Basics of Neuroradiological Imaging: Brain MRI or CT

Modern technology has given us the tools to view the living brain and skull in some detail. In addition, the arteries and veins of the brain and of the meninges can be visualized by mapping the movement of blood through these vascular structures. The resultant images are powerful tools to use in the diagnosis of the neurologically impaired patient. Radiography (x-rays) A plain radiograph of the head or spinal column provides hardly any information about the normal anatomy of the brain or spinal cord - the so-called soft tissues. X-rays are best used for hard tissue such as bone. Sometimes, displacement of parts of the brain can be visualized with an x-ray if a radio-opaque substance such as calcium is present in the brain. For example, the pineal gland often calcifies in adults and displacement of the calcified pineal gland can reveal displacement of midline structures. With contrast media, x-ray images can be more informative. In angiography, a radio-opaque liquid injected into one of the carotid or vertebral arteries shows the branches of the arteries and veins. The chief value of this technique is for detecting arterial disease (occlusion, stenosis, aneurysm) or displacements of blood vessels by lesions such as tumors. Computed tomography (CT) has replaced the older techniques of pneumoencephalography and ventriculography where air was injected into the ventricular system or cranial cavity and then visualized by X-ray.

MRI and CT The most routinely used methods to image the brain and skull are computed tomography (CT) and magnetic resonance imaging (MRI). CT is especially useful in visualizing the skull and the brain in the early stages of subarachnoid or brain hemorrhage (such as a stroke.) On the other hand, MRI shows brain anatomy in elegant detail, as well as cisternal relationships, cranial nerves, and a wide variety of clinical abnormalities. An MRI is the study of choice for tumor, multiple sclerosis, and ischemic stroke. A contrast medium, gadolinium, is often added to further evaluate tumor and abscess.

Magnetic resonance angiography (MRA) is a MRI technique that visualizes arteries and veins by measuring the velocity of flow in these structures. Knowledge of cranial cross-sectional anatomy is very important for analyzing a head MRI or CT. Once the normal structures are identified, abnormalities can be detected and a diagnosis may be possible. Symmetry is an important concept in anatomy and is almost always present in a normal head MRI and CT unless the patient was incorrectly positioned with the head cocked at an angle. Comparison of brain MRI and brain CT images

Figure 1: Left Axial MRI of brain; Right Axial CT of brain.

Obtaining and viewing images of the brain and skull Patients lie on their back (supine) for imaging of the brain or spinal cord and the surrounding bony structures of the skull and vertebral column. In this position, the dorsal surface of the brainstem and spinal cord and the caudal aspect (occipital pole) of the cerebral hemispheres face down. The ventral surface of the brainstem and spinal cord and the frontal pole are face up. Images of the brain are commonly made in coronal, axial (horizontal), and sagittal planes. Coronal scans are viewed as though you are looking the patient in the face, whereas axial scans are viewed as though you are standing at the patients feet and looking toward his head while the patient lies supine in the machine. Axial scans, in other words, show the cerebral hemispheres from anterior (the more superior portion of the hemisphere), with the patients frontal area and orbits at the top of the image and the occiput at the bottom. In both coronal and axial views, the patients left side is to the observers right.
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Figure 2. Left - patient in CT scanner; Right Patient in MRI scanner.

PLANES

MRI and CT images are commonly viewed in three planes: axial, coronal, and sagittal.

Figure 3: Planes of section

Sagittal

Coronal

Axial

Figure 4. MRI of each plane of section

Sagittal - this slices the brain from the side, i.e., right to left. Coronal these are slices that look at the brain face first, similar to cutting a loaf of bread from front to back. Axial these are horizontal slices viewing the brain from the top down, like layers of a cake. Sequence- A sequence sets the MRI scan to certain parameters, and collects information under those parameters. Different sequences are best at showing different types of disease. Sequences can include T1, T2 and contrast.

Figure 5. MRI sequences.

Magnetic Resonance Imaging (MRI) How MRI works (very, very briefly) Protons (hydrogen) constitute a large proportion of body tissue. These atoms have electrons that spin around the nucleus and as they do so, they induce an electrical current that creates a magnetic field. The protons are aligned randomly because of the changing magnetic effects on each other. But when they are exposed to a powerful magnet, they stop pointing randomly and align themselves in parallel with the external magnetic field but at different energy levels. When undergoing an MRI examination, the patient becomes a magnet, with all the protons aligning along the external magnetic field and spinning at an angle with a certain frequency. During the MRI procedure, short bursts of radio waves (electromagnetic waves) are sent into the magnet containing the patient. These bursts are known as a radiofrequency (RF) pulse. The energy of the RF pulse is absorbed when the RF pulse matches the frequency of the spinning proton. This phenomenon is called resonance and is the resonance in magnetic resonance imaging. But further magical manipulation, the computer generates two main types of MRI image, T1-weighted and T2-weighted (more on that below). Shades of Gray Matter The routine MRI is not in color; instead, an MRI shows pixels from white to black, with many shades of gray in between. The various shades of gray are described in terms of their signal intensity. Low signal intensity means dark, and high signal intensity means bright. Lighter colors are said to have higher signal or to be more intense. Commonly used terms for intensity are hyperintensity or hypointensity. These signify a region that is lighter or darker than expected. This may represent a lesion, but is sometimes due to artifact.

Figure 6. Can you find the regions of hyperintensity? Which areas of this image show very low signal intensity? This patient has multiple sclerosis (MS).

Enhancing Sometimes MRI scans are done using contrast. This involves intravenous injection of a contrast agent, usually gadolinium. The contrast will increase, or enhance, the signal of certain types of lesions. For example, an active multiple sclerosis lesion will enhance under contrast, whereas inactive multiple sclerosis lesions will not enhance.

Figure 7. MRI of patient with left-sided stroke. Image on the left has no contrast. Iimage on the right with gadolinium enhancement.

MRI Weighting: T1 and T2 The most commonly used techniques for MRI imaging are called T1-weighted and T2weighted (if you are interested, also look up Flair and Diffusion-weighted). These different techniques emphasize the normal brain or potential lesions in different ways. The different types of MRI represent computer manipulation of the data with each technique serving to visualize or emphasize certain aspects of anatomy or pathology. T1 weighted images are useful for brain anatomy (brain tissue or parenchyma.) The brain appears medium gray and CSF is dark gray, and air is nearly black. In certain MRIs, it is possible to distinguish gray matter from white matter. Most tumors appear dark, with low signal intensity. Fat has high signal intensity (very bright) on T1. Gadolinium contrast added to the T1 may light up a tumor or abscess. If a lesion has dark signal on T1, and bright signal with gadolinium, it is
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a contrast enhancing lesion. The enhancement may be the same throughout the lesion, making it homogeneously enhancing. gray matter fluid-filled space white matter

air-filled space fat

Figure 8 T1-weighted sagittal MRI, no contrast enhancemment. Look for areas of high-fat-content where tissues appear as bright areas of high signal intensity (hyperintense). Look for areas of high-water-content tissues which appear as dark areas of low signal intensity (hypointense).

T2-weighted images are great to evaluate CSF spaces, which appear bright white. Brain appears light gray. The T2 sequence is used to check the size and symmetry of the ventricles, and to look for bright signal of edema surrounding an aggressive tumor or a subacute stroke or hemorrhage.

Figure 9. Left - T1-weighted MRI. Note that the ventricles are black. Right T2-weighted MRI. Note that the ventricles are bright white.

Also the T2 images are used for multiple sclerosis, with its characteristic periventricular white matter changesbright splotches around the lateral ventricles. The bright signal is the scarring of the myelin sheath in the white matterthe sclerosis shows up on T2 images.

Figure 10. Left - T1 image - no contrast. A tumor is seen on the on patients left side. Right T2-weighted image, no contrast. The tumor is emphasized. Note on T2 images, high-fat-content tissues appear as dark areas of low signal intensity (hypointense while high-water-content tissues appear as bright areas of high signal intensity (hyperintense)

Computed Tomography CT is an x-ray imaging technique that measures the effects that tissue density and the various types of atoms in the tissue have on x-rays passing through the tissue. This technique is valuable in clinical diagnosis because the density of many cerebral lesions is greater or less than the density of normal brain tissue. The higher the atomic number, the greater the ability of the atom to attenuate, or stop, x-rays. The computer transforms the attenuation intensities into numbers that represent values found at all points in the volume of the tissue slice. The values are expressed in Hounsfield units (HUs). HU values are used in an arbitrary scale where bone is specified as +1000 (very white), water as zero, and air as -1000 (very black). Using this scale, HU or CT numbers represent specific shades of gray for each of the various points located in the slice.

Figure 11. CT gray scale [gradient bar] Some approximate numbers: bone +1000 calcification +150 to +200 blood +100 soft tissue +20 to +60 brain +30 fluid 0 to +15 CSF +5 water 0 fat -20 to -200 air -1000

Skull (bone)

Ventricle (fluid-filled space)

brain

Figure 12. Axial CT scan.

CT is a fast and accurate method of detecting hemorrhages such as recent subarachnoid hemorrhage. An acute subarachnoid hemorrhage in a noncontrast CT scan appears hyperdense (white) in contrast to the subarachnoid spaces and cisterns, which normally are hypodense (dark).

Figure 13. Left CT scan showing subacute subdural hematoma (arrowheads). Note the compression of gray and white matter in the left hemisphere due to the mass effect. Right CT scan showing high density blood (arrowheads) that fills the sulci over the right cerebral convexity in this subarachnoid hemorrhage.

A CT scan can be enhanced by using iodinated contrast material injected intravenously followed by the CT examination. Iodine has a large atomic number and attenuates x-rays. As a result, vasculature is visualized as hyperdense (white) structures. The contrast material may also enhance neoplasms or areas of inflammation, because the contrast agent leaks from the vessels into the cellular spaces owing to a breakdown of the blood-brain barrier.

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Self-study summary: 1. What are the 3 commonly used planes for brain imaging?

2. Describe the most common (advantageous) uses of each neuroradiological technique below: Xray:

MRI:

CT:

3. Which of the 3 techniques shows the most detailed brain anatomy?

4. Which technique is most closely related to the plain xray, MRI or CT?

5. T1 and T2 weighting are related to which imaging technique?

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6. On the scale between darkest and brightest, make check marks the charts below to indicate the relative intensity of each substance listed:

T1 weighted MRI:

DARKEST----------------------------------------------------BRIGHTEST Fat CSF Brain Tumor How would the tumor appear if gadolinium was given intravenously?

T2 weighted MRI: DARKEST----------------------------------------------------BRIGHTEST Fat CSF Brain Tumor Another disease state that T2 is commonly used to diagnose is _________________________.

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