YL6

NEURO Submodule on Disorders of Nervous System [RADIOLOGY]

1 February 2011

Pattern Recognition in Common Neurologic Diseases on CT and MRI

Dr. Catherine Lazaro

OUTLINE I. CT Scan History A. B. Basic principles C. Hounsfield Unit Values of Various Substances II. MRI History A. B. Types of Scanners C. Terminologies III. HYPERDENSE LESIONS A. Acute Hemorrhage B. Acute Epidural Hematoma C. Acute Subdural Hematoma D. Physiologic Calcifications in the Globus Pallidum E. Focal Falcine Calcification F. Herniation IV. HYPODENSE LESIONS A. Acute Infarct B. Chronic Strokes V. MRI LESIONS VI. TRAUMA A. Extra- axial B. Intra- axial VII. NEOPLASMS VIII. BRAIN ABSCESS IX. PATTERNS OF EDEMA A. Cytotoxic Edema B. Vasogenic Edema X. SPINAL CORD LESIONS End Plate Damage A. B. Disc Herniations 1. Disc Bulge 2. Disc Protrusion 3. Disc Extrusion 4. Sequestered Disc

C. Hounsfield Unit Values of Various Substances Numerical Value 1 0 0 0 1 0t o3 0 0 a v e r a g eo f + 3 0 + 3 5t o+ 5 0 + 8 0t o+ 5 0 0 + 1 0 0 0 A i r F a t Wa t e r S o f t t i s s u e s / m u s c l e A c u t eb l o o d / p r o t e i n a c e o u sm a t e r i a l C a l c i u m Me t a l Table 1. Hounsfield Unit Values Hounsfield Unit degree of lightness and darkness on CT Hounsfield Artifact dirt in a CT image N O T E : oNegative units appear black on CT oPositive units appear white on CT oUnits only range from - 1000 to +1000 units. D. Terminologies H y p e r d e n s eo r h i g ha t t e n u a t i o nb r i g h t / w h i t e H y p o d e n s eo r l o wa t t e n u a t i o nd a r k / b l a c k I s o d e n s ed e g r e eo f g r a y n e s ss i m i l a r t ot i s s u eb e i n g r e f e r r e dt oo r e x a m i n e d( i . e . , i s o d e n s et os u r r o u n d i n gb r a i n p a r e n c h y m a ; i s o d e n s et om u s c u l a r t i s s u e ) Substance

II. Magnetic Resonance Imaging (MRI)

Used to be called Nuclear Magnetic Resonance Contraindications: patients with metallic splinter in the eye or those with pacemakers It uses magnetic energy, not radiation. A. History 1 9 3 6D u t c hp h y s i c i s t , C.J. Gorter i n t r o d u c e dt h ec o n c e p t o f N u c l e a r Ma g n e t i cR e s o n a n c e( N MR ) 1 9 7 3Paul Lauterbur s u g g e s t e dt h em e d i c a l a p p l i c a t i o n so f N MR 2 0 0 3L a u t e r b u r a n dMansfield w o nt h eN o b e l p r i z ef o r p h y s i o l o g ya n dm e d i c i n e B. Types of MRI Scanners Open- type n o n p e r m a n e n t m a g n e t oused mainly for claustrophobic patients oimage is not as clear as one rendered from closed- type Closed- type p e r m a n e n t m a g n e t C. Terminologies H y p e r i n t e n s eo r h i g hi n t e n s i t yb r i g h t / w h i t e H y p o i n t e n s eo r l o wi n t e n s i t yd a r k / b l a c k I s o i n t e n s ed e g r e eo f g r a y n e s sc o m p a r e dt ot i s s u eb e i n g r e f e r r e dt oo r s t u d i e d T 1 w e i g h t e d( T 1 W) w a t e r / C S Fa p p e a r sb l a c k / h y p o T 2 w e i g h t e d( T 2 W) w a t e r / C S Fa p p e a r sw h i t e / h y p e r ( Remember: WW2 water is white on T2) oC a l c i f i c a t i o n sa p p e a r b r i g h t oI n f a r c t sa p p e a r a sh y p o d e n s el e s i o n s N O T E : Some T1W images with contrast may look like T2W images. Technique is to look at CSF, which will always be black on T1W.
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I. Computerized Tomography Scan (CT Scan)

A. History F i r s t i n t r o d u c e db yB r i t i s he n g i n e e r Godfrey Hounsfield i n A p r i l o f 1 9 7 2 H o u n s f i e l dt o g e t h e r w i t hp h y s i c i s t Alan Cormack r e c e i v e d t h eN o b e l p r i z ef o r p h y s i o l o g ya n dm e d i c i n ei n1 9 8 2 B. Basic Principles in CT Scan

Figure 1. Basic Principles of CT Scan N O T E : CT is 2D but computers can manipulate it to reconstruct a 3D image.

Team 6

L i a nD e t t eD e n i s eP i aR o n D A r n e lP B G S a n d yP a t s e eT J

Pattern Recognition in Common Neurologic Diseases on CT and MRI

III. HYPERDENSE LESIONS
Can be caused by bone, hemorrhage, or calcifications Do not just identify the lesion. Also describe what it does to surrounding structures (e.g., herniation) A. Acute Hemorrhage D. Physiologic Calcifications in the Globus Pallidum

RADIOLOGY

Figure 5. P h y s i o l o g i c c a l c i f i c a t i o n si n g l o b u sp a l l i d i ( b i l a t e r a l ) . Figure 2. C TS c a n s h o w i n ga ni n t r a c e r e b r a l h e m o r r h a g ed u et oh i g h b l o o dp r e s s u r e( * ) w i t h d i f f e r e n t d e n s i t i e so f l a y e r i n gb l o o d( y e l l o w a r r o w s ) .

E. Pineal Gland Calcification

B. Acute Epidural Hematoma

Figure 3. C TS c a n s h o w i n ge p i d u r a l h e m a t o m ao f t h el e f t t e m p o r o p a r i e t a l ( a r r o w s ) . N O T E : I t a s s u m e sa lentiform shape b e c a u s ei t i sl i m i t e db y t h ed u r a .

Figure 6. P i n e a l G l a n dC a l c i f i c a t i o n F. Focal Falcine Calcification

Figure 7. C a l c i f i e d m e n i n g i o m a sf r o mt h e C. Acute Subdural Hematoma p a r i e t a l c o n v e x i t y Figure 4. C TS c a ns h o w i n g a na c u t es u b d u r a l h e m a t o m a( a r r o w s ) . N O T E : C o m p a r e dt o e p i d u r a l h e m a t o m a , s u b d u r a l h e m a t o m a s a s s u m eaconvexity o f t h e l o b eb e c a u s ei t i snot l i m i t e db yt h ed u r a . G. Herniation Figure 8. S u b d u r a l h e m a t o m ar e s u l t i n g t os u b f a l c i n e h e r n i a t i o n( a r r o w s ) . N O T E : Me a s u r et h e d i s t a n c eb e t w e e nt h e NOTE: As blood ages, the color of hematoma on CT images gets darker and may assume the color of CSF. m i d l i n ea n dt h e l e s i o n s . I f i t i m p e d e s t h a t m u c h , i t n e e d s s u r g e r y

Team 6

L i a nD e t t eD e n i s eP i aR o n D A r n e lP B G S a n d yP a t s e eT J

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Pattern Recognition in Common Neurologic Diseases on CT and MRI

IV. HYPODENSE LESIONS
A. Acute Infarct F r o m2 0 1 3t r a n s :

RADIOLOGY

Figure 9 . N o n c o n t r a s t C Tb r a i no f p a t i e n t w i t h r i g h t MC Ai n f a r c t . E a r l y i s c h e m i cc h a n g e s e v i d e n t a t 4ha f t e r o n s e t a r es u l c a l e f f a c e m e n t ( g r e e n
a r r o w s / a r r o w so nl e f t )

After 24 hours, signs are more visible. Infarcts like this indicate large damage to the brain. What we can do is just to decrease further damage. As infarct progresses, it may be as hypodense as CSF V e n t r i c l e sm a yd i l a t ed u et od e c r e a s e db r a i np a r e n c h y m ai n t h ea r e ao f i n f a r c t C e p h a l i cc y s t sm a ya l s od e v e l o pi nt h ea r e ao f i n f a r c t

V. MRI LESIONS
, D i f f e r e n t p a t t e r no f r e c o g n i t i o nf r o mC T oN o t j u s t s i m p l yb a s e do nd e g r e eo f i n t e n s i t yb u t t i m i n ga n d d u r a t i o na sw e l l oThe most basic are T1W and T2W. oO t h e r i m p o r t a n t s e q u e n c e sa r eD i f f u s i o nWe i g h t e dI m a g i n g a n dA p p a r e n t D i f f u s i o nC o e f f i c i e n t ( A D C ) . oU s e di na s s e s s i n gt r a u m a , n e o p l a s m s , a n da b s c e s s e s A l w a y sc o r r e l a t e dl e s i o ni n t e n s i t yw i t hn o r m a l b r a i np a r e n c h y m a i n t e n s i t ya n dC S Fi n t e n s i t yi na l l s e q u e n c e s . Have a reference point. For MRI lesions, we may need to look at both T1 and T2; do not depend on just one study. For Acute infarcts = Diffusion weighted image is very valuable! Memorize these tables!! a n d A g eo f H e m o r r h a g e H y p e r a c u t e A c u t e S u b a c u t e O l d T 1 W I n t e r m e d i a t e * I n t e r m e d i a t e * B r i g h t D a r k T 2 W B r i g h t D a r k B r i g h t D a r k

a n dp a r e n c h y m a l h y p o a t t e n u a t i o n ( p i n k
a r r o w / a r r o wo nr i g h t )

d u et oe d e m a .

Figure 10. A f t e r 2 4 h o u r s , m o r e p r o n o u n c e d p a r e n c h y m a l h y p o d e n s i t yd u et o s w e l l i n g( y e l l o w
a r r o w / a r r o wo nl e f t )

p e t e c h i a l h e m o r r h a g i c t r a n s f o r m a t i o n ( r e d
a r r o w / a r r o wo nr i g h t ) .

* I n t e r m e d i a t en e i t h e rd a r kn o rb r i g h t

Hypodense lesions are difficult to identify because almost everything is hypodense. Infarcts are the most common lesions seen in ER or in general practice. Infarcts can be hyperacute (<6 hours) that makes it hardly perceptible, but as the infarct progresses it will be easier to visualize because it becomes more delineated. oThey will show subtle signs like effacement of sulci oAlso, the lentiform nucleus will no longer be well- defined. The doctors job is to identify lesions at the highly critical period of 3 hours. B. Chronic Strokes
D u r a t i o n A c u t e

Table 2. Appearance of Lesion Based of Duration T 1 W

H y p o i n t e n s e

T 2 W
H y p e r i n t e n s e

D WI
H y p e r i n t e n s e D e c r e a s e d i n t e n s i t y

A D C
H y p o i n t e n s e H y p e r i n t e n s e

S u b a c u t eH y p o i n t e n s e H y p e r i n t e n s e O l d I s o i n t e n s et o C S F I s o i n t e n s et o C S F

Table 3. Age of Occlusive Infarct CASE 1: Patient presenting with right- sided weakness.

Figure 11. I m a g i n gu s i n gn o n c o n t r a s t e n h a n c e dc o m p u t e r t o m o g r a p h y( N E C T )

First few hours to months, CT screening can return negative. When something is seen on CT during the first 6 hours of an infarct, prognosis is grim. Figure 10. C h r o n i cS t r o k e s oI ni n f a r c t s , b a s a l g a n g l i a / l e n t i f o r mn u c l e u si su s u a l l yn o t s e e n .
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Team 6

L i a nD e t t eD e n i s eP i aR o n D A r n e lP B G S a n d yP a t s e eT J

Pattern Recognition in Common Neurologic Diseases on CT and MRI

RADIOLOGY

MRI is the best screening choice for rapid detection of lesions. However, CT remains the most commonly used because MRI is very expensive (CT: P2000; MRI: P8000) CASE 2:

Perfusion Scan s h o w sh o wm u c hb l o o df l o w si n t oap a r t i c u l a r a r e ao f t h eb r a i n . oMatch/superimpose diffusion sequence (the lesion as seen on T1W or T2W) with perfusion sequence. oIf they are completely superimposable (no penumbra), it means that theres no more salvageable brain in the lesion. oIf there is a penumbra, the salvageable parenchyma must be reperfused within 3 hours of onset (not at detection of infarct). Penumbra d e f i n e da sa na r e ao f m a r k e d l yr e d u c e d p e r f u s i o nw i t hl o s so f f u n c t i o no f s t i l l v i a b l en e u r o n s . T i m e l yp e r f u s i o no f t h i st i s s u em a yp r e v e n t c e l l d e a t ha n d h e l pr e e s t a b l i s hn o r m a l f u n c t i o n .

T2 FLAIR T1 Figure 12. Comparison of T2W, FLAIR, and T1W MRI T2W image reveals hyperintensity in lentiform nucleus which is hardly perceptible using T1. Hyperintensity is seen more using Fluid Attenuation Inversion Recovery (FLAIR)

Figure 15. Penumbra in an Infarction

VI. Trauma
Figure 16. S c h e m a t i cC TS c a no f t h e DWI ADC Figure 13. Infarct seen using DWI MR I i sc o n s i d e r e dab e t t e r t e s t t h a nC Tf o r i d e n t i f y i n ga c u t e i s c h e m i cc h a n g e sw i t hd i f f u s i o nMR b e i n gh i g h l ys p e c i f i ct e s t f o r e a r l yd e t e c t i o no f i n f a r c t . oInfarct is very hyperintense using Diffusion Weighted Imaging (DWI) H o w e v e r ,a f t e r1 2h o u r s ,t h es e n s i t i v i t yo fC Ts c a ni sa l m o s t t h es a m ea sMR I . Apparent Diffusion Coefficient (ADC) is used with DWI. oWill determine if infarct is acute, hyperacute, or chronic oIf an infarct were 4 days old, medications would not work anymore. m o s t c o m m o ns k u l l a n db r a i ni n j u r i e s a t t r a u m a 1L i n e a r f r a c t u r e 2D e p r e s s e df r a c t u r e 3F o r e i g nb o d yo f m e t a l d e n s i t y 4P n e u m o c r a n i u ma n d p n e u m o c e p h a l u s 5C o n t u s i o nh e m a t o m aw i t he d e m a 6A c u t es u b d u r a l h e m a t o m a 7C h r o n i cs u b d u r a l h e m a t o m aw i t h r e b l e e d i n g 8E x t r a d u r a l h e m a t o m af o r m a t i o n

A. Extra- axial Injuries Injuries outside the brain parenchyma oE p i d u r a l h e m o r r h a g e oS u b d u r a l h e m o r r h a g e oS u b a r a c h n o i dh e m o r r h a g e 1. Epidural Hematoma B l o o dc o l l e c t i o nb e t w e e nt h ei n n e r t a b l eo f s k u l l a n dd u r a m a t t e r F r a c t u r ea c r o s st h em i d d l em e n i g e a l a r t e r yg r o o v e D o e sn o t c r o s ss u t u r e s L e n t i f o r ms h a p e C a nc r o s sf a l xa n dt e n t o r i u m
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Figure 14. Matched Diffusion- Perfusion

Team 6 L i a nD e t t eD e n i s eP i aR o n D A r n e lP B G S a n d yP a t s e eT J

Pattern Recognition in Common Neurologic Diseases on CT and MRI

RADIOLOGY

B. Intra- axial Injuries Figure 17. T 2 W MR I i m a g eo f a ne p i d u r a l h e m a t o m a . N O T E : D u r ai ss e e na sa hyposignal line. Injuries inside the brain parenchyma or spinal cord 1. Cerebral Contusion I n j u r yt ob r a i ns u r f a c e si n v o l v i n gs u p e r f i c i a l g r a ym a t t e r C h a r a c t e r i s t i cl o c a t i o n sa r ea d j a c e n t t ob o n y p r o t r u b e r a n c e o r d u r a l f o l d P a t c h ys u p e r f i c i a l h e m o r r h a g e sw i t h i n e d e m a t o u s b a c k g r o u n d

Epidural hematoma shows mixed hyperdense and isodense (intermediate intensity). This indicates that it is actively bleeding. 2. Subdural Hematoma H e m o r r h a g i cc o l l e c t i o n i nt h es u b d u r a l s p a c e S t r e t c h i n go r t e a r i n go f b r i d g i n gc o r t i c a l v e i n s C r e s c e n t s h a p e d ; concave border Ma yc r o s ss u t u r e s , n o t d u r a l a t t a c h m e n t s Figure 18. A na x i a l T 1 W MR I d e m o n s t r a t e s b i l a t e r a l s u b a c u t e s u b d u r a l h e m a t o m a s w i t hi n c r e a s e ds i g n a l i n t e n s i t y . A r e a so f i n t e r m e d i a t ei n t e n s i t y r e p r e s e n t m o r ea c u t e h e m o r r h a g ei n t ot h e s u b a c u t ec o l l e c t i o n s . 2. Diffuse Axonal Injury (DAI)

Figure 20. C e r e b r a l c o n t u s i o n . N O T E : T h e s ea r e m o r es h a l l o wt h a n D A I s .

T r a u m a t i ca x o n a l s t r e t c hi n j u r y H i g hv e l o c i t ym o t o r v e h i c l ea c c i d e n t T e n d st oo c c u r i nt h r e ef u n d a m e n t a l a n a t o m i ca r e a s( l o b a r w h i t em a t e r ,c o r p u sc a l l o s u i u m a n dt h ed o r s o l a t e r a l a s p e c t o f t h eu p p e r b r a i n s t e mi n v o l v e d ) I n v o l v e m e n t b e c o m i n gs e q u e n t i a l l yd e e p e r w i t hi n c r e a s e d s e v e r i t yo f t r a u m a Figure 21. A na x i a l , n o n e n h a n c e dC Ti m a g eo f t h e b r a i nd e m o n s t r a t e s m u l t i p l es m a l l p e t e c h i a l h e m o r r h a g e sa t t h eg a r y w h i t em a t t e r j u n c t i o n , t h e c a u d a t en u c l e u sa n dt h e c o r p u sc a l l o s u m , c h a r a c t e r i s t i co f d i f f u s e a x o n a l i n j u r yi nt h i sm a l e w h ow a si nam o t o r v e h i c l e a c c i d e n t .

3. Subarachnoid Hemorrhage Collect around the sulci

MR I i st h eb e s t i m a g i n gm o d a l i t yf o r c e r e b r a l c o n t u s i o n s

Figure 19. MR Is h o w ss u b a r a c h n o i dh e m o r r h a g e ,w h i c h a p p e a r sh y p e r i n t e n s eo nT 2 W a n dF L A I Ri m a g e sa n d i s o i n t e n s et oh y p o i n t e n s eo nt h eT 1 Wi m a g e . F i n d i n g si n t h er i g h tp a r i e t a lr e g i o ne x t e n di n t oc o r t i c a ls u l c ia n d s u g g e s t h y p e r a c u t eo r a c u t eh e m o r r h a g e .

Figure 22. Coup and Contrecoup Injuries

Team 6

L i a nD e t t eD e n i s eP i aR o n D A r n e lP B G S a n d yP a t s e eT J

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Pattern Recognition in Common Neurologic Diseases on CT and MRI

VII. Neoplasms
A. Astrocytoma oP r i m a r yb r a i nn e o p l a s m oH a sd i f f e r e n t c o n f i g u r a t i o n ss od i f f i c u l t t od i a g n o s es o l e l yo n u s i n gi m a g i n g oT h ep r i m a r yt u m o r i sd i f f i c u l t t od i a g n o s ef r o mt h e e d e m a t o u sp a r e n c h y m a

RADIOLOGY

Figure 25. MRI of a pyogenic brain abscess

IX. Patterns of Edema

A. CYTOTOXIC EDEMA D u et oc e l l d e a t ha n di n j u r y D i s r u p t i o no f N a K p u m pa n da u t o r e g u l a t i o no f i n f l o w / o u t f l o wo f f l u i da t t h ec e l l u l a r l e v e l C e l l b u r s t sw h e nt o om u c hf l u i di sa c c u m u l a t e dr e s u l t i n gi n f l u i dc o l l e c t i o na r o u n dt h el e s i o no r a t i t sp e r i m e t r yt h u sa perimetric configuration

O nT 1 W h y p o i n t e n s e

O nT 2 W h y p e r i n t e n s e

Figure 23. MRI of astrocytoma B. Glioblastoma Multiforme A h i g hg r a d ea s t r o c y t o m a O nT 1 W h y p o i n t e n s e O nT 2 W h y p e r i n t e n s e oP e r i m e t r i ce d e m a H y p o i n t e n s eo nT 1 W H y p e r i n t e n s eo nT 2 W

Figure 26. C y t o t o x i c e d e m am a ya p p e a r a sh y p o d e n s i t i e s s u r r o u n d i n gt h e l e s i o n . T h i si s c o m m o ni ni n f a r c t s

B. VASOGENIC EDEMA D i s r u p t i o no f n o r m a l b l o o db r a i nb a r r i e r T h i r ds p a c el o s s F l u i de x t r a v a s a t e si n t ot h ea r e ao f l e a s t r e s i s t a n c ea n dl e s s c e l l u l a r i t y( w h i t em a t t e r ) f r o n d l i k e o r f i n g e r l i k e c o n f i g u r a t i o n , which are projections affecting mainly white matter

Figure 27. V a s o g e n i c e d e m ai n t e r d i g i t a t e s i n t ot h es p a c e s Figure 24. MRI of Glioblastom Multiforme p r o d u c i n gf i n g e r l i k e a p p e a r a n c e . D u et ot h e b r e a k d o w no f t h eb l o o d b r a i nb a r r i e r , f l u i d e x t r a v a s a t e si n t ot h e w h i t em a t t e r .

VIII. Brain Abscess (Mature)

R i me n h a n c i n gl e s i o n so nI Vc o n t r a s t e n h a n c e ds e q u e n c e s E n h a n c e m e n t i ss e c o n d a r yt oc o l l a g e n o u sc a p s u l e s u r r o u n d i n gt h el i q u e f i e dn e c r o t i cm a t e r i a l P a t h o g n o m o n i co f b r a i na b s c e s s : inner necrotic tissue s u r r o u n d e db yenhancing rim

Team 6

L i a nD e t t eD e n i s eP i aR o n D A r n e lP B G S a n d yP a t s e eT J

P a g e6 o f8

Pattern Recognition in Common Neurologic Diseases on CT and MRI

X. Overview of Spine Pathology
I m a g i n gd e a l sw i t ht h er e l a t i o n s h i pb e t w e e n oV e r t e b r a l b o d i e s oI n t e r v e r t e b r a l d i s c s oP o s t e r i o r e l e m e n t s oS p i n a l c o r d / c o l u m n MR I d e a l sw i t hs o f t t i s s u e s , c a r t i l a g e , d i s cd i s e a s e s , e n d p l a t e c h a n g e sa n dc o r dd i s e a s e oMRI modality of choice for spinal cord C Td e a l sw i t ht h eo s s e o u ss t r u c t u r e sa n di m a g e sa n a t o m ya s w e l l a sf r a c t u r e sb e t t e r t h a nMR I oCT Scan modality of choice for spinal column A. End Plate Change Seen in degenerative diseases. These have to be typed to distinguish them from neoplasm Figure 29. Disc Bulge 2. Disc protrusion

RADIOLOGY

oI f i t b u l g e sl a t e r a l l yn o t s i g n i f i c a n t i nt h a t i t d o e s n t c o m p r e s sa n y t h i n g ; n ob a c kp a i n

Figure 28. End Plate Change on MRI Modic Type 1 2 3 Changes F i b r o v a s c u l a r c h a n g e s F a t t ym a r r o w c h a n g e s S c l e r o t i cc h a n g e s T1W H y p o i n t e n s e T2W H y p e r i n t e n s e

F o c a l a s y m m e t r i ce x t e n s i o no f d i s ct i s s u eb e y o n dv e r t e b r a l b o d ym a r g i ni nt os p i n a l c a n a l o r n e u r a l f o r a m i n a Me d i o l a t e r a l d i m e n s i o nb r o a d e r t h a na n yo t h e r d i m e n s i o n S o m eo u t e r a n n u l a r f i b e r si n t a c t D o e sn o t e x t e n di nt h ec r a n i a l o r c a u d a l d i r e c t i o n T 1 W &T 2 Wl o ws i g n a l Wi d t ho f t h ep r o t r u d i n gd i s ci sw i d e r t h a ni t sA Pd i a m e t e r ( Wi d t h>A Pd i a m e t e r ) S i g n i f i c a n t w h e ni t c o m p r e s s e st h en e r v er o o t sa st h i s p r o d u c e sp a i n A n n u l a r f i b e r sa r ei n t a c t , k e e p i n gt h en u c l e u sp u l p o s u si n p l a c e

H y p e r i n t e n s e H y p e r i n t e n s e H y p o i n t e n s e H y p o i n t e n s e

Table 4. Comparisons of Modic Types of End Plate Changes

B. Disc Herniations Mo s t c o m m o nc a u s eo f c o m p l a i n t so f b a c kp a i n sa s i d ef r o m k i d n e ys t o n e s C l a s s i f i e di n t of o u r c a t e g o r i e sb e c a u s et h em a n a g e m e n t a n d p i c t u r ef o r e a c hw o u l dd i f f e r a l t h o u g ht h e ya r ev e r ys i m i l a r 1. Disc bulge

T h e r ec o u l da l s ob es p i n a l c a n a l s t e n o s i s Nucleus pulposus protrudes into canal

D i f f u s e l yb u l g i n gd i s c se x t e n d i n gs y m m e t r i c a l l ya n d c i r c u m f e r e n t i a l l y > 2m mb e y o n dm a r g i n so f a d j a c e n t v e r t e b r a l b o d y D i s cb u l g e so u t s i d et h er i mo f t h ev e r t e b r a l b o d y oI f y o us e et h eb u l g ep o s t e r i o r l y , c o r d sm a yb e c o m p r e s s e da n dt h e r e f o r em a n i f e s t sa sb a c kp a i n .
Team 6 L i a nD e t t eD e n i s eP i aR o n D A r n e lP B G S a n d yP a t s e eT J

Figure 30. D i s cP r o t r u s i o n

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Pattern Recognition in Common Neurologic Diseases on CT and MRI

3. Disc extrusion

RADIOLOGY

QUIZ!!
Modified T/F. I f f a l s e , c o r r e c t t h es t a t e m e n t . 1 . 2 4 ha f t e r aC V A , a nMR I b e c o m e so n l ya ss e n s i t i v ea saC Ts c a n . 2 . T h ep e n u m b r ai st h es a l v a g e a b l ep a r t o f a ni s c h e m i cl e s i o na n d h a sm a r k e d l yr e d u c e dp e r f u s i o nw i t hl o s so f f u n c t i o n .

Mo r ep r o n o u n c e dt h a np r o t r u s i o n D i s r u p t i o no f o u t e r a n n u l a r f i b e r s G r e a t e r A Pd i m e n s i o nt h a nb a s e( n e c ka r e a / m e d i o l a t e r a l d i m e n s i o n ) Mi g r a t e su po r d o w nb e h i n da d j a c e n t v e r t e b r a l b o d yb u t m a i n t a i n sc o n t i n u i t yw i t ht h ep a r e n t d i s c S a m es i g n a l a sp a r e n t d i s co na l l p u l s es e q u e n c e s A Pd i a m e t e r o f t h ee x t r u d i n gd i s ci sg r e a t e r t h a ni t sw i d t h ( A P>w i d t h ) C a u s e ss i g n i f i c a n t n a r r o w i n go f s p i n a l c a n a l C a nm i g r a t eu po r d o w n , b u t s t i l l b o u n d e db ya n n u l a r f i b e r s I f t h e r ei sm i g r a t i o ng o i n gu po r d o w n , i t w i l l p r o d u c em o r e s y m p t o m sd e p e n d i n go nl e v e l i n v o l v e d

3 . Y o um u s t a c t w i t h i n3 ha f t e r d i a g n o s i n gap a t i e n t w i t hC V A . 4 . A ne p i d u r a l h e m a t o m af o r m sac r e s c e n t s h a p e , w h i l eas u b d u r a l h e m a t o m af o r m sal e n t i f o r ms h a p e . 5 . O nT 2 W, ah e m o r r h a g eg r a d u a l l yd e c r e a s e sf r o mb r i g h t t od a r k w h e ns h i f t i n gf r o mh y p e r a c u t et oo l d . 6 . O nT 1 W, ah e m o r r h a g ei sh y p e r a c u t e l yt oa c u t e l yi n t e r m e d i a t e , s u b a c u t e l yb r i g h t , a n dd a r kw h e no l d . 7 . C y t o t o x i cc e r e b r a l e d e m ah a sf l o o d i n go f t h ec e l l sf o r m i n gf r o n d o r f i n g e r l i k ef o r m so ni m a g i n g . 8 . As e q u e s t e r e dd i s ci sap r o t r u d e dd i s ct h a t m a ym i g r a t eu po r d o w nw h i l em a i n t a i n i n gc o n t i n u i t yw i t ha d j o i n i n gd i s c s . 9 . Mo s t s u p r a t e n t o r i a l a s t r o c y t o m a sa r eh y p e r i n t e n s eo nT 1a n d s l i g h t l yh y p o i n t e n s eo nT 2 . 1 0 . I nap a t i e n t w i t hs u b d u r a l h e m a t o m a , w h e nt h eb l o o dh a sb e e n a r o u n df o r af e wd a y s , i t a p p e a r sh y p o d e n s eo nC T . Answers: 1 . 12h a f t e r aC V A , a nMR I b e c o m e so n l ya ss e n s i t i v ea saC Ts c a n . 2 . TRUE ( I t sm a r k e d l yr e d u c e d , BUT t h en e u r o n sa r es t i l l v i a b l e . ) 3 . Y o um u s t a c t w i t h i n3 ha f t e r the CVA. 4 . A ne p i d u r a l h e m a t o m af o r m salentiform s h a p e , w h i l eas u b d u r a l h e m a t o m af o r m sacrescent s h a p e . 5 . O nT 2 W, ah e m o r r h a g ealternates between bright and dark w h e ns h i f t i n gf r o mh y p e r a c u t et oa c u t et os u b a c u t et oo l d . 6 . TRUE ( I n t e r m e d i a t et ob r i g h t t od a r k . ) 7 . Vasogenic c e r e b r a l e d e m ah a sf l o o d i n go f t h ebrain parenchyma f o r m i n gf r o n do r f i n g e r l i k ef o r m so ni m a g i n g . 8 . As e q u e s t e r e dd i s ci san extruded d i s ct h a t m a ym i g r a t eu po r d o w na n ddoes not m a i n t a i nc o n t i n u i t yw i t ha d j o i n i n gd i s c s . 9 . Mo s t s u p r a t e n t o r i a l a s t r o c y t o m a sa r eslightly hypointense o nT 1 a n dhyperintense o nT 2 . 1 0 . I nap a t i e n t w i t hs u b d u r a l h e m a t o m a , w h e nt h eb l o o dh a sb e e n a r o u n df o r af e wd a y s , i t a p p e a r sisodense o nC T .

Figure 18. D i s cE x t r u s i o n 4. Sequestered Disc L o ws i g n a l s i m i l a r t op a r e n t d i s c P e r i p h e r a l o r d i f f u s eh i g hs i g n a l o nT 2 Wa n dT 1 C + A n n u l a r f i b e r sa r et o r n C a np r o d u c es y m p t o m sf a r a w a yf r o mt h el e v e l w h e r ei t p i n c h e do f f f r o m( S e q u e s t e r e dd i s cm a yo r i g i n a l l yc o m e f r o ml e v e l Xb u t t h es y m p t o m sm a n i f e s t e da r ec h a r a c t e r i s t i c o f l e v e l Y )

Figure 19. S e q u e s t e r e dD i s c

Team 6

L i a nD e t t eD e n i s eP i aR o n D A r n e lP B G S a n d yP a t s e eT J

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