Neuroradiology

Case 1
 20 year old man
 Head Trauma previous day. Transient loss
of consciousness. Headache, nausea and
vomiting
 Arrived unconscious
 Neurological examination- stupor ,
hemiparesis and elevated blood pressure
 What is examination of choice and why is
it so?
 • Describe findings
• Diagnosis
• Differential

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Epidural haematoma
 These arise between the
inner table of the skull and
the dura.
 90% arterial, 10% venous
 middle meningeal artery or
one of its branches
 Lucid interval or “Talk and
Die Syndrome” (40%)
 Another
sudnv example of
Epidural
Hematoma
 Differential diagnosis

 Sub Dural Hematoma

 Tumor, Meningioma or Metastasis
Meningioma
 Case 2
 80 year old man. Recurrent falls.
 Arrives after fall with confusion and
unstable gait
 Neurological examination – short period of
amnesia. Confused as to location and time
 What is examination of choice and why is
it so?
• Describe findings
• Diagnosis
• Differential
Subdural haematoma
 These arise between
the dura and
arachnoid
 often from ruptured
veins crossing this
potential space
Another example of Subdural Hematoma
Another example of Subdural Hematoma
 Differential diagnosis
 Subdural hygroma
 Effusion
 Empyema
 Subdural metastasis
 Epidural hematoma
 Dural thickness
 Case 3
 30 year old man truck driver. Motor -
Vehicle Accident.
 Arrived confused with focal neurological
deficit. Convulsion.
 Neurological examination – confused,
aggressive with ‘ frontal ‘ behavior and
forehead hematoma
 What is examination of choice and why is
it so?
• Describe findings
• Diagnosis
• Differential
Intracerebral Haemorrhage
 Haemorrhagic
contusion
 These occur due to
stretching and
shearing injury
Cerebral contusion
 Coup (same side
as impact)
 Contre-coup

(opposite impact)
 Intermediate

(central)
- (DAI / shearing
injury)
Example of DAI brain contussion
 Differential Diagnosis

 Intracranial bleeding of other etiology

 Tumor
 Infarct
 Case 4
 43 years old, fell from a ladder
 Arrived with headache nausea and
vomiting
 What is examination of choice and why is
it so?
• Describe findings
• Diagnosis
• Differential
Subarachnoid haemorrhage
 This may occur alone
or in association with
other hematomas
 Increased attenuation
is seen in the CSF
spaces
 Differential Diagnosis

 Non Traumatic subarachnoid bleeding

 Aneurism rupture
 AVM
 Hypertension
 Anticoagulation
 Case 5
 50 year old woman arrived in ER with
complaints of sudden headache,
increasing severity, worst headache she
has ever had (“THUNDERCLAP
HEADACHE”)
 Neurological examination
 Neck stiffness
 Papilledema
 What is examination of choice and why is
it so?
• Describe findings
• Diagnosis
• Differential
 Subarachnoid Hemorrhage
 In the absence of trauma, the most
common cause of SAH is a ruptured
cerebral aneurysm.
Common aneurysm locations include the:
 anterior and posterior communicating

arteries
 the middle cerebral artery bifurcation

 the tip of the basilar artery

CT angiography
 Angiography
Digital subtraction angiography (DSA)

a method for showing contrast-filled

vessels without any interfering
background
 Differential Diagnosis

 Traumatic subarachnoid
 AVM
 anticoagulation
 Case 6
 60 year old man with left side hemiparesis
of increasing severity
 Neurological examination – left
hemiparesis
 What is examination of choice and why is
it so?
• Describe findings
• Diagnosis
• Differential
 Stages of Stroke

”Dense MCA sign“ ”Dot sign“

 Insular Ribbon Sign
 The insular ribbon
sign is the loss of the
gray-white interface in
the lateral margins of
the insula.
 The insular ribbon
sign may involve only
the anterior or the
posterior insula.
Diffuse Hypodensity and Sulcal
Effacement
 Diffuse hypodensity
and sulcal effacement
is the most consistent
sign of infarction.
 Extensive
parenchymal
hypodensity is
associated with poor
outcome.
HR 4 days 2
Another
example
of acute
stroke
 Diffusion-weighted Imaging (DWI)

 Diffusion-weighted MR imaging is even more sensitive

than conventional MR imaging for detection of
hyperacute cerebral ischemia.
 Tissues with a lower rate of water diffusion appear
brighter.
CT(-)
DWI

CTA

T2
 Case 7
 70 year old woman with hypertension
 Arrived confused with stupor and
complaint of headache
 Hemiparesis on the right
 What is examination of choice and why is
it so?
• Describe findings
• Diagnosis
• Differential
 Hypertensive Hemorrhage
 Accounts for 70-90% of non-traumatic
intracerebral hemorrhages.
 Predilection for deep structures including
the thalamus, pons, cerebellum, and basal
ganglia.
 Blood may extend into the ventricular
system (poor prognosis).
More examples of intracranial
bleeding due to hypertension
 Case 8
 50 year old woman
 Cognitive deterioration in past few months
 ‘frontal behavior’
 Arrived confused and convulsed
 What is examination of choice and why is
it so?
 ‫תאר את הממצאים‬ 

‫אבחנה‬ 

‫אבחנה מבדלת‬ 

• Describe findings
• Diagnosis
• Differential
 Glioblastoma Multiforme
 GBM is the most aggressive grade of
astrocytoma. The two-year survival rate is
10-15%.
 On CT, GBM is characterized by necrosis
and irregular enhancement.
 It is one of very few lesions that
frequently cross the corpus callosum.
MRI - GBM
 Differential Dignosis of GBM

 Abscess
 Single Metastasis
 Primary CNS Lymphoma
 Tumefactive Demyelinating Lesion
 Case 9
 40 year old man comes to ER due to
headache and fever
 Convulsion
 Deterioration in consciousness
 Lab Results:
 Leukocystosis
 Increased Erythrocyte sedimentation rate
(ESR)
• Describe findings
• Diagnosis
• Differential
 Cerebral Abscess
 On CT, an Cerebral abscess appears as a
focal low-density mass with ring
enhancement , edema and mass effect
 MRI : T2 – hypointense abscess rim with
surrounding edema
 T1 with Gd rim enchantment
 Restricted diffusion
MRI-Cerebral Abscess
Differential diagnosis of Abscess
 GBM
 Single Metastasis
 Hematoma in stages of resorption
 Tumefactive Demyelinating Lesion
 Case 10
 10 year old boy arrives in ER with severe
headache, nausea and vomiting
 Neurological examination shows stiffness
of neck, bilateral papilledema
 What is examination of choice and why is
it so?
• Describe findings
• Diagnosis
• Differential
 OBSTRUCTIVE
HYDROCEPHALUS
 On CT,’ ballooned’ ventricles
 With or without periventricular low density
‘halo’
 Basal cisterns and sulci obliteration
 On CECT typically no enhancement
 The most common causes : aqueductal
stenosis or tumor
 Differential diagnosis of
obstructive hydrocephalus
 NPH
 Atrophy