New Diagnostics in Radiology

9/14/19 Touro University Alumni lecture

Travis Snyder, D.O.

Touro University NV Class of 2009

Assistant Adjunct Professor of Radiology and Neuroradiology Touro University NV

SimonMed Radiologist Las Vegas

ConflictsI have no conflicts to disclose.

Objectives

• Cardiac Scoring• Virtual Colonoscopy• Dat Scan• New advances in NeuroImaging

• SWI, fMRI, CSF flow, Volumetric Software, Perfusion, DTI

Calcium Scoring

• CALCIUM SCORE/IMPLICATION/RISK OF CORONARY ARTERY DISEASE

0: No identifiable plaque. Very low, generally less than5 percent.1-10: Minimal identifiable plaque. Very unlikely, less than 10percent.11-100: Definite, at least mild atherosclerotic plaque. Mild orminimal coronary narrowing is likely.101-400: Definite, at least moderate atherosclerotic plaque. Mildcoronary artery disease is highly likely, significant narrowing ispossible.401 or Higher: Extensive atherosclerotic plaque. High likelihood of at leastone significant coronary narrowing.

Virtual Colonoscopy

• Provides a computer-simulated bi-dimensional or tri-dimensional image of the air-filled, distended colon.

DAT Scan (Parkinsons, Parksinsons +)

Normal Abnormal

DAT Quant Software (age matched controls)

Advanced NeuroImaging Options

• SWI• CSF Flow• Spectroscopy• NeuroQuant• LesionQuant• fMRI• Perfusion• DTI

Susceptibility Weighted Imaging [SWI] (4-6 x more sensitive than GRE)

SWI (susceptibility weighted sequence) 4-6 x superior to GRE (Gradient Echo) for hemorrhages

Tong KA, Ashwal S, Holshouser BA, Shutter LA, Herigault G, Haacke EM, Kido DK.Hemorrhagic shearing lesions in children and adolescents with posttraumatic diffuse axonal injury: improved detection and initial results.Radiology. 2003 May;227(2):332-9.

CSF Flow MRI studies

•NPH

•Chiari

•3rd Ventriculostomy

Spectroscopy

•Tumor, tumor, tumor

•Grade of Tumor, Tumor versus Stroke

•Other

NeuroQuant

•Volumetric Software to assess size of regions of brain and ventricles against age matched controls

•Dementia (Temporal Parietal) [companion to PET]

•Objective Evidence for atrophy

•Hippocampus (dementia, head trauma)

Hippocampal Atrophy

Patient

Hippocampal Atrophy

Normal

Imaging findings more likely relating to head trauma? • Atrophy

• Cortical

Chong CD, Berisha V, Chiang CC, Ross K, Schwedt TJ.Less Cortical Thickness in Patients With Persistent Post-Traumatic Headache Compared With Healthy Controls: An MRI Study.Headache. 2018 Jan;58(1):53-61. doi: 10.1111/head.13223. Epub 2017 Nov 15.

Koushik A. Govindarajan, Ponnada A. Khader M. Hasan, Elisabeth A. Wilde, Harvey S. Levin, Jill V. Hunter, Emmy R. Miller, Vipul Kumar S. Patel, Claudia S. Robertson, and James Cortical Thickness in Mild Traumatic Brain InjuryJ. McCarthy J Neurotrauma. 2016 Oct 15; 33(20): 1809–1817.

LesionQuant, 3D FLAIR Cube

fMRI

•Auditory (Boca's, Wernicke's area) Trauma?

•Motor

•Olfactory

•Resting State?

Perfusion

•Penumbra in stroke in hospital setting

•Tumor versus radiation necrosis

•Tumor vascularity

•Other (vasculopathy, head trauma)

Why Perfusion?

Abnormal Perfusion (blood flow) Beyond Contusions

DTI (Diffusion Tensor Tracking)

•Diffusion Weighted Imaging (Straws in a glass)•Assess health of axons•3D and FA values (numerical value)

•Head trauma•MS•Any process that damages axons

•Can this impact treatment?

Abnormal Ventricular Volumes (Volumetric Tracing Technique)

Arnold Tóth,Ilona Schmalfuss, Shelley C. Heaton, Andrea Gabrielli, H. Julia Hannay, Linda Papa, Gretchen M. Brophy, Kevin K.W. Wang, András Büki, Attila Schwarcz, Ronald L. Hayes, Claudia S. Robertson, and Steven A. RobicsekLateral Ventricle Volume Asymmetry Predicts Midline Shift in Severe Traumatic Brain InjuryJ Neurotrauma. 2015 Sep 1; 32(17): 1307–1311.

Abnormal Ventricular Volumes (Diffuse Post Traumatic Brain Injury and Poor Prognosis)

Actual Increasevs.

Anticipated Increase with Normal Aging

Scahill, R. I., C. Frost, R. Jenkins, J. L. Whitwell, M. N. Rossor and N. C. Fox (2003). "A longitudinal study of brain volume changes in normal aging using serial registered magnetic resonance imaging.”

Arch Neurol 60(7): 989-994.

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Diffusion Tensor Imaging

• Diffusion Tensor Imaging measures water flow along axons.

• Axons are the ‘telephone wires’ of the brain.

• FA values give a numerical value to the health of the axons.

• Low values are indicative of axonal injury.

Acquired axial images and regions of interest

Diffusion Tensor ImagingBrain MRI 09/21/18

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AnteriorInferior

Anterior Mid Body Posterior PosteriorInferior

Kim et al., 2008 - FA Values

Kim EY, Park HJ, Kim DH, Lee SK, Kim J, (2008) Measuring fractional anisotropy of the corpus callosum using diffusion tensor imaging, Korean J Radiol, 9: 391-396.

Abnormal Normal

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AnteriorInferior

Anterior Mid Body Posterior PosteriorInferior

Trauma Patient- FA Values

Body of Corpus Callosum

Diffusion Tensor Tracking

Fiber tracts from an MS patient using only the midline of the CC

Head Trauma Patient

Fiber tracts from normal subject using only the midline of the CC

Fiber tracts from normal subject using the entire CC

3D Diffusion Tensor Imaging Matches Contusions (Severe Anterior Injury)

Diffusion Tensor Imaging Matches Injury

3D Diffusion Tensor Imaging Matches Hemorrhage and Shearing

Diffusion Tensor ImagingSynchronized Scanner to a normal database

Venkatraman VK1, Gonzalez CE, Landman B, Goh J, Reiter DA, An Y, Resnick SM.Region of interest correction factors improve reliability of diffusion imaging measures within and across scanners and field strengths. Neuroimage. 2015 Oct 1;119:406-16. doi: 10.1016/j.neuroimage.2015.06.078. Epub 2015 Jul 2.

- Human Phantom phenomena (scan a control ‘patient’ on 2 scanners)

- Accounts for differences in DTI technique and allows cross scanner comparison

- Changes an ‘individual scan’ to a ‘group scan’ – Z score (Standard deviations)

Palacios et al Towards Precision and Reproducibility of Diffusion Tensor Imaging: A Multicenter Diffusion Phantom and Traveling Volunteer Study AJNR Am J Neuroradiol. 2017 Mar; 38(3): 537–545.

Patient with 3 contusions, DAI and life saving Neurosurgery

Diffusion Tensor Imaging (Severe Anterior Injury)

Questions?

Travis Snyder DOSimonMed Imaging/Touro U

tsnyder@simonmed.comtravishsnyder@gmail.com