INTRODUCTION TO

BRAIN IMAGING

Michael S. Gordon
Center for Research in Medical Education

MILLER SCHOOL OF MEDICINE

UNIVERSITY OF MIAMI
 INTRODUCTION TO BRAIN IMAGING:
OBJECTIVES
• Distinguish normal and abnormal CT & MRI scans of the brain and
identify mass lesion, ischemia, and hemorrhage;
• Identify neurologic structures on brain CT & MRI scans, including:
– Brainstem (medulla, pons, and midbrain) and cerebellum
– CSF structures: all 4 ventricles, Sylvian aqueduct, quadrigeminal plate
cistern, perimesencephalic cistern, suprasellar cistern, Sylvian fissure,
interhemispheric fissure
– Deep white matter: corpus callosum, internal capsule, corona radiata,
and centrum semiovale
– Subcortical gray matter: thalamus, lentiform nucleus (globus pallidus
and putamen), caudate nucleus
– Cortex: frontal, parietal, temporal, and occipital lobes; insula
– Arteries: circle of Willis and arterial branches (middle cerebral, anterior
cerebral, posterior cerebral arteries)

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CT BRAIN MENU
Click on the box to go the designated image To MRI menu

BASICS ANATOMY PATHOLOGY

Introduction Anatomy 1 Intracerebral hemorrhage
White Things Anatomy 2 Subarachnoid hemorrhage
Acute infarct
Black Things Anatomy 3
Subacute infarct
Gray Things Anatomy 4
Arterial territories
Axial view Anatomy 5 Arterial pattern 1
orientation Anatomy 6 Arterial pattern 2
Anatomy 7 Arterial pattern 3
Arterial pattern 4
Anatomy 8
Arterial pattern 5
Anatomy 9
Mass lesion noncontrast
Mass lesion contrast
Subdural hematoma

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COMPUTED TOMOGRAPHY
(CT) SCAN OF THE BRAIN: To CT menu

INTRODUCTION To MRI menu

• Detects acute blood, major cerebral structures

• Optimal test for suspected:
– head trauma
– acute stroke
– cerebral herniation
• Fair sensitivity for parenchymal disease
• Bony artifact interferes w/ visualization of:
– posterior fossa (brainstem, cerebellum)
– inferior temporal lobes

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 THINGS THAT ARE WHITE To CT menu

(HYPERDENSE) ON A CT SCAN To MRI menu

ocular lens bone contrast (dye)

calcifications acute blood metal (bullets w/

streak artifact)

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THINGS THAT ARE BLACK To CT menu

(HYPODENSE) ON A CT SCAN To MRI menu

fat

air

CSF = water

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 THINGS THAT ARE GRAY To CT menu

(ISODENSE) ON A CT SCAN To MRI menu

Note that white

matter is less dense than
gray matter and therefore:
white matter is darker than
gray matter

Gray matter (cerebral cortex)

Gray matter (basal ganglia)

White matter

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CT SCAN OF THE BRAIN: To CT menu

AXIAL VIEW IS MOST COMMON To MRI menu

Anterior

Right Left

Posterior
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BRAIN CT: ANATOMY 1 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Nose
Eye
Sphenoid bone
Temporal lobe
Clivus
Petrous bone
Mastoid air cells
Pons
Cerebellum

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 BRAIN CT: ANATOMY 2 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Eye Sella turcica

Optic nerve Dorsum sellae
Lateral rectus Petrous bone
Medial rectus Mastoid air cells
Sphenoid bone Pons
Temporal lobe Brachium pontis
4th ventricle
Cerebellum

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 BRAIN CT: ANATOMY 3 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Frontal sinus
Orbit
Frontal lobe
Sylvian fissure
Carotid artery
Temporal lobe
Suprasellar cistern
Perimesencephalic cistern
Midbrain
Quadrigeminal plate cistern
Cerebellum

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 BRAIN CT: ANATOMY 4 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Frontal lobe
Interhemispheric fissure
Sylvian fissure
Middle cerebral artery
Temporal lobe
Lateral ventricle (temporal horn)
Posterior cerebral artery
Suprasellar cistern
Perimesencephalic cistern
Interpeduncular cistern
Midbrain
Quadrigeminal plate cistern
Cerebellum (vermis)
Occipital lobe

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 BRAIN CT: ANATOMY 5 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Frontal lobe
Interhemispheric fissure
Sylvian fissure
Third ventricle
Temporal lobe
Lateral ventricle (temporal horn)
Sylvian aqueduct
Cerebellum (vermis)
Occipital lobe
Falx

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BRAIN CT: ANATOMY 6 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Frontal lobe
Lateral ventricle (frontal horn)
Caudate nucleus (head)
Sylvian fissure
Insula (cortex)
External capsule
Lentiform nucleus
Internal capsule (post. Limb)
Thalamus
Temporal lobe
Pineal gland (calcified)
Lateral ventricle (atrium)
Choroid plexus (calcified)
Occipital lobe

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 BRAIN CT: ANATOMY 7 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Frontal lobe
Interhemispheric fissure
Corpus callosum (genu)
Caudate nucleus (head)
Lateral ventricle (body)
Thalamus/choroid plexus
Corona radiata (white matter)
Parietal lobe
Occipital lobe
Falx

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 BRAIN CT: ANATOMY 8 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Frontal lobe
Interhemispheric fissure
Corpus callosum (genu)
Caudate nucleus (body)
Lateral ventricle (body)
Corona radiata (white matter)
Parietal lobe
Falx

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 BRAIN CT: ANATOMY 9 To CT menu

Click on label to make arrow appear and disappear To MRI menu

Frontal lobe
Interhemispheric fissure and falx
Centrum semiovale (white matter)
Parietal lobe

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NONCONTRAST CT SCAN: To CT menu
INTRACEREBRAL HEMORRHAGE
Click on box to make description appear and disappear To MRI menu

Description

Acute blood is white

(hyperdense)
and is within the brain
parenchyma—in this
case, the right thalamus

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NONCONTRAST CT SCAN: To CT menu
SUBARACHNOID HEMORRHAGE
Click on box to make description appear and disappear To MRI menu

Description

Acute blood is white

(hyperdense) around
the brain in the
subarachnoid space,
in this case in the:
basal cisterns &
4th ventricle

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 NONCONTRAST CT SCAN: To CT menu
ACUTE CEREBRAL INFARCTION (4 HOURS)
Click on box to make description appear and disappear To MRI menu

Normal
gray-white Large, acute
junction MCA-territory
(distinct
infarction with:
ribbon of
cortical 1) blurring of
gray matter) gray-white
junction &
2) sulcal
effacement
Normal
sulcus

R Description L Description

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 NONCONTRAST CT SCAN: To CT menu
SUBACUTE CEREBRAL INFARCTION (4 DAYS)
Click on box to make description appear and disappear To MRI menu

Subacute infarction is
dark (hypodense)
with mass effect
(note: this is cytotoxic edema,
Normal occurring 2-5 days after
lateral ischemia & affecting both
ventricle gray and white matter)

Compressed
lateral
ventricle

R Description L Description

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CT SCAN OF THE BRAIN To CT menu

ARTERIAL TERRITORIES To MRI menu

ACA
MCA

AChA
PCA
Middle cerebral artery Posterior cerebral artery
Anterior cerebral artery Anterior choroidal artery

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CT SCAN OF THE BRAIN
To CT menu
ARTERIAL PATTERN 1
Click on box to make description appear and disappear To MRI menu

Medial cortex
Description

Subacute infarction in proximal ACA territory

involving medial cortex (frontal); proximal ACA
occlusions involve the frontal lobe +/- parietal lobe;
more-distal ACA occlusions involve only parietal lobe

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CT SCAN OF THE BRAIN
To CT menu
ARTERIAL PATTERN 2
Click on box to make description appear and disappear To MRI menu

Description Subcortex

Lateral
Cortex

Subacute infarction in distal MCA territory

involving cortex and sparing subcortex;
this pattern is often due to distal MCA
occlusion by a cardioembolus

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CT SCAN OF THE BRAIN
To CT menu
ARTERIAL PATTERN 3
Click on box to make description appear and disappear To MRI menu

Description

Thalamus

Occipital lobe

Subacute infarction in proximal PCA territory

involving both thalamus and occipital lobe;
note that a distal PCA occlusion spares the thalamus

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CT SCAN OF THE BRAIN
To CT menu
ARTERIAL PATTERN 4
Click on box to make description appear and disappear To MRI menu

Description R L ACA-MCA
watershed

PCA-MCA
watershed

Infarctions in watershed territories (arrows);

in this case, L > R (with concurrent left LMCA infarction
outlined in red) due to hypotension in patient
with LICA occlusion and RICA stenosis

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 CT SCAN OF THE BRAIN
To CT menu
ARTERIAL PATTERN 5
Click on box to make description appear and disappear To MRI menu

Description

Subcortex

Infarction in lenticulostriate (MCA perforator) territory

in subcortical white matter, in this case, corona radiata; small-artery
infarctions may be due to small-artery disease or any embolic
source, including large-artery or cardiac sources

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NONCONTRAST CT SCAN: To CT menu
MASS LESION (TOXOPLASMOSIS ABSCESS)
Click on label to make arrow(s) appear and disappear To MRI menu

Abscess (vague ring)

Mass effect (compressed ventricle)

Mass effect (R-to-L shift

= subfalcine herniation)

Vasogenic edema
(due to mass lesions, e.g., abscess,
tumor; represents blood-brain barrier
disruption; involves only white matter)

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CONTRAST CT SCAN: To CT menu
MASS LESION (TOXOPLASMOSIS ABSCESS)
Click on label to make arrow appear and disappear To MRI menu

Abscess (ring enhancement)

Note that the mass lesion is

more clearly defined
(called “ring enhancement”).
Enhancement with contrast
is due to leakage of dye
around the lesion
and occurs as a result of
blood-brain barrier disruption.

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NONCONTRAST CT SCAN: To CT menu
SUBACUTE/CHRONIC SUBDURAL HEMATOMA
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SDH chronic component

SDH subacute component

Subdural hematomas (SDHs) layer

concave to the brain like a crescent.
Although acute blood is white,
subacute blood (days to wks) is gray
& chronic blood (wks to mos) is black.
Since subacute SDHs are isodense
with brain parenchyma, they may be
hard to detect: look for sulcal
effacement & cerebral cortex that is
buckled and does not
extend to the skull.

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MRI BRAIN MENU To CT menu

Click on the box to go the designated image

Introduction
3 MRI Categories
T1-weighted
T2-weighted
FLAIR
DWI
Blood Flow
GRE & MRA
MRA Anatomy

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 MAGNETIC RESONANCE IMAGING
(MRI) SCAN OF THE BRAIN: To CT menu

INTRODUCTION To MRI menu

• Technically difficult in obese/very ill pt (though some

outpt facilities have “open” magnets)
• MRI advantages over CT
– Detects ischemic changes within minutes (DWI MRI)
– More sensitive for infarcts & older blood
– Superior visualization of brainstem, inferior temporal lobe
– Gives information about flow in vessels
• T2*GRE MRI detects blood as well as CT (in past, MRI
felt to be inferior to CT for detecting acute blood)

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 THREE MAIN To CT menu

CATEGORIES OF MRI To MRI menu

• Spin Echo (SE) parenchyma, lesions

– T1 weighted, T2 weighted, FLAIR
• Echo Planar (EP) acute ischemia
– diffusion weighted imaging (DWI)
• Gradient Recall Echo (GRE or GRASS) flow, hemorrhage

FLAIR DWI GRE = GRASS

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SPIN ECHO (SE): To CT menu

T1-WEIGHTED IMAGES To MRI menu

• CSF is black
• Lesions are dark
– edema
– water
– acute infarction
– gliosis
• Lesions poorly seen without
IV contrast (gadolinium)
• Best used for pre- & post-
gadolinium comparisons
• Ca++ & bone black

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 SPIN ECHO (SE):
To CT menu
T2-WEIGHTED IMAGES
Click on label to make arrows appear and disappear To MRI menu

• CSF is white Gliosis from

• Lesions are white old infarcts
– edema
– water
– acute infarction
– gliosis
• Lesions well seen
• May be difficult to distinguish
lesion and CSF
• Cannot distinguish new and
old lesions
Pt X
• Ca++ & bone black
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SPIN ECHO (SE):
To CT menu
FLAIR (INVERSION RECOVERY)
Click on label to make arrows appear and disappear To MRI menu

• CSF is black Gliosis from

– standing water is old infarcts
black, including old
lacunes
• Lesions are white
– edema
– acute infarction
– gliosis
• Lesions very well seen
• Cannot distinguish new
and old lesions
• Ca++ & bone black
Pt X

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 ECHO PLANAR (EP): To CT menu
DIFFUSION-WEIGHTED IMAGING (DWI)
Click on label to make arrow appear and disappear To MRI menu

• CSF black New infarct

• New infarctions are white
– 30 min to few wks
• Old lesions not seen
• Compare to T2 or FLAIR to
distinguish new & old lesions
• Only takes a minute

May show lesions due to other

conditions as a result of “T2-shine-
through” phenomenon (corrected Pt X
by correlating w/ ADC image)

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 BLOOD FLOW ON MRI To CT menu

Click on label to make arrows appear and disappear To MRI menu

• Spin Echo (SE): T1, T2, Normal flow: No or low flow:

FLAIR black RICA gray or white
– Normal vessels are black & basilar a. LICA
(“flow-void phenomenon”)
• Gradient Recall Echo (GRE
= GRASS)
– Normal flow white, no or
low flow black
– GRE images used for
magnetic resonance
angiography (MRA)
T2

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GRE (= GRASS) AND
To CT menu
MR ANGIOGRAPHY (MRA)
Click on label to make arrow appear and disappear To MRI menu

T2*GRE
• T2*GRE images
– Most sensitive technique for detecting
intraparenchymal blood (black)
– Parenchyma and nonblood lesions fuzzy

• MR angiography (MRA) Blood

– MRI w/ software change (GR technology) MRA
– Can’t differentiate low flow vs. occlusion
– Can specify veins vs. arteries, anterior
circulation vs. posterior circulation
– Normal flow is white
– No or low flow is black Normal Poor
flow flow

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MAGNETIC RESONANCE ANGIOGRAPHY To CT menu
(MRA) INTRACRANIAL ANATOMY
Click on label to make arrow appears and disappear To MRI menu

Axial view ACA Coronal view

MCA

ICA

PCommA

BA

PCA

VA

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 THE END

Michael S. Gordon
Center for Research in Medical Education

MILLER SCHOOL OF MEDICINE

UNIVERSITY OF MIAMI