k10 - Kuliah Fk-usu Nervous System

8/12/2019 k10 - Kuliah Fk-usu Nervous System

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Dr Rudolf H Pakpahan Sp.RadDr Netty Lubis Sp.RadRadiology FK - USU


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MODALITIES

1. X-Ray2. CT Scan

3. MRI


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The Skull

The standard projections are :1. The lateral view

2. The PA view


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Routine method of study of SkullX ray Examine : the inner and outer table Examine trabeculasi and densitas bone

Examine: Sutures Examine :Vascular markings Examine : sella

Examine : intracranial kalsifikasi


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Normal Skull Films

AP Skull-X Ray Lateral Skull-X Ray


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8/99Lateral view


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Abnormal Skull

1.Fracture.

2.Metastasis3.Congenital disorders4.Kalsifikasi

5.Raised intracranial pressure


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Metastasis

Lesi lytik


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Lesi lytik luas


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Multiple Myeloma


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Congenital disorders

Scaphocephaly


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Scaphocephaly


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Raised intracranial pressure

Hydrocephalus


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Computed tomography


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CT schematic


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INDICATION

1.HEAD INJURY 2.CEBROVASLULAR DISEASES (CVD)

3.BRAIN TUMOR 4.CEREBRAL INFECTION 5.CONGENITAL DISORDER

6.CEREBRAL ATROPHY OR7.DEGENERATIVE DISEASES


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THE BRAIN LAYER ANATOMY

SKIN BONE

EPIDURAL

DURAMATERSUBDURAL

ARACHNOID

SUBARACHNOID PIAMATER


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THE

BRAIN

LAYER

ANATOM

Y


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ANATOMY BRAIN


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HEAD Scan NORMAL


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High density (hiperdens) : densitas lesilebih tinggi dari jaringan normal.

Isodens :densitas lesi sama dengan jaringan sekitarny a

Low density(hipodens) : densitas lesilebihrendah dari jaringan normal


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Skull Fractures

-Associated with pneumocephaly(air in head) rarely can developtension pneumocephalus

-Only significant if open toair,cosmetically disfiguring(greater

than full thickness displacement)or


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associate with air sinus(for risk of infection) orunderlying bleed

(epidural hematom)-Treatment ONLY forcosmetic or prevention of

infection ( if opento air or to an air sinus


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Fracture


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Intracranial Hemorrhage

Intracranial hemorrhage can be classifiedaccording to the space occupied by the

blood:

Epidural Hemorrhage Subdural Hemorrhage Subarachnoid Hemorrhage Intraparenchymal Hemorrhage Intraventricular Hemorrhage


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Intracranial Hemorrhage:Types


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Epidural Hemorrhage

Between skull and dura, limited by periosteal layer so stops at sutures ofskull and thus biconvex (lens) shaped

Due to middle meningeal arterytear,often associated with skull fracture


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Subdural Hematoma

Occur in the 4 As : alcoholic,anti -coagulant-treated,aged and abuse victims(shaken baby syndrome)

Between dura and archnoid of brainFollow contour of brain so Crescent Shape .

Due to cortical bridging vein tear ashemoglobin broken down,blood changes color

on CT scan and can be easily mised(see sub acute )


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Usually patients withsubdural hematoma haveworse Brain injury thanepidural hematoma

Small size bleeds can bespontaneusly absorbed bythe body, but if midlineshift is present Surgicalevacuation


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Subdural Hemorrhage

ACUTE SUB ACUTE CHRONIC


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Subarachnoid Hemorrhage

Subarachnoid hemorrhage isgenerally feathery in appearanceon CT scan, as itsmixed in withcerebrospinal fluid


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The MOST COMMON cause of

subarachnoid haemorrhage is1.Trauma2.The 2 nd and 3 rd most

common causes areaneurysms or arteriovenousmalformations

No intervention is generallyperformed for subarachnoidhemorrhage alone.


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However ,subarachnoidhemorrhage can causehydrocephalus (due toobstruction of CSF flow)or vasospasm (due to ?blood product irritating avessel) in delayed fashion


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SAH


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SA

H


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- Can develop extreme amount

of edema or blossom,so mustfollow closely with repeat CTscans

-Can be caused byhypertensive hemorrhage incharacteristic locations

(basal ganglia,thalamus pons,

cerebellum) or arteriovenousmalformations


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-In older patients (> 60 )can be caused bycerebral amyloidangiopathy, usually ina lobar location

-Surgical evacuation ifexcessive mass effect


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Intraparenchymalhemorrhage


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Intraventricular Hemorrhage

-Usually due to extension ofintraparenchymal bleed (most

Commonly from hypertension-Treatment depends on whetherhydrocephalus develops then

patients may need ventriculostomy placement


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Intraventricular

hemorrhage


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Stroke divided to become twotype

1.Cerebral infarction(ischemiattack,encephalomalacia) thrombotic material occludesan artery,the supply area ofwhich then becomes necroticas a result of the local ischaemi

Computed tomography (CT)-The first few hours after vascular

occlusion CT NORMAL- Later the density decreases

hypodense lesion


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Cerebral infarct


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Infarct pons


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Cerebral hemorrhage


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INFECTIOUS DISEASES

Subdural Empyema

-about 13 to 20 % of all cases of intracranial

bacterial infection-the most common cause of sub empyemais paranasal sinusitis

-NCCT : crescentic or lentiform-shaped

area of low density (0 to 16 HU)-CECT : a zone of enhancement separates the

hypodense extra cerebral collection


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Subdural Empyema

CT MRI


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INFECTIOUS DISEASES

CEREBRAL ABSCESS-is an encapsulated inflammation-the centrally softened and infected area is

surrounded by granulation tissue rich incapillaries and fibrolasts( abscessmembrane) age thickens to form a

multilayered connective-tissue capsulerich in vessel and collagen


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Compoted tomography-NCCT

mass effect on the ventriculersystem or the midline structuresis noted in more than

80% of brain abscess.ill defined hypodense lesion

-CECT ring contras enhancement


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Cerebral abscess


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Cerebral abscess


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Cerebral abscess


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CEREBRITIS

Result from initial infection of the brain parenchyma

Brain cerebritis and abcess occur asresult of preceding extracerebralinfection(such as otitismastoiditis,sinusitis,facial cutaneus

infection,dental abscess,penetratingskull injury)


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NCCT :- area hypodensity in the white matter with poorly

defined borders regional or widespread mass effectCECT:-early stage no contrast enhancement- Mottled irreguler areas of enhancement mostly

in the regional gray matter

MR is more accurate than CT in the evaluationof the Early stages of cerebritis


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Hydrocephalus

Normal CSF flow is from lateralventricles to third ventricle, viaaquaduct silvii to fourth V, thenthrough foramina ofmagendieand luschka tosubarachnoid space,thenabsorption via arachnoidgranulations into the superior

sagittal sinus


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-Any obstruction on this pathwaycan cause hydrocephalus

-Treatment is temporarily bydiverting spinal fluid via

ventriculostomy catheterpermanently,a shunt ( e.g.ventriculoperitoneal , or VPshunt)


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H

YDRO

CEPHALUS


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BRAIN TUMOURS


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CT or MRI Findings

Lesion location and extent Intraaxial or extraaxial Supratentorial or infratentorial

Single or multiple Tumor margin

Well circumscribed or poorly

marginatedReguler or irreguler


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CT or MRI findings

Tumor characterizationcalcificationHomogeneous or inhomogeneous

contrast enhancement Necrotic,cystic

Mass effect

Localized,focal shiftGeneralized,remote effects


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CT or MRI findings

Edema Vasogenic , interstitial

Brain herniations

Subfalcine Descending transentorial Ascending transentorial Tonsillar


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BRAIN TUMOURS


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Brain Tu (pylocytic astrocytoma)


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Brain tumors

CT vs MRI


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CT vs MRICT MRI

Biaya Mahal Sangat mahalP.Rad sedang - tinggi (-)Prinsip X-ray Magnet &

gel radioWaktu Biasa +/- 5 mnt +/- 30 mntSoft tissue tidak baik sangat baikTulang Baik tidak baik

Perub-imag (-) images beberapa potongan potongan


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MRI : Normal brain (axial)


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MRI : Normal brain (sagital)


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MRI : normal brain (coronal)


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MRI lebih sensitif dibanding CT,

Beberaoa menit setelah klinis /sympton Gambaran MRI (+)

Cerebral Infarct


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Cerebral Infarct

CT T1 MRI T2 MRI

C b l i f


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Cerebral infract

Encephalitis


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p

E h li i


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Encephalitis

S b h id h h


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Subarachnoid hemorrhage

B i t ( it l)


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Brain tumor (sagital)

MRI B i t


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MRI : Brain tumor

D d W lk lf ti


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Dandy Walker malformation


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k10 - Kuliah Fk-usu Nervous System