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CT BRAIN / MR – An introduction CT BRAIN / MR – An introduction to Normal Anatomy, to Normal Anatomy,
Interpretation and Some Interpretation and Some Common PathologiesCommon Pathologies
Anupama ChandrasekharanAnupama ChandrasekharanAssociate Professor & Consultant RadiologistAssociate Professor & Consultant Radiologist
Dept of Radiology and Imaging SciencesDept of Radiology and Imaging SciencesSri Ramachandra Medical College & Research Sri Ramachandra Medical College & Research
InstituteInstituteChennaiChennai
Indications for CT / MR ……..Indications for CT / MR ……..
StrokeStroke TraumaTrauma Altered sensoriumAltered sensorium Neurological deficitNeurological deficit SeizuresSeizures Headache Headache
How the CT study is usually How the CT study is usually planned…planned…
15-20 degree angulation to canthomeatal line to decrease radiation to the lens.
Plain CT Contrast CT
Indications for a contrast Indications for a contrast CT….CT….
SeizuresSeizures InfectionsInfections Venous thrombosisVenous thrombosis TumorsTumors Atypical stroke findings on plain CTAtypical stroke findings on plain CT Atypical hemorrhage on plain CTAtypical hemorrhage on plain CT Focal edema on plain CTFocal edema on plain CT
Brain Window Bone Window
Descriptive Terms …….Descriptive Terms …….
Hypodense / HypointenseHypodense / Hypointense
Isodense / IsointenseIsodense / Isointense
Hyperdense / HyperintenseHyperdense / Hyperintense
Lesions appearing Lesions appearing Hypodense on Plain CTHypodense on Plain CT
InfarctInfarct (non (non hemorrhagic)hemorrhagic)
EdemaEdema
Lesions appearing Lesions appearing Hyperdense on Plain CTHyperdense on Plain CT
HemorrhageHemorrhage
CalcificationsCalcifications
Normal Intracranial CalcificationsNormal Intracranial Calcifications
NINDS trial
Thrombolysis
CT criteria
No hemorrhage
CT criteria
No hemorrhage
Parenchymal hypodensity
in 1/3 MCA
ECASS
Purpose of imaging in strokePurpose of imaging in stroke
Definite diagnosis of stroke.Definite diagnosis of stroke. To document the presence or absence To document the presence or absence
of hemorrhageof hemorrhage This information is critical since This information is critical since
anticoagulation is a standard therapy anticoagulation is a standard therapy for ischemic strokefor ischemic stroke
Identify ischemic penumbraIdentify ischemic penumbra Assess location & extent of brain Assess location & extent of brain
damage (e.g. impending herniation)damage (e.g. impending herniation) To exclude stroke mimics.To exclude stroke mimics.
Ischemic Penumbra
Stroke Frequency Based on Aetiology : Stroke Frequency Based on Aetiology : Harvard Stroke SeriesHarvard Stroke Series
Ischaemic Ischaemic (82%)(82%)Atherosclerotic Thrombosis – 22%
Embolism – 30 %
Lacunar – 18 %
Indeterminate
Cerebral Venous
Dissection Haemorrhagic (18%)
Primary Intracerebral Hematoma – 12%
AVM + Aneurysm – 4%
Others: Cavernoma, AVF, bleeding disorders -2 %
Stroke Based on TerritoryStroke Based on Territory
Anterior circulation strokeAnterior circulation strokeEmbolus : 70%
Thrombosis : 30%
Posterior circulation stroke
Thrombosis : 70%
Embolus : 30%
Normal in 50% of ischemic strokes < 6 hrs
2 hrs 24 hrs
CT in Hyperacute Stroke ( 0-6 hrs )CT in Hyperacute Stroke ( 0-6 hrs )
Not v.sensitive for infarctionNot v.sensitive for infarction
Sensitive for a/c hemorrhage & gross Sensitive for a/c hemorrhage & gross lesions precluding thrombolytic lesions precluding thrombolytic therapytherapy
20 % within 2 hrs
82 % within 6 hrs
Neuroradiology.1996
Jan;38(1):31-33
Hyperacute Stroke On CT
EARLY ISCHEMIC CHANGES
Hyperdense vessel sign
Attenuation of lentiform nucleus
Loss of insular ribbon
Effacement of sulci
Loss of corticomedullary differentiation
Significance of Early Ischemic Signs
No contraindication to thrombolysisPatel et al JAMA 2001;286:2830–2838
Indicate more extensive ischemiaAJNR 2004;25:933-938
Hyperdense vessel signObscuration of basal gangliaLoss of grey-white matter interfaceEffacement of sulci
Strong association with later hemorrhagic transformation AJNR 1991;12:1115-1121
Subacute infarct (1-7 days )Subacute infarct (1-7 days )
Hemorrhagic transformation in 5-40 % of Hemorrhagic transformation in 5-40 % of all ischemic strokeall ischemic stroke Neurology 2001; 57:1603-1610
Stroke 1999;30:761-764
Lacunar InfarctsLacunar Infarcts
Diffusion Weighted ImagingDiffusion Weighted Imaging
Radiology 2000;217:331-345
Detects Infarct As Early As 15-30 minutes
AJNR 2003 ;24:878-885
• 46 patients with acute stroke
• CT and DWI within 6 hours
• Mean delay 24.5 min. (R 10–41 min.)
• EIC on CT - 33/46 (Sn 73%)
• DWI 42/45 - (Sn 93%)
CT vs DWI
Hyperacute hemorrhage
2.5 hr 18 hr
GRE T2* WI
MRI as sensitive as CT for acute hemorrhage
More sensitive than CT for chronic hemorrhage(JAMA 2004;292:1823-30)
CT sensitivity for SAHCT sensitivity for SAH
Day of SAH – 98 %Day of SAH – 98 % After Day 1 – 90 %After Day 1 – 90 % After Day 5 – 80 %After Day 5 – 80 % After 1 wk – 50 %After 1 wk – 50 %
Neuroradiology 1982:23:153-156
Acute SAH - 100 %
Chronic SAH – 63 %
Chronic SAH ( CT ) – 46 %
Radiology .1995;196(3):773-777
Radiology.1997;203(1):257-262
Acute hemorrhageAcute hemorrhage MRI – 96% sens. 99% accuracyMRI – 96% sens. 99% accuracy CT - 89% sens. 98% accuracyCT - 89% sens. 98% accuracy
Chronic hemorrhage•MRI – 96% sens. 99% accuracy•CT - 40% sens. 78 accuracy
HEME study
CT AngiographyCT Angiography
Site of occlusionSite of occlusion Length of occluded Length of occluded
segmentsegment Arteries beyond Arteries beyond
occluded segment – occluded segment – collateral flowcollateral flow
Detection & exclusion of Detection & exclusion of large vessel intracranial large vessel intracranial occlusion – sens – occlusion – sens – 98.4% and spec.-98.1%98.4% and spec.-98.1%
JCAT 2001; 25(4):520-8
CT PerfusionCT Perfusion
If no penumbra…..increased risk of bleed with If no penumbra…..increased risk of bleed with thrombolysisthrombolysis
RCNA 44(2006)41-62
MTT rCBVrCBF
DWI ADC
Can MR replace CT as first imaging Can MR replace CT as first imaging modality in hyperacute stroke?modality in hyperacute stroke?
YesYes
MR immediately availableMR immediately available Protocol is optimizedProtocol is optimized Skilled personnelSkilled personnel
Unlikely to replace CT .......
• Cost
• Limited availability
• Time
• Lack of evidence that MR has a positive influence on prognosis
Delta SignDelta Sign
Extradural Extradural haematomahaematoma
Subdural Subdural haematoma haematoma
Subarachnoid Subarachnoid haemorrhagehaemorrhage
IntraventricularIntraventricular haemorrhagehaemorrhage
Cerebral Cerebral contusions contusions
Intracerebral Intracerebral haemorrhagehaemorrhage
Diffuse cerebral Diffuse cerebral edemaedema
EXTRA-AXIAL LESIONS INTRA-AXIAL LESIONS
Imaging in Craniocerebral TraumaImaging in Craniocerebral Trauma
Extradural Extradural HematomaHematoma
Acute Subdural Hematoma
Diffuse Axonal Injury Diffuse Axonal Injury
23 yr old male c/o fever and intense headache23 yr old male c/o fever and intense headache
Ring enhancing lesions – Ring enhancing lesions – granuloma / abscessgranuloma / abscess
CalcificationsCalcifications CerebritisCerebritis Meningeal abnormalities Meningeal abnormalities ComplicationsComplications
Differential Diagnosis of Ring Differential Diagnosis of Ring Enhancing LesionsEnhancing Lesions
GranulomasGranulomas Brain abscessBrain abscess Tumors – metastasis, Tumors – metastasis,
gliomaglioma Resolving hematomaResolving hematoma
EncephalitisEncephalitis
MRI – within 48 hrs MRI – within 48 hrs CT - at least 3-5 daysCT - at least 3-5 days
Widely availableWidely available CostCost QuickQuick HemorrhageHemorrhage TraumaTrauma
Hyperacute infarctsHyperacute infarcts Posterior fossaPosterior fossa Diffuse axonal Diffuse axonal
injuriesinjuries White matter White matter
diseasesdiseases Subtle Subtle
abnormalities of abnormalities of neuroparenchymaneuroparenchyma
Contraindications for MRIContraindications for MRI
Metallic implants Metallic implants PacemakersPacemakers Prosthetic valvesProsthetic valves Aneurysm clipsAneurysm clips ClaustrophobiaClaustrophobia
Thank UThank U
Epidural Abscess Subdural Epidural Abscess Subdural Empyema Empyema
Notice the rim Notice the rim
enhancing epdural enhancing epdural fluid collection fluid collection (arrowheads)(arrowheads)
).
EncephalitisEncephalitis Diffuse nonfocal brain parenchymal Diffuse nonfocal brain parenchymal
inflammatory processinflammatory process Most common agents - virusesMost common agents - viruses Immunocompetent individuals - Herpes Immunocompetent individuals - Herpes
virusesviruses Immunocompromised individualsImmunocompromised individuals
Human immunodeficency virus (HIV)Human immunodeficency virus (HIV) Cytomegalovirus (CMV)Cytomegalovirus (CMV) PapovavirusPapovavirus
Tuberculous meningitisTuberculous meningitis
Cerebellar AtrophyCerebellar AtrophyCerebral Atrophy
ARTERIOVENOUS MALFORMATION
ARTERIOVENOUS MALFORMATION
SUBACUTE SDH
ACUTE ON CHRONIC SDH
CONTUSION SAH
ComplicationsComplications
EARLYEARLY ABSCESSABSCESS SUBDURAL/SUBDURAL/
EPIDURAL EMPYEMAEPIDURAL EMPYEMA VENTRICULITISVENTRICULITIS INFARCTIONINFARCTION VENOUS VENOUS
THROMBOSISTHROMBOSIS
LATELATE SUBDURAL/ EPIDURAL SUBDURAL/ EPIDURAL
EFFUSIONEFFUSION ENCEPHALOMALACIAENCEPHALOMALACIA HYDROCEPHALUSHYDROCEPHALUS ATROPHYATROPHY
SUBDURAL EMPYEMA
EXTRA-AXIAL INTRA-AXIAL
Hypertensive Hemorrhage Hypertensive Hemorrhage Hypertensive hemorrhage accounts for Hypertensive hemorrhage accounts for
approximately 70-90% of non-traumatic primary approximately 70-90% of non-traumatic primary intracerebral hemorrhages. It is commonly due to intracerebral hemorrhages. It is commonly due to vasculopathy involving deep penetrating arteries of vasculopathy involving deep penetrating arteries of the brain. Hypertensive hemorrhage has a the brain. Hypertensive hemorrhage has a predilection for deep structures including the predilection for deep structures including the thalamus, pons, cerebellum, and basal ganglia, thalamus, pons, cerebellum, and basal ganglia, particularly the putamen and external capsule. Thus, particularly the putamen and external capsule. Thus, it often appears as a high-density hemorrhage in the it often appears as a high-density hemorrhage in the region of the basal ganglia. Blood may extend into region of the basal ganglia. Blood may extend into the ventricular system. Intraventricular extension of the ventricular system. Intraventricular extension of the hematoma is associated with a poor prognosis.the hematoma is associated with a poor prognosis.
Haemorrhagic StrokeHaemorrhagic StrokeEtiologyEtiology HypertensionHypertension Vascular malformationVascular malformation AneurysmAneurysm TraumaTrauma Amyloid angiopathyAmyloid angiopathy TumorTumor CoagulopathyCoagulopathy Hemorrhages can occur in the Hemorrhages can occur in the
intraparenchymal, subarachnoid, intraparenchymal, subarachnoid, intraventricular, subdural and extradural spaces.intraventricular, subdural and extradural spaces.
Location of hypertensive hemorrhage: Location of hypertensive hemorrhage: Putamen, external capsule, thalamus, pons, Putamen, external capsule, thalamus, pons, cerebellum, subcortical white mattercerebellum, subcortical white matter
Subarachnoid hemorrhageSubarachnoid hemorrhage In the absence of trauma, the most common cause of In the absence of trauma, the most common cause of
subarachnoid hemorrhage is a ruptured cerebral subarachnoid hemorrhage is a ruptured cerebral aneurysm. Cerebral aneurysms tend to occur at branch aneurysm. Cerebral aneurysms tend to occur at branch points of intracranial vessels and thus are frequently points of intracranial vessels and thus are frequently located around the Circle of Willis. Common aneurysm located around the Circle of Willis. Common aneurysm locations include the anterior and posterior locations include the anterior and posterior communicating arteries, the middle cerebral artery communicating arteries, the middle cerebral artery bifurcation and the tip of the basilar artery. bifurcation and the tip of the basilar artery. Subarachnoid hemorrhage typically presents as the Subarachnoid hemorrhage typically presents as the "worst headache of life" for the patient. Detection of a "worst headache of life" for the patient. Detection of a subarachnoid hemorrhage is crucial because the subarachnoid hemorrhage is crucial because the rehemorrhage rate of ruptured aneurysms is high and rehemorrhage rate of ruptured aneurysms is high and rehemorrhage is often fatal.rehemorrhage is often fatal.
Subarachnoid hemorrhageSubarachnoid hemorrhage CT is currently the imaging modality of choice because of its high CT is currently the imaging modality of choice because of its high
sensitivity for the detection of subarachnoid hemorrhage. CT is sensitivity for the detection of subarachnoid hemorrhage. CT is most sensitive for acute subarachnoid hemorrhage. After a period most sensitive for acute subarachnoid hemorrhage. After a period of days to weeks CT becomes much less sensitive as blood is of days to weeks CT becomes much less sensitive as blood is resorbed from the CSF. If there is a strong clinical indication, LP resorbed from the CSF. If there is a strong clinical indication, LP may be warranted despite a negative CT since small bleeds can may be warranted despite a negative CT since small bleeds can be unapparent on imaging.be unapparent on imaging.On CT, a subarachnoid hemorrhage appears as high density On CT, a subarachnoid hemorrhage appears as high density within sulci and cisterns. The insular regions and basilar cisterns within sulci and cisterns. The insular regions and basilar cisterns should be carefully scrutinized for subtle signs of subarachnoid should be carefully scrutinized for subtle signs of subarachnoid hemorrhage. Subarachnoid hemorrhage may have associated hemorrhage. Subarachnoid hemorrhage may have associated intraventricular hemorrhage and hydrocephalus.intraventricular hemorrhage and hydrocephalus.
MR SpectroscopyMR Spectroscopy
Normal Infarct
Venous Sinus Thrombosis with Venous Sinus Thrombosis with
Venous InfarctVenous Infarct Clinical symptoms – head ache, seizuresClinical symptoms – head ache, seizures Pathology is due to decrease in perfusion pressure Pathology is due to decrease in perfusion pressure
as the venous pressures elevate due to occlusion. as the venous pressures elevate due to occlusion. Predisposing conditions are dehydration, infection, Predisposing conditions are dehydration, infection,
polycythemia, sickle cell disease, hypercoagulable polycythemia, sickle cell disease, hypercoagulable states, peripartum, OCP poisoning.states, peripartum, OCP poisoning.
Imaging findingsImaging findings Unilateral / bilateral parenchymal hypodensitiesUnilateral / bilateral parenchymal hypodensities Not limited to an arterial territoryNot limited to an arterial territory May be associated with hemorrhageMay be associated with hemorrhage Signs: Delta sign, Enhancement of walls of sinus Signs: Delta sign, Enhancement of walls of sinus
than their contents.than their contents.
MR SpectroscopyMR Spectroscopy Dynamic study depicting Dynamic study depicting
intracellular metabolism of intracellular metabolism of cerebral ischemia.cerebral ischemia.
Within the region of infarct, Within the region of infarct, lactate appears elevated whereas lactate appears elevated whereas NAA and total creatinine are NAA and total creatinine are reduced.reduced.
Radionucleotide studies in acute Radionucleotide studies in acute strokestroke
PET is an accurate method of quantifying PET is an accurate method of quantifying changes in cerebral hemodynamics.changes in cerebral hemodynamics.
As cerebral blood flow (CBF) falls, cerebral As cerebral blood flow (CBF) falls, cerebral blood volume (CBV) and oxygen extraction blood volume (CBV) and oxygen extraction factor (OEF) increase.factor (OEF) increase.
PET measures changes in CBF, CBV and PET measures changes in CBF, CBV and OEF using O15 OEF using O15
Plays a limited role due to limited Plays a limited role due to limited availability .availability .
SPECT with Tc 99m HMPAO or ECD will SPECT with Tc 99m HMPAO or ECD will show a perfusion defect.show a perfusion defect.
RadionucleotideRadionucleotide Studies in Acute Studies in Acute StrokeStroke
SPECT – Tc99m HMPAOSPECT – Tc99m HMPAO PET – O15PET – O15 Adv – Early detectionAdv – Early detection Limitation - Not widely Limitation - Not widely
availableavailable
MRI has been increasingly utilized MRI has been increasingly utilized in early stroke since it is more in early stroke since it is more sensitive than CT in the first sensitive than CT in the first twelve hourstwelve hours
Bright on Diffusion weighted Bright on Diffusion weighted images (detected as early as 15 to images (detected as early as 15 to 30 min after vessel occlusion).30 min after vessel occlusion).
CT / MR Perfusion imagingCT / MR Perfusion imaging Concentrates on the assessment of Concentrates on the assessment of
mean transit time (MTT), relative cerebral mean transit time (MTT), relative cerebral blood volume (RCBV) and derived relative blood volume (RCBV) and derived relative cerebral blood flow. RCBF = MTT / RCBVcerebral blood flow. RCBF = MTT / RCBV
Prolonged MTT is the earliest & most Prolonged MTT is the earliest & most consistent sign of impaired perfusion.consistent sign of impaired perfusion.
In addition to this, there is a simultaneous In addition to this, there is a simultaneous drop in RCBV indicating tissue at risk for drop in RCBV indicating tissue at risk for infarction.infarction.
Stroke in ChildrenStroke in Children Constitutes 3% of cerebral infarcts Constitutes 3% of cerebral infarcts Most common cause is congenital Most common cause is congenital
heart disease. Other causes are heart disease. Other causes are vasospasm & vasculitis, vasospasm & vasculitis,
Echo, CT, MRI & catheter Echo, CT, MRI & catheter angiogram should be performed as angiogram should be performed as and when required.and when required.
There are several There are several advantages to performing a CTadvantages to performing a CT scanscan instead of other imaging modalities. A CT scan: instead of other imaging modalities. A CT scan:- Is readily available- Is readily available- Is rapid- Is rapid- Allows easy exclusion of hemorrhage- Allows easy exclusion of hemorrhage- Allows the assessment of parenchymal damage- Allows the assessment of parenchymal damage
The The disadvantages of CTdisadvantages of CT include the following: include the following:- Old versus new infarcts is not always clear- Old versus new infarcts is not always clear- No functional information (yet)- No functional information (yet)- Relatively limited evaluation of vertebrobasilar - Relatively limited evaluation of vertebrobasilar systemsystem
A CT is 58% sensitive for infarction within the first 24 A CT is 58% sensitive for infarction within the first 24 hours (Bryan et al, 1991). MRI is 82% sensitive. If the hours (Bryan et al, 1991). MRI is 82% sensitive. If the patient is imaged greater than 24 hours after the patient is imaged greater than 24 hours after the event, both CT and MR are greater thanevent, both CT and MR are greater than 90% 90% sensitive.sensitive.
Epidural Hematoma Epidural Hematoma
An epidural hematoma is usually associated with a An epidural hematoma is usually associated with a skull fracture. It often occurs when an impact skull fracture. It often occurs when an impact fractures the calvarium. The fractured bone fractures the calvarium. The fractured bone lacerates a dural artery or a venous sinus. The lacerates a dural artery or a venous sinus. The blood from the ruptured vessel collects between the blood from the ruptured vessel collects between the skull and dura. On CT, the hematoma forms a skull and dura. On CT, the hematoma forms a hyperdense biconvex masshyperdense biconvex mass. It is usually uniformly . It is usually uniformly high density but may contain hypodense foci due to high density but may contain hypodense foci due to active bleeding. Since an epidural hematoma is active bleeding. Since an epidural hematoma is extradural it can cross the dural reflections unlike a extradural it can cross the dural reflections unlike a subdural hematoma. However an epidural subdural hematoma. However an epidural hematoma usually does not cross suture lines hematoma usually does not cross suture lines where the dura tightly adheres to the adjacent skullwhere the dura tightly adheres to the adjacent skull
Cerebral Contusion Cerebral Contusion Cerebral contusions are the most common Cerebral contusions are the most common
primary intra-axial injury. They often occur primary intra-axial injury. They often occur when the brain impacts an osseous ridge when the brain impacts an osseous ridge or a dural fold. The foci of punctate or a dural fold. The foci of punctate hemorrhage or edema are located along hemorrhage or edema are located along gyral crests. The following are common gyral crests. The following are common locations:locations:- Temporal lobe - anterior tip, inferior - Temporal lobe - anterior tip, inferior surface, sylvian regionsurface, sylvian region- Frontal lobe - anterior pole, inferior - Frontal lobe - anterior pole, inferior surfacesurface- Dorsolateral midbrain- Dorsolateral midbrain- Inferior cerebellum- Inferior cerebellum
Cerebral ContusionCerebral Contusion On CT, cerebral On CT, cerebral contusion appears as an contusion appears as an ill-defined hypodense ill-defined hypodense area mixed with foci of area mixed with foci of hemorrhage.hemorrhage. Adjacent Adjacent subarachnoid subarachnoid hemorrhage is common. hemorrhage is common. After 24-48 hours, After 24-48 hours, hemorrhagic hemorrhagic transformation or transformation or coalescence of petechial coalescence of petechial hemorrhages into a hemorrhages into a rounded hematoma is rounded hematoma is common.common.
Diffuse Axonal Injury Diffuse Axonal Injury Diffuse axonal injury is often referred to as "shear injury". It is Diffuse axonal injury is often referred to as "shear injury". It is
the most common cause of significant morbidity in CNS trauma. the most common cause of significant morbidity in CNS trauma. Fifty percent of all primary intra-axial injuries are diffuse axonal Fifty percent of all primary intra-axial injuries are diffuse axonal injuries. Acceleration, deceleration and rotational forces cause injuries. Acceleration, deceleration and rotational forces cause portions of the brain with different densities to move relative to portions of the brain with different densities to move relative to each other resulting in the deformation and tearing of axons. each other resulting in the deformation and tearing of axons. Immediate loss of consciousness is typical of these injuries. Immediate loss of consciousness is typical of these injuries. The The CTCT of a patient with diffuse axonal injury of a patient with diffuse axonal injury may be normalmay be normal despite despite the patient's presentation with a profound neurological deficit.the patient's presentation with a profound neurological deficit. With CT, diffuse axonal injury may appear as ill-defined areas of With CT, diffuse axonal injury may appear as ill-defined areas of high density or hemorrhage in characteristic locations.high density or hemorrhage in characteristic locations. The injury The injury occurs in a sequential pattern of locations based on the severity occurs in a sequential pattern of locations based on the severity of the trauma. The following list of diffuse axonal injury locations of the trauma. The following list of diffuse axonal injury locations is ordered with the most likely location listed first followed by is ordered with the most likely location listed first followed by successively less likely locations:successively less likely locations:- Subcortical white matter - Subcortical white matter - Posterior limb internal capsule- Posterior limb internal capsule- Corpus callosum- Corpus callosum- Dorsolateral midbrain- Dorsolateral midbrain
EncephalitisEncephalitis CT scan is often normal , especially CT scan is often normal , especially early in the disease.early in the disease.
Ill defined hypodense lesions may be Ill defined hypodense lesions may be seen e.g. temporal lobe changes are seen e.g. temporal lobe changes are predominant in Herpes Encephalitis.predominant in Herpes Encephalitis.
MRI is far more sensitive in the MRI is far more sensitive in the evaluation of patients with encephalitisevaluation of patients with encephalitis
Skull FracturesSkull Fractures Skull fractures are categorized as Skull fractures are categorized as linear or linear or
depressed,depressed, depending on whether the fracture depending on whether the fracture fragments are depressed below the surface of fragments are depressed below the surface of the skull. Linear fractures are more common. the skull. Linear fractures are more common. The bone windows must be examined carefully.The bone windows must be examined carefully. A skull fracture is most clinically significant if A skull fracture is most clinically significant if the paranasal sinus or skull base is involved. the paranasal sinus or skull base is involved. Fractures must be distinguished from sutures Fractures must be distinguished from sutures that occur in anatomical locations (sagittal, that occur in anatomical locations (sagittal, coronal, lambdoidal) and venous channels. coronal, lambdoidal) and venous channels. Sutures have undulating margins both sutures Sutures have undulating margins both sutures and venous channels have sclerotic margins. and venous channels have sclerotic margins. Venous channels have undulating sides. Venous channels have undulating sides. Depressed fractures are characterized by Depressed fractures are characterized by inward displacement of fracture fragments.inward displacement of fracture fragments.
Ventriculitis / EpendymitisVentriculitis / Ependymitis
Inflammation and enlargement of the Inflammation and enlargement of the ventricles characterizes ventriculitis. ventricles characterizes ventriculitis. Ependymitis shows hydrocephalus with Ependymitis shows hydrocephalus with damage to the ependymal lining and damage to the ependymal lining and proliferation of subependymal glia. A CT proliferation of subependymal glia. A CT of patients with these conditions reveals of patients with these conditions reveals the presence of periventricular edema the presence of periventricular edema and subependymal enhancement. and subependymal enhancement. Ventriculitis and Ependymitis affect Ventriculitis and Ependymitis affect approximately 30% of the adult patients approximately 30% of the adult patients and 90% of the pediatric patients with and 90% of the pediatric patients with meningitis.meningitis.
Cerebrovascular Complications Cerebrovascular Complications of Meningitisof Meningitis
The development of cerebrovascular The development of cerebrovascular problems is the most common complication problems is the most common complication of meningitis. Arterial infarction can occur of meningitis. Arterial infarction can occur which often affects the basal ganglia due to which often affects the basal ganglia due to the occlusion of small perforating vessels. the occlusion of small perforating vessels. Hemispheric infarction can also occur due Hemispheric infarction can also occur due to major vessel spasm. Venous infarctions to major vessel spasm. Venous infarctions are also common and can include cortical are also common and can include cortical venous occlusion or the involvement of the venous occlusion or the involvement of the superior sagittal sinus.superior sagittal sinus.
Subdural Empyema Subdural Empyema Subdural empyema is usually due to Subdural empyema is usually due to
meningitis, sinusitis, trauma or prior surgery. meningitis, sinusitis, trauma or prior surgery. It is a neurosurgical emergency. Subdural It is a neurosurgical emergency. Subdural empyema leads to rapid clinical deterioration, empyema leads to rapid clinical deterioration, especially if it is due to sinusitis. especially if it is due to sinusitis. On CT it On CT it appears as an isodense or hypodense extra-appears as an isodense or hypodense extra-axial mass. It has a lentiform or crescentic axial mass. It has a lentiform or crescentic shape.shape.The margin of collection often enhances with The margin of collection often enhances with contrast material administrationcontrast material administration due to the due to the presence of granulation tissue or subjacent presence of granulation tissue or subjacent cortical inflammation.cortical inflammation.
Extra-axial CNS Infection Extra-axial CNS Infection
Extra-axial CNS infections can cause epidural Extra-axial CNS infections can cause epidural abscess or subdural empyema. Extra-axial CNS abscess or subdural empyema. Extra-axial CNS infections account for 20-30% of CNS infections account for 20-30% of CNS infections. Fifty percent of extra-axial infections infections. Fifty percent of extra-axial infections are associated with sinusitis, usually frontal are associated with sinusitis, usually frontal sinusitis. The infection occurs by direct sinusitis. The infection occurs by direct extension or septic thrombophlebitis. Thirty extension or septic thrombophlebitis. Thirty percent of extra-axial infections occur post-percent of extra-axial infections occur post-craniotomy. Finally, 10-15% of extra-axial CNS craniotomy. Finally, 10-15% of extra-axial CNS infections are related to meningitis. infections are related to meningitis. CT findings CT findings include a focal fluid collection usually with an include a focal fluid collection usually with an enhancing margin in a subdural or epidural enhancing margin in a subdural or epidural location.location.
PathophysiologyPathophysiology
Flow abnormalities - Perfusion
Cellular dysfunction – DWI / CT/ MR
Structural breakdown – CT / MRI
Ischemic StrokeIschemic Stroke
Occurs due to obstruction of cerebral arteries or Occurs due to obstruction of cerebral arteries or cerebral veins. cerebral veins.
The clinical spectrum of ischemia includesThe clinical spectrum of ischemia includes TIA (Transient ischemic attacks) TIA (Transient ischemic attacks) RIND (Reversible ischemic neurological deficit)RIND (Reversible ischemic neurological deficit) PRIND (partially reversible ischemic PRIND (partially reversible ischemic
neurological neurological deficit)deficit)
Evolved strokeEvolved stroke
Pathophysiology:Pathophysiology: Normal cerebral blood flow to the brain cortex is Normal cerebral blood flow to the brain cortex is
approximately 50 to 66 ml/100gm/min. When cerebral approximately 50 to 66 ml/100gm/min. When cerebral perfusion pressure falls below critical levels perfusion pressure falls below critical levels (<15ml/gm/min) ischemia results. Ischemia produces (<15ml/gm/min) ischemia results. Ischemia produces energy depletion in the affected cells. This results in energy depletion in the affected cells. This results in accumulation of Ca++, Na+ and Cl-, along with accumulation of Ca++, Na+ and Cl-, along with osmotically obligated water. This secondary osmotically obligated water. This secondary accumulation of water results in the imaging features of accumulation of water results in the imaging features of stroke such as edema and mass effect.stroke such as edema and mass effect.
Hyperdense vessel signHyperdense vessel sign
Seen in 25% of stroke patients.Seen in 25% of stroke patients. In patients presenting with clinical deficit In patients presenting with clinical deficit
referable to the middle cerebral artery referable to the middle cerebral artery territory, the hyperdense vessel sign is territory, the hyperdense vessel sign is present 35-50% of the time.present 35-50% of the time.
This signThis sign
Lentiform Nucleus ObscurationLentiform Nucleus Obscuration
Due to cytotoxic edema in the basal Due to cytotoxic edema in the basal gangliaganglia
Indicates proximal middle cerebral Indicates proximal middle cerebral artery occlusion, which results in artery occlusion, which results in limited flow to lenticulostriate arterieslimited flow to lenticulostriate arteries
Can be seen as early as one hour post Can be seen as early as one hour post onset of stroke.onset of stroke.
Insular Ribbon SignInsular Ribbon Sign Loss of the gray-white interface at the Loss of the gray-white interface at the
lateral margins of the insula. lateral margins of the insula. Supplied by the insular segment of the Supplied by the insular segment of the
middle cerebral artery middle cerebral artery Particularly susceptible to ischemia Particularly susceptible to ischemia
because it is the most distal region from because it is the most distal region from either anterior or posterior collateralseither anterior or posterior collaterals
May involve only the anterior or the May involve only the anterior or the posterior insulaposterior insula
Diffuse Hypodensity and Sulcal Diffuse Hypodensity and Sulcal EffacementEffacement
Most consistent sign of infarction. Most consistent sign of infarction. Extensive parenchymal hypodensity is Extensive parenchymal hypodensity is
associated with poor outcome.associated with poor outcome. If > 50% of MCA territory If > 50% of MCA territory
involvement ,there is, on average, an 85% involvement ,there is, on average, an 85% mortality rate. Hypodensity in greater than mortality rate. Hypodensity in greater than one-third of the middle cerebral artery one-third of the middle cerebral artery territory is generally considered to be a territory is generally considered to be a contra-indication to thrombolytic therapy.contra-indication to thrombolytic therapy.
Newer Imaging Techniques In Acute Newer Imaging Techniques In Acute StrokeStroke
MR Diffusion imaging: MR Diffusion imaging: CT / MR Perfusion imagingCT / MR Perfusion imaging Combined MR perfusion & Diffusion Combined MR perfusion & Diffusion
imagingimaging MR SpectroscopyMR Spectroscopy Radionucleotide studiesRadionucleotide studies
Ventriculitis / Ventriculitis / Ependymitis Ependymitis
Cerebral Blood flow for Cerebral Blood flow for SurvivalSurvival
Average blood flow Average blood flow :: 55ml/ 100gm/ mt55ml/ 100gm/ mt
Ischemic threshold Ischemic threshold :: 20 ml/ 100gm/ mt20 ml/ 100gm/ mt
Tissue deathTissue death : : <10 ml/ 100gm/ mt <10 ml/ 100gm/ mt
Functional failure without cell death: Functional failure without cell death: 10-20ml/ 100gm/ mt.10-20ml/ 100gm/ mt.
Concept of Ischemic PenumbraIschemic Insult
Focal core area of infarct (irreversible)
Surrounded by viable neuronal cell on
the brink of cell death
“Ischemic Penumbra”
Geographic area of tissue surrounding a profoundly ischemic core. Identified on DWI / per MRI
Saving this potential salvageable area leads to significant chance of improvement
Ischemic strokeIschemic stroke
Thrombotic strokeThrombotic stroke Embolic strokeEmbolic stroke Lacunar infarctLacunar infarct Global cerebral hypoperfusionGlobal cerebral hypoperfusion
• Ischemic Stroke (83-85%)
• Hemorrhagic Stroke (15-17%)
MRI in Hyperacute StrokeMRI in Hyperacute Stroke DWI – Infarct coreDWI – Infarct core FLAIR - SAH , Parenchymal changesFLAIR - SAH , Parenchymal changes T2* GRE – Intracranial hemorrhageT2* GRE – Intracranial hemorrhage PWI – Perfusion deficitPWI – Perfusion deficit MRA – Vessel occlusionMRA – Vessel occlusion
Diffusion Weighted ImagingDiffusion Weighted Imaging Sensitivity : 88 – 100 %Sensitivity : 88 – 100 % Specificity : 95 – 100 %Specificity : 95 – 100 % Initial diffusion lesion volume Initial diffusion lesion volume
correlates well with final infarct correlates well with final infarct volume & neurologic and volume & neurologic and functional outcomefunctional outcome
Multiple a/c lesions in diff.vasc Multiple a/c lesions in diff.vasc territories in pts. with 1 territories in pts. with 1 symptomatic insult …. embolicsymptomatic insult …. embolic
Neurology.1999 Jun 10;52(9):1784-
1792
Ann Neurol.1997 Aug;42(2):164-170
False Negative DWI
Brainstem infarct
Deep GM nucleus infarct
Neuroradiology2000;42:444–447 Stroke2000;31:1965–1972 AJNR 1999;20:1871–1875
Neurology 1999;52:1784-52
4 h 24 h
Dept. Neurosciences Univ. of Rome La SapienzaDept. Neurosciences Univ. of Rome La Sapienza
Reversibility of Ischemic lesions on DWI
Occlusion of MCA 1 hour - DWI lesion or resolution
Occlusion of MCA 2 hour - Lesion size same or
Radiology 2000;217:331-345
Successful thrombolysis may revert DWI changes
Diffusion changes in TIAs
• 29% to 67% will show restricted diffusion
• May reverse or persist
• Perfusion deficits
Stroke vs TIADWI lesions of TIA are less intense
Stroke 2004;35:1095
AJNR 2004;25:1645-52
Hyperacute Hemorrhage
Wiesmann M, et al. Eur Radiol. 2001;11:849-53.
Stroke 2004;35:502-506
Nederkoorn PJ et al. Stroke 2003;34:1324-32
MR Spectroscopy in acute stroke Stroke 2003;34:e82-876 pts within 7 hrs of stroke onset
Lactate alone – metabolic injury - Reversible
Lactate + NAA- more severe – Irreversible
Lac/Cho ratio from acute lesions improves the prediction of stroke outcome
Neurology 2000;55:498
CT VenographyCT Venography
25 yr old lady c/o fever and altered sensorium 25 yr old lady c/o fever and altered sensorium x 1 wk. Had 1 episode of GTC seizures. x 1 wk. Had 1 episode of GTC seizures. Admitted elsewhere , LP done showed Admitted elsewhere , LP done showed
proteins-55 mg % and sugar –105 mg % ..proteins-55 mg % and sugar –105 mg % ..ABG- pH – 7.55ABG- pH – 7.55
HCO3 – 28.3 , PCO2-32.9, PO2 –322.9,SPO2-HCO3 – 28.3 , PCO2-32.9, PO2 –322.9,SPO2-99.899.8
CT – Normal CT – Normal Discharged at request.Discharged at request.
H/o fever,headache and vomitting on and off H/o fever,headache and vomitting on and off x 5 mths -x 5 mths -
O/E – GCS – E1V1M5O/E – GCS – E1V1M5BP – 140/100 , PR – 116BP – 140/100 , PR – 116Pupils – 4mm dilated , sluggish light Pupils – 4mm dilated , sluggish light reactionreactionNeck Rigidity +Neck Rigidity +Kernig’s & Brudeski’s - veKernig’s & Brudeski’s - ve Hb-13.5 Hb-13.5 TC- 12,200TC- 12,200 Platelets-4.2Platelets-4.2 MP/MF – negativeMP/MF – negative BUN, creatinine – normalBUN, creatinine – normal Urine R/E – proteins +++, pus cells 5-8Urine R/E – proteins +++, pus cells 5-8 Coagulation Profile - WNLCoagulation Profile - WNL 134/3.4/26/102134/3.4/26/102
QQ qqqq
HIV EncephalopathyHIV Encephalopathy
Thank YouThank You
Hyperdense artery
•SPECIFICTY 100%
•SENSITIVITY 10% TO 50%
Seen as early as 90 minutes AJNR 1996; 17:79-85
Hyperdense MCA / Vessel SignHyperdense MCA / Vessel Sign
Persistent large vessel occlusion Persistent large vessel occlusion Large clot burdenLarge clot burden Not a contraindication for i.v. Not a contraindication for i.v.
thrombolysisthrombolysis Neurology 2001:57:1603-1610
Infarct Infarct VS VS
TumorTumor
CT Findings in StrokeCT Findings in Stroke
Hyperacute infarct (<12 hrs)Hyperacute infarct (<12 hrs) Normal (50 to 60%)Normal (50 to 60%) Hyperdense MCAHyperdense MCA Obscuration of lentiform nucleusObscuration of lentiform nucleus
Acute infarct (12 – 24hrs)Acute infarct (12 – 24hrs) Loss of grey - white matter interface Loss of grey - white matter interface
(insular ribbon sign)(insular ribbon sign) Low density basal gangliaLow density basal ganglia Sulcal effacement.Sulcal effacement.
Hyperdense vessel signHyperdense vessel sign
• Indicates poor outcome and poor response to iv - TPA therapy.
CT Findings in Stroke (CT Findings in Stroke (ContdContd))……
Subacute infarct (1- 7days)Subacute infarct (1- 7days) Mass effectMass effect Wedge shaped hypodensity involving Wedge shaped hypodensity involving
grey & white mattergrey & white matter Hemorrhagic transformation.Hemorrhagic transformation. Gyral enhancement.Gyral enhancement.
Chronic infarct ( 1 to 8 weeks)Chronic infarct ( 1 to 8 weeks) Encephalomalacic changesEncephalomalacic changes Reduced mass effectReduced mass effect
Global Cerebral HypoperfusionGlobal Cerebral Hypoperfusion
Consequence of global hypoperfusion.Consequence of global hypoperfusion. Common causes are hypotension, cardiac Common causes are hypotension, cardiac
arrest with successful resuscitation, neonatal arrest with successful resuscitation, neonatal asphyxia and CO inhalation.asphyxia and CO inhalation.
Imaging patternsImaging patterns 1)1) Water shed infarct in the parieto-Water shed infarct in the parieto-
occipital region & basal ganglia infarcts.occipital region & basal ganglia infarcts. 2)2) Cortical laminar necrosis with Cortical laminar necrosis with
hemorrhagic foci in basal ganglia & cerebral hemorrhagic foci in basal ganglia & cerebral cortical gyri.cortical gyri.
3)3) In severe cases “reversal sign” is noted. In severe cases “reversal sign” is noted.
Reversal signReversal sign
Infarct With Hemorrhagic Infarct With Hemorrhagic TransformationTransformation
CT CT VSVS MRI in the setting of acute MRI in the setting of acute strokestroke
MRI is more sensitiveMRI is more sensitive Diffusion weighted MR images has the Diffusion weighted MR images has the
highest sensitivity & specificity for acute highest sensitivity & specificity for acute cerebral infarction.cerebral infarction.
CT is more sensitive to detect hemorrhage.CT is more sensitive to detect hemorrhage. CT is more widely available in many CT is more widely available in many
institutions.institutions. CT is less expensiveCT is less expensive CT is more rapidCT is more rapid
CT AngiographyCT Angiography
Useful in MCA embolic stroke & Useful in MCA embolic stroke & predictive of infarction volume in MCA predictive of infarction volume in MCA territoryterritory
Less useful –deep grey matter & Less useful –deep grey matter & brainstem brainstem
strokestroke(Taipei)1999:62:255-260
Subacute SAHSubacute SAH FLAIR + (GRE) T2*-weighted superior FLAIR + (GRE) T2*-weighted superior
to either aloneto either alone
J Neurol Neurosurg Psychiatry.200170(2):205-211
Hypertensive HemorrhageHypertensive Hemorrhage
Subarachnoid hemorrhageSubarachnoid hemorrhage
Combined MR Perfusion & Combined MR Perfusion & Diffusion ImagingDiffusion Imaging
In hyperacute stage, larger In hyperacute stage, larger abnormality is noted on the perfusion abnormality is noted on the perfusion images than on diffusion weighted images than on diffusion weighted images. This diffusion perfusion images. This diffusion perfusion mismatch is the ischemic penumbra. mismatch is the ischemic penumbra. This is the tissue at risk which would This is the tissue at risk which would benefit from thrombolysis.benefit from thrombolysis.
Stroke Protocol
Normal Infarct Haemorrhage
Diffusion / Perfusion
CT Perfusion Intraparenchymal SAH
HT Atypical site Angiogr
Angiogram
Mismatch Matches
Angiogr
Thrombolysis
To Summarize the Role of CT To Summarize the Role of CT in Strokein Stroke
Haemorrhagic or non-haemorrhagicHaemorrhagic or non-haemorrhagic Arterial or venousArterial or venous Territory involvedTerritory involved Acute,subacute or chronicAcute,subacute or chronic Assess the mass effectAssess the mass effect Exclude Stroke mimics like subdural Exclude Stroke mimics like subdural
hematoma, tumorshematoma, tumors
How the CT study is usually planned…How the CT study is usually planned…
Thinner Thinner sections are sections are studied studied through the through the posterior posterior fossafossa
Hounsfield UnitsHounsfield Units
AIRAIR -- - 1000- 1000
FATFAT -- - 30 to -100- 30 to -100
CSFCSF -- 0 0
GREY MATTERGREY MATTER -- 32 - 41 32 - 41
WHITE MATTERWHITE MATTER -- 23 - 34 23 - 34
ACUTE BLOODACUTE BLOOD -- 56 - 76 56 - 76
CALCIFICATION - 60 - 400CALCIFICATION - 60 - 400
BONEBONE - - 1000 1000