Brain Imaging

"Cord sign" in cerebral venous thrombosis

• The diagnosis can be achieved by means of CT (the
most readily available), magnetic resonance
imaging (MRI) (the method of choice) or by
conventional angiography (CA) (the most invasive
method). In 20% of cases, CT scans are normal.
• CVT findings can be classified in direct and indirect.
1. Direct signs include: The cord sign and the empty
delta sign
2. Indirect signs include: edema, infarction and
hemorrhage.
• The cord sign is characterized as increased density
of the sinuses or of the cortical or deep veins
• The cord sign is most frequently identified within
two weeks after the first symptoms onset.
• With time, the thrombus becomes isodense and
subsequently, hypodense
"Empty delta sign" in venous sinuses
thrombosis
• Postcontrast axial CT scan of the
brain (A) shows the nonenhancing
lumen of the superior sagittal sinus
surrounded by enhancing dura
(arrows).
• Nonenhanced axial CT scan of the
brain (B) shows a hyperdense
superior sagittal sinus (arrow)
suggestive of thrombus within. This
is called the ‘triangle sign.’
• Sagittal reconstruction of a contrast-
enhanced CT scan (C) shows filling
defects in the superior sagittal sinus
(long arrows) and in the straight
sinus (thick arrow), suggestive of
thrombus
"Arrow sign" in ruptured middle cerebral
artery aneurysm
• In ruptured aneurysms the pattern of
distribution of subarachnoid
hemorrhage can indicate its most likely
location.
• In cases of bifurcation middle cerebral
artery (MCA) aneurismal rupture the
bleed may present the shape of an
arrow, with the shaft and the tip
representing blood in the horizontal
segment of the Sylvian fissure and in
the frontotemporal opercular area,
respectively
"Dense artery sign" in acute middle cerebral
artery infarction
• The dense MCA sign is one of the early signs
of infarct.
• This is due an increase in density of its
proximal segments, secondary to
thrombosis
• False-positive results may occur, particularly
in cases of parietal calcification.
• It is important to observe that the distal
branches of the MCAs rarely present parietal
calcifications.
• Focal subarachnoid hemorrhage may
simulate an abnormally dense MCA
especially when located at the Sylvian
fissure and constitute an additional cause
for falsepositive results
"Dot sign" in acute middle cerebral artery
infarction
• The dot sign is one of the early signs of
acute infarction and corresponds to a
punctate hyperdensity in the Sylvian
fissure.
• The signal represents thrombosis in the
M2 and M3 segments of the MCA on plain
CT scans.
• The presence of a thrombus/clot within
the vessel alters and increases its density
• The dot sign has a high specificity and
high positive predictive value, but has low
sensitivity
"Hot nose sign" at brain death
• Hot nose sign dapat terlihat pada kasus mati
otak. Hot nose ditandai dengan ada nya
peningkatan awal aktivitas radiotracer pada
regio nasofaringeal. Tampilan depan dari
pemindaian radionuklida menunjukkan
peningkatan aktivitas tracer di daerah
nasofaring (panah) yang menunjukkan
peningkatan aliran darah
• Tanda ini dapat juga terlihat sebagai hiperemia
pada arteri carotid. fenomena ini disebabkan
oleh adanya penurunan tekanan darah dari
arteri carotid interna dan peningkatan tekanan
darah pada cabang carotid externa.
• tanda ini tidak esklusif untuk mati otak dan
mungkin saja dapat ditemukan pada kondisi
yang berbeda yang mengarah pada penurunan
aliran intrakranial pada satu atau kedua arteri
carotid interna
"Tau (t) sign" in persistent trigeminal artery
• The tau sign represents the appearance of the presellar
internal carotid artery (ICA) when a persistent trigeminal
artery (PTA) originates from it, on a T1W sagittal MRI image
• The configuration of the flow void in the presellar segment
of the ICA with the PTA arising from it, resembles the Greek
letter ‘τ’ (tau). The sign is suggestive of a PTA
• The PTA arises from the ICA as it exits the carotid canal and
enters the cavernous sinusIt joins the distal third of the
basilar artery between the origins of the anterior, inferior,
and superior cerebellar arteries.
• A PTA can be of two types:
1) The artery may supply the entire vertebrobasilar system distal
to the anastomosis or
2) The anastomosis may mainly supply the superior cerebellar
arteries bilaterally. PTA can be associated with aneurysms,
arteriovenous malformations, moya moya disease, and other
persistent carotid-vertebrobasilar anastomosis.
"Caput medusae sign" in developmental
venous anomaly
• Medusa head sign terlihat pada
kasus developmental venous
anomaly (DVA).
• Tanda ini paling terlihat pada
gambaran gadolinium-enhanced
T1W.
• DVA biasanya terletak pada
juxtacortical dan regio
periventricular dan sangat sering
terlihat pada lobus frontal &
parietal dan di brachium pontis
"Eccentric target sign" in toxoplasmosis
• The eccentric or asymmetrical target sign is
highly suggestive of central nervous system
toxoplasmosis.
• The sign represents a ring enhancing abscess
associated with an enhancing mural nodule
• This finding is highly specific, but has low
sensitivity, being found in approximately
30% of cases.
• The pathological correlation of such sign is
not completely understood, but it is believed
to represent internal folds and invaginations
of the abscess walls
"Reversal sign" in diffuse cerebral anoxia
• Such sign is characterized by the relative
inversion of attenuation between the
supra and infratentorial structures on
unenhanced CT and may indicate diffuse
brain ischemia.
• The sign can explained by relative increase
in the density of the cerebellum, basal
ganglia and thalami, and decreased
density of the cerebral cortex and white
matter
• Reversal sign can occur secondary to head
trauma, hypoxia, birth anoxia, near
drowning, status epilepticus, hypothermia,
bacterial meningitis and strangulation. The
pathogenesis is not completely clarified
White Cerebellum Sign
• On CT imaging, white (or dense)
cerebellum sign is seen when the
cerebellum appears dense with
respect to the cerebral
parenchyma.
• The “increase” in attenuation of
cerebellum is in fact a relative
hyperdensity caused by decreased
attenutation of the brain
• It represents anoxic-ischemic
cerebral injury
"Mount Fuji sign" in hypertensive
pneumocephalus
• This sign is seen in bilateral subdural hypertensive
pneumocephalus. These air collections cause compression
of the frontal lobes, which take up a shape similar to the
Mount Fuji silhouette
• Hypertensive pneumocephalus is a neurosurgical
emergency, in which the increased air pressure is thought
to be secondary to a check-valve mechanism.
• Air would enter freely into the subdural space by a defect in
the bone but would not escape with obstructive and the
egress of air being blocked by an obstruction.
• This sign is useful in the differentiation between
hypertensive and non-hypertensive pneumocephalus.
• Hypertensive pneumocephalus may be seen after the
drainage of subdural hematomas, following skull base,
paranasal sinuses and posterior fossa surgeries and in cases
of head trauma
"Molar tooth sign" in Joubert syndrome
• The molar tooth sign is represented by an
alteration of the mesencephalon which is
seen on axial sections of computed
tomography (CT) and magnetic resonance
imaging (MRI).
• This sign is seen mainly in cases of Joubert
syndrome.
• The normal superior cerebellar peduncles
decussation is absent and these become
thickened and with a more horizontal course
as they extend perpendicularly from the
brainstem.
"Spoke wheel sign" in meningioma
• The spoke wheel sign refers to the typical
angiographic appearance found in
meningiomas.
• This sign corresponds to multiple small arteries
radially distributed from a dominant feeding
artery Meningiomas are the most common
primary intracranial tumors in adults.
• They are extra-axial, slow-growing, well-
vascularized lesions with a benign behavior
(grade I, according to the World Health
Organization).
• Another remarkable and very common
characteristic of meningiomas is the presence
of a dural tail and, in 25% of cases,
hyperostosis of the adjacent bone.
"Dural tail sign" in meningiomas
• This sign represents thickening and enhancement of
the dura mater in continuity with a mass, which on MR
images, gives the appearance of a tail arising from the
mass
• Three criteria need to be met for a ‘positive’ dural tail
sign:
1. the tail should be seen on two successive images
through the tumor,
2. it should taper away from the tumor,
3. and it must enhance more than the tumor.
• This sign has been traditionally considered as highly
specific for meningioma.
• However, it is seen only in 60% of meningiomas and
has also been reported in nonmeningiomatous lesions
such as chloromas, primary CNS lymphomas,
sarcoidosis, schwannomas, metastases, and syphilitic
gummata.
"Salt and pepper sign" in paraganglioma
• This sign is seen on MRI images in
paragangliomas such as glomus tumors
• Four common locations of paragangliomas
in the head and neck are the carotid body,
the jugular foramen, along the path of the
vagus nerve, and the middle ear.
• The sign is indicative of the
hypervascularity of the mass. The ‘pepper’
represents multiple areas of signal void of
vessels and the ‘salt’ represents the
hyperintense foci due to slow-flow vessels
or hemorrhages in these hypervascular
tumors.
• The sign is seen in tumors that are more
than 1 cm in diameter.
• The sign is not specific for paragangliomas
and has been reported in other
hypervascular lesions such as metastatic
hypernephroma and metastatic thyroid
carcinoma
"Pancake brain sign" in alobar
holoprosencephaly
• This sign describes the appearance of
the abnormal brain in alobar
holoprosencephaly (HPE).
• The appearance is caused by fusion of
the cerebral hemispheres and the
presence of a single ventricle in the
center
• Axial T1W MRI images (A, B) of the
brain in alobar holoprosencephaly
show fusion of the cerebral
hemispheres, with a single ventricular
cavity (star) in the center; this gives
the brain the appearance of a pancake.
(Note the fusion of the thalami
(arrows))
"Hot cross bun sign" in C-type multiple
systems atrophy
• The hot cross bun sign can be
observed in multiple systems
atrophy type C.
• Such sign is characterized by a
cruciform pontine hyperintensity
due to selective loss of neurons
of the transverse
pontocerebellar fibers, with
preservation of the pontine
tegumentum and of the fibers of
the corticospinal tract.
"Figure eight sign" in lissencephaly
• Lissencephalies represent a group of disorders
caused by defective neuronal migration in the
period between the 8th and 14th gestational
weeks, resulting in lack of development of gyri and
sulci.
• Lissencephalies are classified into complete (type I
- agyria) or incomplete (type II - agyriapachygyria).
• Lissencephaly type I, Sylvian fissures are shallow
and verticalized and the brain takes a figure eight
configuration because of a narrowing of its middle
portion by the Sylvian fissures, associated with the
presence of colpocephaly, flat gyri, thickened
cortex and cortico/subcortical atrophy,
characterizing Miller-Dieker syndrome
• Lissencephaly type II, the cortex is thickened, with
an appearance of polymicrogyria, pachygyria,
brainstem and cerebellar hypoplasia,
hydrocephalus, characterizing Walker-Warburg
syndrome
The "face of the giant panda" sign in Wilson's
disease
• MRI T2 weighted sequences, one
can observe hyperintensity in
the pontine tegmentum,
hypointensity of the
periaqueductal gray matter and
partially preserved signal in the
red nuclei, in the lateral aspect
of the substantia nigra pars
reticulata and of the upper
colliculus
"Boxcar ventricle sign" in Huntington's disease
Bare orbit sign
A. Frontal CT scan scannogram of the head
(A) shows a bare and large orbit on the left,
with absence of the greater wing of the left
sphenoid bone, in this patient with
neurofibromatosis type 1. Note the normal
lesser (thick small arrow) and greater (thin
long arrow) wings of the sphenoid on the
right side.
B. Frontal surface-shaded display, 3D view of
the skull (B) shows a large left orbit with
dysplasia of the sphenoid wing.
C. Axial CT scan image (C) shows anterior
herniation of the left temporal lobe (thin
long arrow) because of the dysplastic
sphenoid bone. The left globe is small and
calcified (phthisis bulbi) (thick short arrow)
due to plexiform neurofibromatosis of the
left orbit
Eye-of-the-tiger sign
• Axial T2W MRI image of the
brain shows hypointensity of the
globus palladi (arrows).
• There is relative hyperintensity
of the central part, giving the
globus palladi the appearance of
the eyes of a tiger.
• This appearance is seen in
Hallervorden-Spatz syndrome
Stripe sign/ tigroid pattern
• Axial T2W image of the brain in a child with
metachromatic leukodystrophy shows
symmetric, increased signal intensity of the
white matter, with sparing of the subcortical
U fibers.
• Linear low signal intensity areas radiating
away from the ventricular margin (arrows)
represent areas of white matter around the
vessels that have been spared from the
process of demyelination.
• These low signal linear areas within the
hyperintense white matter resemble the skin
of a leopard and hence the term ‘tigroid’
pattern.
• FLAIR axial MRI image (B) shows symmetric
hyperintensity of the white matter sparing
the subcortical U fibers
Radial band sign
• Proton density-weighted axial image
of the brain (A) in a patient with
tuberous sclerosis shows hyperintense
bands in the white matter radiating
from the ventricular margin to the
subcortical region (arrows).
• FLAIR axial MRI image (B) shows
irregular hyperintense areas in the
subcortical white matter suggestive of
subcortical tubers.
• A large hyperintense nodule is seen in
the region of the foramen of Monroe,
representing a subependymal giant
cell astrocytoma (thick arrow)
Moya moya appearance
• Lateral anterior oblique view (A) of
an internal carotid artery (thick
short arrow) angiogram shows
multiple, small, tortuous collateral
vessels in the distribution of the
middle cerebral artery (arrows),
suggestive of the moya moya (puff
of smoke) appearance.
• Axial view of the MRI angiogram
(B) shows complete occlusion of
the middle cerebral arteries
bilaterally. Arrows indicate the
internal carotid arteries
Cloverleaf Skull
• A cloverleaf skull occurs when the
cranium takes a shape similar to a
cloverleaf, appearing trilobular, due
to craniosynostosis.
• It is a typical feature of various
syndromes, and has been
described for type I and II
thanatophoric dysplasia, Boston
type craniosynostosis, and others
such as Carpenter syndrome,
severe cases of Apert syndrome
and Crouzon syndrome
Cotton Wool Sign
• Cotton wool appearance is described
for plain film imaging of Paget's
disease.
• Paget's disease is characterised by a
lytic phase, where areas of osteolysis
appear (osteoporosis circumscripta), a
mixed phase and a sclerotic phase.
• When occurrence of sclerosis in
previous areas of osteoporosis
circumscripta results in a pattern with
focal areas of opacity in a previously
lucent area; this pattern is called the
cotton wool appearance
"Dawson's fingers" in multiple sclerosis
• The Dawson's finger's in multiple sclerosis
are related to white matter inflammatory
changes that occur around the
perimedullary veins. These are ovoid
lesions, with the longest axis perpendicular
to the corpus callosum
• The demyelinating plaques are commonly
located in the juxtacortical and
periventricular white matter, in the corpus
callosum and callosal-septal interface, with
high signal intensity on sequences with long
repetition time and hypo to iso-signal
intensity on T1-weighted image
Black Hole
• Black holes are areas that, with
respect to normal appearing
white matter, appear
hypointense in T1-weighted
images (T1WI) and hyperintense
in T2-weighted images (T2WI),
and are commonly seen in
multiple sclerosis (MS) (1).
Horseshoe Sign

• In active stage of the disease,

MS plaques demonstrate
temporary enhancement.
• An incomplete ring of
enhancement, where the non-
enhancing part points toward
the cortex, resembles a
horseshoe and is observed
especially in large tumefactive
lesions
Ivy Sign
• Ivy sign is an appearance of linear
hyperintensities in the sulci and
subarachnoid space.
• These intensities can be continuous or
discontinuous, and can be observed
on fluid attenuated inversion recovery
(FLAIR) images or postcontrast T1WI
• Contrast-enhanced T1WI are
considered superior to FLAIR images
for demonstration of the ivy sign (34).
• The appearance in postcontrast T1WI
images is considered to be due to
slow flowing enlarged pial vessels
Swirl Sign
• On noncontrast CT, image of the
active bleeding into an epidural
hematoma is identified as the swirl
sign
• The active component of
uncoagulated blood is of lower
attenuation than the surrounding
clotted blood, forming an area of
low attenuation in an otherwise
hyperattenuating hematoma
• The recognition of this sign
identifies actively bleeding epidural
hematomas
Onion Bulb Sign
• Balo's concentric sclerosis is
considered to be a rare variant of
MS.
• T1WI characteristically
demonstrates concentric isointense
and hypointense rings similar to an
onion bulb (Fig. 22) (40).
• Even though conclusive diagnosis
requires histopathologic
evaluation, this typical onion bulb
appearance in MRI is considered
enough for diagnosis
Popcorn Sign (Mulberry Sign)
• Popcorn sign (also known as
mulberry sign) is the appearance of
a well-defined lobulated lesion
with a central area of
heterogeneous intensities on T1WI
and T2WI.
• It is considered characteristic of
cavernous hemangiomas, and can
be seen in both cerebral and spinal
lesions.
• The central area of mixed intensity
is formed by thrombosis, fibrosis,
blood breakdown products and
calcification
The Eye of the Tiger Sign
• The eye of the tiger sign is the
presence of a hypointense area
around a high signal intensity
area in the anteromedial globus
pallidus, in T2WI images
• The hypointensity is caused by
iron accumulation.
• It is classically seen in
Hallervorden-Spatz syndrome
Tiger Stripe Pattern
• The tiger stripe sign is the
presence of inner hyperintense
bands alternating with outer
hypointense areas, observed in
the cerebellum on T2WI
• This appearance is due to the
close apposition of thickened
cerebellar folia.
Tigroid Pattern
• Tigroid pattern, also called as
leopard skin sign, is when the
hypointense lines or spots are seen
in periventricular white matter on
T2WI (Fig. 29).
• It is caused by demyelination, is
prominent in periventricular white
matter and centrum semiovale,
and is characteristically observed in
metachromatic leukodystrophy
• It has also been reported in
Pelizaeus-Merzbacher disease,
globoid cell leukodystrophy and
Lowe syndrome (56).
GCA-scale for Global Cortical Atrophy

GCA scale is the mean score for cortical atrophy throughout the complete
cerebrum:
0: no cortical atrophy
1: mild atrophy: opening of sulci
2: moderate atrophy: volume loss of gyri
3: severe (end-stage) atrophy: 'knife blade' atrophy.

• Cortical atrophy is best scored on FLAIR images. In some neurodegenerative

disorders the atrophy is asymmetric and occurs in specific regions. A radiological
report should mention any regional atrophy or asymmetry. When assessing
atrophy in different regions keep in mind that cranially, the central sulcus lies
more posteriorly than you would expect (figure).
GCA-scale for Global Cortical Atrophy
MTA-scale for Medial Temporal lobe Atrophy
The score is based on a visual rating of the
width of the choroid fissure, the width of
the temporal horn, and the height of the
hippocampal formation.
• Score 0: no atrophy
• Score 1: only widening of choroid fissure
• Score 2: also widening of temporal horn of
lateral ventricle
• Score 3: moderate loss of hippocampal
volume (decrease in height)
• Score 4: severe volume loss of hippocampus
• < 75 years: score 2 or more is abnormal.
• > 75 years: score 3 or more is abnormal.
Fazekas scale for WM lesions
• On MR, white matter hyperintensities (WMH)
and lacunes - both of which are frequently
observed in the elderly - are generally viewed
as evidence of small vessel disease.
• The Fazekas-scale provides an overall
impression of the presence of WMH in the
entire brain.
• It is best scored on transverse FLAIR or T2-
weighted images.
• Score:
• Fazekas 0: None or a single punctate WMH lesion
• Fazekas 1: Multiple punctate lesions
• Fazekas 2: Beginning confluency of lesions
(bridging)
• Fazekas 3: Large confluent lesions
Posterior rating scale
• The following anatomical landmarks were rated in three
different orientations:
1. Sagittal orientation: widening of the posterior cingulate- and
parieto-occipital sulcus, and atrophy of the precuneus on
left and right by considering paramedian-sagittal images.
2. Axial orientation: widening of the posterior cingulate sulcus
and sulcal dilatation in parietal lobes on axial images.
3. Coronal orientation: widening of the posterior cingulate
sulcus and parietal lobes on coronal images.
• Grade 0 represents a closed posterior cingulate- and parieto-
occipital sulcus and closed sulci of the parietal lobes and
precuneus.
• Grade 1 includes a mild widening of the posterior cingulate-
and parieto-occipital sulcus, with mild atrophy of the parietal
lobes and precuneus.
• Grade 2 shows substantial widening of the posterior
cingulate- and parieto-occipital sulcus, with substantial
atrophy of the parietal lobes and precuneus.
• Grade 3 represents end-stage atrophy with evident widening
of both sulci and knife-blade atrophy of the parietal lobes and
precuneus. In case of different scores on different
orientations (e.g. score 1 on sagittal direction and score 2 on
axial direction), the highest score was considered.
Koedam score for Parietal Atrophy
The ERICA Score
The visual pattern for entorhinal cortex
atrophy was defined as follows:
• Score of 0 indicated normal volume of the
entorhinal cortex and parahippocampal
gyrus (marked area); a
• Score of 1, mild atrophy with widening of
the collateral sulcus (black arrow)
• Score of 2, moderate atrophy with
detachment of the entorhinal cortex from
the cerebellar tentorium (the “tentorial
cleft sign”; white arrows)
• Score of 3, pronounced atrophy of the
parahippocampal gyrus and a wide cleft
between entorhinal cortex and the
cerebellar tentorium.
Daftar pustaka
• Kizilca Ö, Öztek A, Kesimal U, Şenol U. Signs in Neuroradiology: A Pictorial
Review. Korean J Radiol. 2017;18(6):992–1004.
doi:10.3348/kjr.2017.18.6.992
• Chavhan GB, Shroff MM. Twenty classic signs in neuroradiology: A pictorial
essay. Indian J Radiol Imaging. 2009;19(2):135–145. doi:10.4103/0971-
3026.50835
• Fabrício GG, Et al. Signs in neuroradiology – Part 1. Radiol Bras. 2011
Mar/Apr;44(2):123–128. Doi:http://dx.doi.org/10.1590/S0100-
39842011000200013
• Barra FR, et al. Signs in neuroradiology – Part 2. Radiol Bras. 2011
Mar/Apr;44(2):129–133. http://dx.doi.org/10.1590/S0100-
39842011000200014
Spinal Cord Imaging
 • Scalpel Sign

• The scalpel sign has been recently

Reardon MA,
Raghavan P,
described in dorsal thoracic arachnoid
Carpenter-
Bailey K et-al.
web on sagittal MRI spine studies. It
Dorsal thoracic
arachnoid web
relates to focal distortion of the thoracic
and the "scalpel
sign": a distinct
cord, appearing anteriorly displaced. The
clinical-
radiologic entity. enlarged dorsal CSF space mimics the
AJNR Am J
Neuroradiol. profile of a surgical scalpel.
2013;34 (5):
1104-
10. doi:10.3174/ • It is helpful in distinguishing cases where
ajnr.A3432 -
Pubmed
citation
the thoracic cord is focally anteriorly
displaced, a finding seen in a couple of
other conditions in addition to dorsal
thoracic arachnoid web, namely ventral
cord herniation and the presence of
a dorsal arachnoid cyst.
 • Rim Sign

The rim sign has been described as a helpful MRI sign of spinal cord
metastases, enabling them to be distinguished from other enhancing spinal
cord lesions (e.g. ependymoma and astrocytoma).

Rykken JB, Diehn FE, Hunt CH,

Eckel LJ, Schwartz KM,
• Radiographic features
Kaufmann TJ, Wald JT, Giannini
C, Wood CP. Rim and flame
-MRI
signs: postgadolinium MRI
findings specific for non-CNS The rim sign is seen on sagittal post contrast T1 weighted imaging of the
intramedullary spinal cord
metastases. (2013) AJNR. spinal cord and appears as a thin line of increased enhancement around the
American journal of
neuroradiology. 34 (4): 908-
margins of the lesion. Superiorly and/or inferiorly it may extend into the cord
15. doi:10.3174/ajnr.A3292 -
Pubmed
as a region of ill-defined enhancement (flame sign).
It has been reported that in 90% of studies of patients who have spinal cord
metastases one or both of the rim and flame sign are present and that this
finding is fairly specific .

• Differential diagnosis
Spinal hemangioblastomas sometimes demonstrate incomplete rim signs .
Rim sign. A 56-year-old woman with
metastatic ovarian adenocarcinoma who
presented to the emergency department
with progressive lower extremity
weakness and intermittent urinary
retention. MR imaging of the thoracic
spine demonstrates intramedullary spinal
cord metastasis at T8–9. Sagittal T2- Rykken JB, Diehn FE, Hunt CH, Eckel
LJ, Schwartz KM, Kaufmann TJ, Wald
weighted (A), T1-weighted (B), JT, Giannini C, Wood CP. Rim and
flame signs: postgadolinium MRI
postcontrast T1-weighted (C), and axial findings specific for non-CNS
intramedullary spinal cord metastases.
postcontrast T1-weighted (D) images. (2013) AJNR. American journal of
Note the rim sign (arrows, C and D): an neuroradiology. 34 (4): 908-
15. doi:10.3174/ajnr.A3292 - Pubmed
enhancing intramedullary mass with a
thin rim of more intense enhancement.
 Flame Sign

Rykken JB, Diehn

• The flame sign has been described as a helpful MRI sign of spinal cord
FE, Hunt CH,
Eckel LJ, Schwartz
metastases, enabling them to be distinguished from other enhancing spinal cord
KM, Kaufmann TJ,
Wald JT, Giannini lesions (e.g. ependymoma, astrocytoma and hemangioblastoma) .
C, Wood CP. Rim
and flame signs:
postgadolinium
MRI findings
specific for non-
CNS • Radiographic features
intramedullary
spinal cord
metastases. (2013) MRI
AJNR. American
journal of
neuroradiology. 34 The flame sign is seen on sagittal post contrast T1 weighted imaging of the spinal
(4): 908-
15. doi:10.3174/ajn cord and appears as an ill-defined triangular extension of enhancement above
r.A3292 - Pubmed
and/or below the lesion (continuous with the rim sign)
Rykken JB, Diehn FE,
Hunt CH, Eckel LJ,
Schwartz KM,
Kaufmann TJ, Wald
JT, Giannini C, Wood
CP. Rim and flame
signs: postgadolinium
MRI findings specific
for non-CNS
intramedullary spinal
cord metastases.
(2013) AJNR.
American journal of
neuroradiology. 34
(4): 908-
15. doi:10.3174/ajnr.A
Flame sign. A 55-year-old man with metastatic small cell lung carcinoma who
3292 - Pubmed presented with severe midback pain, progressive weakness, and altered
sensation in both lower extremities. MR imaging of the thoracic spine
demonstrates intramedullary spinal cord metastasis at T3–4. Sagittal T2-
weighted (A), T1-weighted (B), and postcontrast T1-weighted (C) images. Note
the flame sign (arrow, C): an ill-defined flame-shaped region of enhancement
at the inferior margin of the otherwise well-defined mass.
 Inverted “V” sign

• The inverted "V" sign, also known as the inverted rabbit ears sign, is a
•1. Matsuura H, radiological sign described in subacute combined degeneration of the spinal
Nakamura T. Inverted
V sign; subacute
combined
cord​.
degeneration of the
spinal cord. QJM :
monthly journal of the
• It refers to the appearance of the spinal cord on axial MRI slices 1-3. On these
Association of
Physicians. doi:10.109
slices in a patient with subacute combined degeneration of the spinal cord,
3/qjmed/hcx189 -
Pubmed
there is bilateral high-intensity T2 signal within the posterior funiculus,
•2. Narra R,
Mandapalli A, Jukuri N,
resembling the appearance of an inverted letter "V" 1-3.
Guddanti P. "Inverted
V sign" in Sub-Acute
Combined • This sign is produced because subacute combined degeneration of the spinal
Degeneration of Cord.
Journal of clinical and cord​ is caused by vitamin B12 deficiency 1-3. One theory suggests that this
diagnostic research :
JCDR. 9 (5): deficiency results in an accumulation of methylmalonic acid, which leads to the
TJ01. doi:10.7860/JCD
R/2015/14028.5889 - synthesis of abnormal fatty acids instead of myelin 3. These are then
Pubmed
•3. Naidich MJ, Ho SU. incorporated into neuronal lipids leading to abnormal myelination 3. This
Case 87: Subacute
combined process has a predilection for the dorsal columns, which lie in the posterior
funiculus of the spinal cord 3, which is why an alternate name for subacute
degeneration.
Radiology. 237 (1):
101-
5. doi:10.1148/radiol.2
371031757 - Pubmed
combined degeneration of the spinal cord is "funicular myelosis".
• It should not be confused with the inverted "V" sign of the cerebellum due to
bilateral PICA infarction, or the inverted "V" sign of pneumoperitoneum.
Matsuura H, Nakamura
T. Inverted V sign;
subacute combined
degeneration of the
spinal cord. QJM :
monthly journal of the
Association of
Physicians. doi:10.1093
/qjmed/hcx189 -
Pubmed

(A) Axial T2-weighted MRI of the thoracic spinal cord at

Th10 level shows bilateral high-intensity signal within the
posterior funiculus (white arrow: inverted V sign). (B)
Sagittal T2-weighted MRI shows abnormal high-intensity
signal in the posterior funiculus of the spine from Th7 to
Th11.
 • The Owl Eyes Sign

•1. Masson C, Pruvo JP, Meder -The owl-eyes sign, also referred to as snake-eyes sign or fried-eggs sign, represents bilaterally symmetric
JF et-al. Spinal cord infarction:
clinical and magnetic
resonance imaging findings
circular to ovoid foci of high T2-weighted signals in the anterior horn cells of the spinal cord and is seen on
and short term outcome. J.
Neurol. Neurosurg. Psychiatr. axial MR imaging. The sagittal corollary is a "pencil-like" vertical linear high T2-weighted signal extending
2004;75 (10): 1431-5. J.
Neurol. Neurosurg. Psychiatr.
(full text) -
usually over a number of segments.
doi:10.1136/jnnp.2003.031724

-Although typically described as one of the patterns in spinal cord infarction affecting the anterior spinal
- Free text at pubmed -
Pubmed citation
•2. Novy J, Carruzzo A, Maeder
P et-al. Spinal cord ischemia:
clinical and imaging patterns,
pathogenesis, and outcomes in
artery 1,2, it is seen in multiple other clinical settings and represents the result of increased metabolic activity
27 patients. Arch. Neurol.
2006;63 (8): 1113-
20. doi:10.1001/archneur.63.8.
(thus vulnerability) and reduced collateral supply of the anterior horns of the spinal cord.
1113 - Pubmed citation
•3. C F Hsu, C Y Chen, Y S
Yuh, Y H Chen, Y T Hsu, R A
Zimmerman. MR findings of

• This pattern is seen in the following scenarios 1-7:

Werdnig-Hoffmann disease in
two infants. American Journal
of Neuroradiology. 19 (3):
550. Pubmed
•4. Friedman DP, Tartaglino
LM, Fisher AR, Flanders AE.
MR imaging in the diagnosis of
intramedullary spinal cord
-anterior spinal artery ischemia: common
diseases that involve specific
neural pathways or vascular
territories. AJR. American
journal of roentgenology. 165
-chronic compressive myelopathy: common
• spondylotic
(3): 515-
23. doi:10.2214/ajr.165.3.76454
62 - Pubmed
•5. You JY, Lee JW, Lee E, Lee
GY, Yeom JS, Kang HS. MR
Classification System Based on
Axial Images for Cervical
• due to ossification of the posterior longitudinal ligament (PLL)
Compressive Myelopathy.
Radiology. 276 (2): 553-
61. doi:10.1148/radiol.2015142
• Hirayama disease
384 - Pubmed
•6. Mizuno J, Nakagawa H,
Chang HS, Hashizume Y.
Postmortem study of the spinal
cord showing snake-eyes
-amyotrophic lateral sclerosis (ALS)
appearance due to damage by
ossification of the posterior
longitudinal ligament and
kyphotic deformity. Spinal cord.
-neuromyelitis optica (NMO): uncommon
43 (8): 503-
7. doi:10.1038/sj.sc.3101727 -
Pubmed
•7. Al-Mefty O, Harkey LH,
-poliomyelitis-like syndrome: rare
Middleton TH, Smith RR, Fox
JL. Myelopathic cervical
spondylotic lesions
demonstrated by magnetic
-Hopkins syndrome: rare
resonance imaging. Journal of
neurosurgery. 68 (2): 217-
22. doi:10.3171/jns.1988.68.2.0
217 - Pubmed
-spinal muscular atrophy: rare 3
•1. Masson C, Pruvo JP, Meder JF et-al.
Spinal cord infarction: clinical and
magnetic resonance imaging findings
and short term outcome. J. Neurol.
Neurosurg. Psychiatr. 2004;75 (10):
1431-5. J. Neurol. Neurosurg. Psychiatr.
(full text) -
doi:10.1136/jnnp.2003.031724 - Free
text at pubmed - Pubmed citation
•2. Novy J, Carruzzo A, Maeder P et-al.
Spinal cord ischemia: clinical and
imaging patterns, pathogenesis, and
outcomes in 27 patients. Arch. Neurol.
2006;63 (8): 1113-
20. doi:10.1001/archneur.63.8.1113 -
Pubmed citation
•3. C F Hsu, C Y Chen, Y S Yuh, Y H
Chen, Y T Hsu, R A Zimmerman. MR
findings of Werdnig-Hoffmann disease in
two infants. American Journal of
Neuroradiology. 19 (3): 550. Pubmed
•4. Friedman DP, Tartaglino LM, Fisher
AR, Flanders AE. MR imaging in the
diagnosis of intramedullary spinal cord
diseases that involve specific neural
pathways or vascular territories. AJR.
American journal of roentgenology. 165
(3): 515-
23. doi:10.2214/ajr.165.3.7645462 -
Pubmed
•5. You JY, Lee JW, Lee E, Lee GY,
Yeom JS, Kang HS. MR Classification
System Based on Axial Images for
Cervical Compressive Myelopathy.
Radiology. 276 (2): 553-
61. doi:10.1148/radiol.2015142384 -
Pubmed
•6. Mizuno J, Nakagawa H, Chang HS,
Hashizume Y. Postmortem study of the
spinal cord showing snake-eyes
appearance due to damage by
ossification of the posterior longitudinal
ligament and kyphotic deformity. Spinal
cord. 43 (8): 503-
7. doi:10.1038/sj.sc.3101727 - Pubmed
•7. Al-Mefty O, Harkey LH, Middleton TH,
Smith RR, Fox JL. Myelopathic cervical
spondylotic lesions demonstrated by
magnetic resonance imaging. Journal of
neurosurgery. 68 (2): 217-
22. doi:10.3171/jns.1988.68.2.0217 -
Pubmed

Ischemia
•1. Bilsky MH,
Epidural spinal cord compression (ESCC) scale
Laufer I,
Fourney DR, -Epidural spinal cord compression (ESCC) scale has evolved in the era of radiotherapy to qualify the extent of vertebral body
Groff M,
Schmidt MH,
metastasis and serve as a guideline as to when intervention (either radiotherapy or surgery) is helpful.
Varga PP,
Vrionis FD, To this end, Bilsky and colleagues devised a 6-point, MR imaging-based grading system for ESCC 1.
Yamada Y,
Gerszten PC,
Kuklo TR.
The system uses axial T2-weighted images at the site of most severe compression.
Reliability
analysis of the
epidural
spinal cord • Parameters
compression
scale. (2010)
Journal of
-grade 0: bone-only disease
neurosurgery.
Spine. 13 (3): -grade 1:
• grade 1a: epidural impingement, without deformation of thecal sac
324-
8. doi:10.3171
/2010.3.SPIN
E09459 - • grade 1b: deformation of thecal sac, without spinal cord abutment
Pubmed
•2. Bilsky MH, • grade 1c: deformation of thecal sac, with spinal cord abutment, without cord compression
Laufer I,
Burch S. -grade 2: spinal cord compression, with cerebral spinal fluid (CSF) visible around the cord
Shifting
paradigms in
the treatment -grade 3: spinal cord compression, no CSF visible around the cord Important points
of metastatic
spine disease.
(2009) Spine.
34 (22 Suppl):
S101-
-Practical points
7. doi:10.1097
/BRS.0b013e -in the absence of mechanical instability, Grades 0, 1a, and 1b are considered for radiation as initial treatment
3181bac4b2 -
Pubmed -the role of surgery and radiosurgery in patients with grade 1c epidural is controversial with high-dose hypofractionated
radiation as a possible SRS option 2
-grades 2 and 3 describe high-grade ESCC and, unless the tumor is highly radiosensitive, require surgical decompression prior
to radiation therapy.
•1. Bilsky MH,
Laufer I,
Fourney DR,
Groff M,
Schmidt MH,
Varga PP,
Vrionis FD,
Yamada Y,
Gerszten PC,
Kuklo TR.
Reliability
analysis of the
epidural
spinal cord
compression
scale. (2010)
Journal of
neurosurgery.
Spine. 13 (3):
324-
8. doi:10.3171
/2010.3.SPIN
E09459 -
Pubmed
•2. Bilsky MH,
Laufer I,
Burch S.
Shifting
paradigms in
the treatment
of metastatic
spine disease.
(2009) Spine.
34 (22 Suppl):
S101-
7. doi:10.1097
/BRS.0b013e
3181bac4b2 -
Pubmed
Terima kasih