels before
annihilation and the detector element size both
contribute to relatively poor spatial resolution
• physiological muscle uptake usually appears
symmetrically and diffusely on PET imaging
 Normal physiological uptake
• brain
• Waldeyer ring, e.g. palatine tonsils symmetrically
especially when younger
• skeletal muscle, especially after strenuous activity
and laryngeal muscles following speech
• myocardium
• gastrointestinal tract, e.g. intestinal wall
• genitourinary tract: FDG is excreted via the renal
system and passes into the collecting systems
• Brown fat
• thymus
• Bone marrow
• lactating breasts
 False-positive FDG uptake
This may occur due to the following conditions:
• granulomatous disease
• abscess
• surgical changes
• foreign body reaction e.g. talk pleurodosis
• excessive bowel uptake with metformin therapy
• inflammation (although at times e.g. evaluating for
vasculitis, this may be the finding of interest)
• Fat necrosis
 Applications
• oncologic
– detection, staging, response to treatment
– differentiation between radiation necrosis and
recurrence
• neurologic
– early diagnosis of Alzheimer disease
– localization of seizure focus in interictal phase
– localizing eloquent areas (e.g. speech, motor function)
• cardiac
– identification of hibernating myocardium
infection/inflammation
– Pyrexia of unknown origin
– vasculitis
Positron emission tomography (PET)
 REFERENCES AND SUPPLEMENTARY
MATERIALS

BOOK
William E. Brant and Clyde A. Helmes, 2012,
Fundamentals of Diagnostic Radiology 5thEdition
• https://b-ok.cc/book/3679051/3d16cd
 REFERENCES AND SUPPLEMENTARY
MATERIALS
Online Supplementary Reading Materials
BASIC APPROACH TO HEAD CT INTERPRETATION
• https://www.brighamandwomens.org/assets/BWH/ra
diology/pdfs/basic-approach-to-evaluating-a-
headct.pdf
Diffusion Tensor Imaging (DTI) Explained
• https://www.news-medical.net/health/Diffusion-
Tensor-Imaging-(DTI)-Explained.aspx
CT Angiography (CTA)
• https://www.radiologyinfo.org/en/info.cfm?pg=angio
ct
 REFERENCES AND SUPPLEMENTARY
MATERIALS
VIDEOS
What’s the Difference Between an MRI and a CT?
• https://www.youtube.com/watch?v=aQZ8tTZnQ8A&t=34s
Head CT Interpretation Made Easy
• https://www.youtube.com/watch?v=4OJIDkG9yTM
MRA (magnetic resonance angiogram) head radiology search
pattern
• https://www.youtube.com/watch?v=NKTVKRMfONU
2-Minute Neuroscience: Neuroimaging
• https://www.youtube.com/watch?v=N2apCx1rlIQ
END