CHAPTER 2 INTRODUCTION TO BRAIN

IMAGING
Suprasellar cistern
- Interhemispheric fissure (anterior)
- Sylvian cisterns (anterolateral)
- Ambient cisterns (posterolateral)
- Interperduncular fossa (posterior)
NNIDS thrombolysis criteria:
 Mass, bleed, and acute infarct
Obex
 Most posterior projection of the dorsal
medulla
 N: above the imaginary line defining the
foramen magnum

CURRENT NEUROIMAGING OPTIONS
US
 First test in infants or for evaluation of the
carotids or with transcranial techniques for
evaluation of the intracranial vessels after
initial imaging triad
CT
- For acute neurologic illness
- Onset of neurologic symptoms referable to
the brain was within 24 to 48 hours
MRI
- chronic and subacute cases
- older than 2 days
MR angiography
- best for screening for AVMs
CTA
- for problem solving and aneurysm treatment
planning
*** If CT or MR fails to demonstrate an acute infarct
and the symptoms suggest a transient ischemic
attack or stroke, do a carotid Doppler US or MRA or
CTA.
***Don’t use intravenous iodinated contrast for CT
in the acute setting unless brain abscess or tumor
is a strong consideration or if needed for your
stroke triage protocol.
Proton MR Spectroscopy
 Shows the distribution of brain metabolites
based upon the chemical shift of the protons
within them
 Choline: marker for cellular turnover
 N-acetyl aspartate (NAA): marker of
neuronal density
 Creatine: reference standard
 Lactate: markers of anaerobic metabolic
metabolism
 Lipids: markers of necrosis
 Decrease in the NAA-to-creatine ratio:
neuronal death
 Focally decreased NAA: mesial temporal
sclerosis and infarcts
 Global depletion of NAA: multiple sclerosis
and dementing diseases (Alzheimer’s
disease)
 Nonspecific lipid necrosis peak: malignant
tumors, infections, and some active
demyelinating lesions
 Amino acid peaks: intracranial infections
 Doublet peak of lactic acid: ischemia
DWI
- key sequence in the early detection of
stroke
Hemorrhage-sensitive sequences:
- MC: T2* or GRE sequence without the 180
degrees refocusing pulse
- SWI: more sensitive than T2* imaging for
blood
o Phase data can differentiate
between blood products and
calcification
Diffusion tensor imaging (DTI)
 Allows reconstruction of white matter tracts
or tractography
Functional MR imaging (fMRI)
- Refers to studies of the brain using blood
oxygen level-dependent imaging (BOLD)
- local increase in oxy to deoxyhemoglobin
ratio produces changes in magnetic
susceptibility that are measurable on fMRI
sequences and correlate well with neuronal
activity
IMAGING STRATEGY FOR COMMON CLINICAL
SYNDROMES
Acute trauma
- Noncontrast-enhanced CT
- Most important abnormalities to be
detected: extracerebral hematomas
Posttraumatic encephalopathy/Chronic traumatic
encephalopathy
- Gradient echo MR sequence or SWI
hemorrhagic contusions/diffuse axonal
injury
Stroke
 - Noncontrast CT scan: preferred initial
imaging study
- For subarachnoid hemorrhage
o Further work-up: MR and/or
angiography search for aneurysm
or AVM
- MR
o T2* used to exclude hemorrhage
o DWI: defines infarcted tissue
o Perfusion scans: show areas of
diminished blood flow
o MRA: defines the vascular lesion
directly
Prethrombolytic evaluation
 Contraindications to thrombolytic therapy:
o Loss of gray/white distinction
o Low attenuation in the basal ganglia
o Poor definition of the insula on CT
Seizure
- First seizure: preferred: contrast-enhanced
MR or contrast-enhanced CT
- If in immediate postictal state or if a residual
neurologic deficit is present at the time of
imaging noncontrast CT scan
- If chronic: MR
Infectious disease and Cancer
- Contrast-enhanced MR
Headache
- Severe, acute headaches  noncontrast
head CT
- Chronic headache  MR
- Not accompanied by local neurologic
symptoms Noncontrast MR
- With neurologic complaints  gadolinium-
enhanced MR
Coma
 Noncontrast CT
Dementia
- Noncontrast MR
ANALYSIS OF THE ABNORMALITY
Mass
- Object occupying space
Reversible atrophy
- Causes: dehydration and starvation
Mass Lesion
- Intra-axial:
o within the brain and expanding it
o surrounded completely by brain
o Posterior fossa: narrow ipsilateral
subarachnoid space
o Supratentorial compartment: gyrj are
expanded and CSF spaces are
compressed
o Gadolinium: ring-like or irregular
fashion
- Extra-axial:
o outside the brain and compressing it
o (+) broad dural surface
o Posterior fossa: most reliable sign of
extra-axial mass  widening of the
ipsilateral and subarachnoid
space
o Supratentorial compartment: CSF
spaces become larger
o Gadolinium: enhance
homogeneously or not at all
 (+) Dural enhancement
Gray matter pattern
- Cytotoxic edema: white matter expansion
and increase T2 signal on MR or lucency on
CT with gray matter involvement
Herpes simplex encephalitis
- MC locations for involvement:
o medial temporal lobes adjacent to
the trigeminal ganglia
o orbital frontal regions adjacent to
the olfactory bulbs
Contrast Enhancement
- *** Enhancement of the brain parenchyma
means that the blood–brain barrier has
broken down and that the process is
biologically active.
Hemorrhage
 white on CT or white on T1 MR or black on
T2 MR
 DW MRI: bright as a light bulb --> infarct