Introduction to Brain Imaging

Dr. Christine Valerie Ucab

Brain Imaging
• Looking at the brain
• Current Neuroimaging Options
• Imaging strategy for Clinical Syndromes
• Analysis of Abnormality
Emergency CT checklist
• Is the middle of the brain in the middle of the head?
• Do the two sides of the brain look alike?
• Can you see the smile and the pentagon?
• Is the fourth ventricle midline and more or less symmetrical?
• Are the lateral ventricles enlarged, with effaced sulci?
Emergency CT checklist
• MIDLINE
• Is the middle of
the brain in the
middle of the
head?
Looking at the brain
• SYMMETRY
• Do the two sides
of the brain look
alike?
Looking at the brain
• BASAL CISTERNS
• Can you see the Smile and
the Pentagon?

Suprasellar cistern
Looking at the brain
• BASAL CISTERNS
• Can you see the Smile and
the Pentagon?
Looking at the brain
• VENTRICLES
• Is the fourth ventricle midline
and more or less symmetrical?
 Looking at the brain
• LATERAL VENTRICLES
• Are the Lateral Ventricles
enalarged, with effaced sulci?

Third ventricle
Midline Structures
• Sella and Suprasellar Region
Midline Structures
• Sella and Suprasellar Region
Midline Structures
• Pineal Region
Midline Structures
• Craniocervical Junction
Current Neuroimaging Options
Current Neuroimaging Options
• Conventional radiography
• Nuclear medicine brain scans
• CT, MR, US, and angiography in the evaluation of the acute
neurological patient
• First Tests are MR and CT.
Current Neuroimaging Options
Standard Emergency MR
examination
• T1-weighted sequence
• T2- weighted sequence
• Diffusion-weighted imaging
(DWI)
• Fluid-attenuated inversion
recovery (FLAIR)
Current Neuroimaging Options
• Proton MR Spectrometry
• Distribution of brain metabolites
• Three main metabolite: Choline,
N-acertyl aspartate and creatine
Choline
• May be a considered a tumor marker
• Tumor grading
• Histologic grade correlates with
choline-to-creatine ratio
• Better reflect nature of lesion
• Very high levels may be due to
meningioma
Current Neuroimaging Options
• Proton MR Spectrometry
• Distribution of brain metabolites
• Three main metabolite: Choline,
N-acertyl aspartate and creatine
N-acetyl aspartate
• Found only in neurons
• Marker for neuron density
• Decrease NAA-creatine ratio
associated with neuronal death
• Global depletion– multiple sclerosis or
Alzheimer’s disease
• SOL have small NAA peak
Current Neuroimaging Options
• Noninvasive Angiographic Techniques
• Iodinated contrast and rapid imaging
• Relatively thick cross sectional images
• Shaded 3D surface renderings
• Bone may be hard to distinguish from vessels
Current Neuroimaging Options
• Diffusion-weighted imaging
• Diagnose cerebral infarct early and
accurately
• Ischemic areas tend to swell
following osmosis into dying cells
• Become bright in DWI
• Precedes changes on T2 and FLAIR
• Tumor, trauma and infection can
have ambiguous appearance
• Also used for MS, brain abscess,
primary and metastatic brain tumors
and lymphoma
Current Neuroimaging Options
• Functional MRI (FMRI)
• Use blood oxygen level- dependent
imaging
• Neuronal activation increases the
blood flow
• Increase of oxy- to deoxyhemoglobin
ratio correlate with neuronal activity
• Highlights responsible brain function
in question
• Planning surgery for epilepsy and
brain tumors
• Neurobehavioral and
neurophsychological research
Imaging Strategies for Common Clinical
Syndromes
Acute Trauma
• Obtain noncontrast-
enahanced CT
• Detect extracerebral
hematomas
• Intracerebral contusions
Stroke
• Noncontrast CT scan
• Search for evidence of
haemorrhage
• Assume bland infarcts if no
haemorrhage
• MR- depicts irreversible
infarcts sooner
Prethrombolytic Evaluation
• Hemorrhagic complications more common with large infarcts present
• Loss of gray-white distinction
• Low attenuation in Basal Ganglia
• Poor definition of the insula
Seizure
• First episode: exclude intracranial tumor, infection and other acute
processes
• Contast-enhanced CT or contast-enhanced MRI
• Chronic seizure, refractory to medication: MRI is best
Infection and Cancer
• Contast-enhanced MR is preferred
• Advantage of detecting meningeal
disease
Headache
• “Thunderclap”—noncontrast head CT
• Chronic Headache– MR scanning
• With focal neurologic complaints– gadolinium enhanced MR
• Uncomplicated migraine may not require imaging
Coma
• Distinguish between coma, acute confusional state or dementia
• R/o intracranial haemorrhage or other lesions
• Non-contrast CT
• Majority will have no structural lesion
Dementia
• Noncontrast MR
• Patterns of atrophy
• Demonstrate small-vessel
ischemic changes
• PET studies for prognosis
Dementia
Posttraumatic encephalopathy
• Focal or diffuse atrophy
• Hemosiderin deposition
• Hemorrhagic MRI lesions
Analysis of the Abnormality
Analysis of the abnormality
• Mass
• Displacement of normal structures
• Shift in midline structures
• Effaced sulci
• Ventricles may be compressed
Analysis of the abnormality
• Atrophy
• Widening of the sulci
• Enlargement of the
ventricle
• Midline shift is unusual
• Diffuse atrophy– age-
appropriate cerebral
volume loss
• Dementia is diagnosed
clinically
• Consider rare conditions if
patient is <65 y.o.
Analysis of the abnormality
• Reversible atrophy
• dehydration and starvation
• Addison’s disease, high dose steroids and abnormal fluid balance
• Annorexia Nervosa and bulimia
• Alcoholism
Analysis of the abnormality
• Signal intensity or Attenuation pattern
• abnormality is white on CT or white on T1 MR or black on T2 MR
• brain is as bright as a light bulb on diffusion-weighted MR images
Mass lesion
• Intra-axial or Extra-axial mass?
• Extra-axial masses generally possess a broad
dural surface
• intra-axial masses are surrounded
completely by brain.
• posterior fossa– widening of the
subarachnoid space
• Supratentorial compartment:
• Intra-axial mass: expanded gyrus with
compressed CSF space
• Extra-axial mass: larger CSF space
• Gadolinium: dural enhancement for Extra-
axial mass
Mass lesion
• Solitary or multiple?
• Solitary– isolated primary cerebral disease
• Multiple– widespread or systemic diseases
Mass lesion
• Gray or white matter?
Gray matter– result of infarct,
trauma, or encephalitis
• With mass effect: acute
• Atrophic: likely chronic
White matter– if exclusively
involved, vasogenic edema
• Disturbance in tight capillary
junction
• Relatively slow and persists
overtime
Mass lesion
Lesion Distribution?

• Infarcts:
• vascular patterns
• Area of involvement
• Between two major vascular territories-- border zone or “watershed” infarct
Mass lesion
Lesion distribution?

• Traumatic lesion
• Orbital fossa, frontal polar
regions, temporal poles,
occipital poles
• Contra-coupe injury
• Penetrating brain wounds
Mass lesion
Lesion distribution?

• Herpes simplex encephalitis

• Medial temporal lobes, adjacent to the
trigeminal ganglia
• Orbital frontal regions adjacent to
olfactory bulbs
Mass lesion
• Contrast enhancement
• Does not imply malignancy
• Infarcts, hemorrhages, abscesses, and encephalitis
Thank you!