Post on 07-Apr-2018
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CT scan of head
most closely
resembles MR-FLAIR & is
identified by the
heavy ring of
skull bone (*)
*
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Whichneuroimaging
study is this &
why? Identify
heavy ring of
skull bone(*)
*
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CT scan of
head most
closely
resemblesMR-FLAIR
& identified
by the
heavy ring
of skull
bone(*)
*
ANS.
CT scan
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5
6
7
8
8
9
CT scan with sequences from
infratentorial to supratentorial.
Major structures are indicated by
arrowhead & numbers . Review
them here & try to name them onnext slide.
Arrowhead=basilar
artery
1=4th ventric
2=pons
a=cerebellum
Arrowhead=
qudrigemminal
cistern
3=vermis of
cerebellum
4=midbrain
Arrowhead=thalamus
5=lenticular nucleus (putamen
-lateral & globus pallidus-
medial)
6=third ventricle
7=caudate nucleus (head)
8= osterior limb internal ca sule
9=centrum
semiovale
0=lateral
venticle
0
a
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Name the structures mark by arrowheads & numbers .
In image on far left identify the black structure (#1) shaped like Napoleons
hat. The pons is anterior & cerebellum posterior to the 4th ventricle. The
basilar artery, is the round structure anterior to the pons (). In 2nd image
from left the midbrain is anterior to the quadrigemminal cistern () & the
vermis of cerebellum is posterior. The thalami are the walls of the 3rd
venticle (6) & the the globus pallidus is lateral to the internal capsule(8).
a
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DWI ADC FLAIR T2 GRE
The MR imaging sequences from left to
right are Diffusion-weighted imaging (DWI),
Apparent-diffusion coeficient (ADC),Fluid-
attenuation inversion recovery (FLAIR),
T2W & Gradient echo (GRE).
CSF is black in DWI & FLAIR with FLAIRappearing more in focus.Notice the anatomic
landmarks on FLAIR are similar to those
seen on CT images. Identify the seq to the
left & ID #1,2&3. No. 3 is the genu of corpus
callosum .
1
2
3
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DWI ADC FLAIR T2 GRE
The MR imaging sequences from left to
right are Diffusion-weighted imaging (DWI),
Apparent-diffusion coeficient (ADC),Fluid-
attenuation inversion recovery (FLAIR),
T2W & Gradient echo (GRE).
CSF is black in DWI & FLAIR with FLAIRappearing more in focus.Notice the anatomic
landmarks on FLAIR are similar to those
seen on prior CT images. Identify the seq to
the left & ID #1,2&3. What part of the corpus
callosum is # 3.
1
2
3
1=head of caudate
2=thalamus
3=genu of corp. call.
FLAIR
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Top row are CT scan sequences from
infratentorial to supratentorial. Bottom row
are the various MR imaging sequences can
you name them.
Hint: CSF is black in DWI & FLAIR with
FLAIR appearing more in focus.
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DWI ADC FLAIR T2 GRE
DWI is most helpful in dx of acute CVA ie.manifests + in < 1hr.
FLAIR seq. best in subacute/chronic conditions as MS,
neoplasm, degener dis. GRE (gradient echo) shows evidence
of blood products (deoxyhemoglobin) in macrophages 24 to 48
hrs after bleed ie. cavernous malf, ICH,dissecting aneury,SAH
& microbleeds.
What major category of brain disease are each of the
sequences most helpful diagnosing & why?
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DWI ADC FLAIR T2
GRE
Acute
cva(within
minutes to
hrs),brain
abscess
Acute
cva,abscess
Subacute-
chronic
process ie MS
plaque,
neoplasm,cva
(after > 6 hrs)
Blood producrts &
Calcium ie SAH,
microbleeds, ICH,
cavernous
angiomas, arterial
dissection (dev
over 1 to 2 days)
Same as
FLAIR
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DWI ADC FLAIR T2 GRE
Acute cva,abscess
1st to show
CVA6hrs)
Generally, besides
CVA only abscess
(+) on DWI acutely
Acutecva,abscess
Subacute-chronic
process ie MS
plaque, neopl,cva
Blood producrts &
Ca ie SAH,microbleeds, ICH,
cavernous angiomas
Same as
FLAIR
Best sequence to
show blood
products (at times
the only one).
Usually by 24-48
hrs
Best sequence to
show subacute-
chronic process
of above
conditions
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DWI ADC FLAIR T2 GRE
Acutecva,absc
ess
Acutecva,absc
ess
Subacute-chronicprocess ie MS
plaque, neopl,cva
Blood producrts &
Ca ie. SAH,microbld, ICH
DWI -Fungal abscess GRE-microbleeds
DWI ADC FLAIR
R- MCA Infarct at 12hrs
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T1W non-gado (L), gado-enhanced (R)
Another MR sequence is T1-weighted
performed without or with gadolinium
enhancement. Acute infarcts do not enhance
but other conditions as neoplasm & abscess
frequenty do. How does the MR below help
diagnostically in a pt. with sudden neurodeficit with hx of lung CA. T1W MR is also
helpful in identifying gross anatomic
landmarks particularly on sagittal view as
seen below at far right.
T1W sag
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Enhancement in the left occipital
lobe (arrowhead) was key in dx of
metastatic disease & ruling out
stroke.
T1-W non-gado (L) gado (R)
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2
3
4
5
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7
8
9
a
b
c
d
e
f
1=corpus callosum (cc)
2=pons
3=4th ventricle
4=prepontine cistern
5=vermis of cerebellum
6=mammilary body
7=qudrigeminal cistern
8=quadrigeminal plate
9=medulla
a=spleenium of cc
b=superior sag sinus
c=midbrain
d=straight sinus
e=sphenoid sinus
f=3rd ventricle
g=optic chiasm
h=cerebellar tonsil
i=genu of corpus callosum
g
Below are key anatomic
landmarks on T1W sagittal MR.
Try to name them and name one
major disease entity that may
affect each entry. Next slide
gives answer.
h
i
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1
2
3
4
5
6
7
8
9
a
b
c
d
e
f
g
Below are key anatomic
landmarks on T1W sagittal MR.
Try to name them and name one
major disease entity that may
affect each entry. Use what you
learned from prior CT & MRimage landmarks in naming
these structures.
Next slide gives answer.
h
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1
2
3
4
5
6
7
8
9
a
b
c
d
e
f
1=corpus callosum,body (cc) (MS)
2=pons (Stroke, MS)
3=4th ventricle
4=prepontine cistern (SAH)
5=vermis of cerebellum (ETOH-atrophy)
6=mammilary body ( Wernickie enceph)
7=qudrigeminal cistern (herniation)
8=quadrigeminal plate
9=medulla (stroke, MS, neopl)
a=spleenium of cc (stroke, neopl)
b=superior sag sinus(cereb vein thromb)
c=midbrain (Stroke)
d=straight sinus (CVT)
e=sphenoid sinus (abscess)
f=3rd ventricle (colloid cyst, ICH)
g=optic chiasm (optic neuritis, Neopl)
h=cerebellar tonsil (Arnold Ch mlf, herniation)
g
h
Landmarks
with major
diseases
assoc with@
area.
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Stroke
Case History #1
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75 yo with
sudden onset
L sided
weakness.What type of
image is this
and what
findings if any
does it show.
Hint:
Skull bone
is dense /
prominent &
there are 4
features of
early
infarction
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What is
arrowhead
pointing to.
What are long
arrows
demarcating.
What is doublearrowhead
pointing to in L
hemisphere that
is missing on R
at (*).
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Answer:
Arrowhead pointing to
dense middle cerebral
artery sign.
Long arrows demarcate
R-MCA infarction
characterized by
attenuation (*).
Double arrowhead
shows preserved grey/
white junction (L), lost
in acute CVA as seen
on (R) (*) .
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What are each of the MR
imaging sequences in this
patient and how do they help
in dating the age of the
infarction ?
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DWI ADC FLAIR
Bright signal on DWI with
corresponding decreased signal on
ADC in asoc with intermediate
signal on FLAIR times the age of the
infarction to between 12- 48hrs old.
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DWI ADC FLAIR
Answer:
Arrowhead pointing to
dense middle cerebral
artery sign.
Long arrows demarcate
R-MCA infarction
characterized by
attenuation (*).
Double arrowhead shows
preserved grey/whitejunction (L), lost in acute
CVA as seen on (R) (*) .
Bright DWI & dark ADC
with intermed FLAIR
signal dates inf from 12-
48 hrs old
CT scan
MRI
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Case History #2
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Case Hx: 60 y.o. WM diabetic
dev sudden R arm & gait ataxia
along with N/V
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What is the imaging study
& describe the findings.
What is your plan for this
pt.
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Follow-up CT scan at 24
hrs. Describe the
findings.
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CT scan showing L cerebellar round
hypodensity( arrowhead)consistent
with infarct with assoc hydrocephalus
manifest by enlarged temporal horns
(arrowhead).
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Case History #3
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Case Hx: 32y.o. presented to an
outside ER with the worst HA ofher life
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What is the image & what does it show.
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Normal control
= SAH
(blood) in
prepontinecistern
CT scan with blood in prepontine cistern
(arrowhead) & both lateral venticlesconsistent with subarachnoid
hemorrhage.
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Case History #4
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Case Hx: 70 y.o. WM with hx of
hypertension dev sudden HA &inability to walk
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What is the image
& what is the
lesion?
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What problem has this hypertensive
cerebellar hemorrhage caused on CT ?
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Case History #5
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Case Hx: Mr D is a 78 yo with
afib rx with coumadin whopresents with a 1 wk hx of
severe HA
Wh t th i h t d it h &
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What s the image , what does it show &
why did it happen?
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What is bright area at
arrowhead ?
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Acute blood in pool of
subacute blood .
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42 yo HF with (-)
PMH presented to
HHER with abrupt
onset of not feelingwell with vomiting,R
hemiparesis & LOC.
What does CT show , what isDDx & what study would you
order next & why,
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What does this CTA show?
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Infectious Disease
Case History # 1
HPIHPI
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HPIHPI
82 yo female admitted to the ER, after being found on82 yo female admitted to the ER, after being found onher bathroom floor confused, agitated with left facialher bathroom floor confused, agitated with left facial
bruises.Last seen well 2 days prior. PMH R ACA infarctbruises.Last seen well 2 days prior. PMH R ACA infarct
3yrs ago.3yrs ago.
Exam:T=101.4, L gaze dev, PERRLA, L hemiparesisExam:T=101.4, L gaze dev, PERRLA, L hemiparesis
leg> arm,leg> arm,
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LaboratoryLaboratory
15.4 134 95 2515.4 134 95 2516.8 214 20316.8 214 203
(85% g.)(85% g.) 44.1 3.5 30 0.844.1 3.5 30 0.8
CK = 1973 Trop T< 0.01CK = 1973 Trop T< 0.01
CXR: No acute disease.CXR: No acute disease.
U/A : 0 WBCU/A : 0 WBC
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CT HEAD
CT
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What do you consider in the Diff Dxand
What do you do next
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CSF:CSF:
ClearClear
Tube #4: 37 WBC (33 lymphs, 4 monocytes).Tube #4: 37 WBC (33 lymphs, 4 monocytes).
9 RBC9 RBC
Glucose: 127Glucose: 127
Proteins: 31Proteins: 31
Because of increased temp=101 &
increased WBC=16K in absence of
findings for CVA an LP is warrented.
Do you want any other studies inviewof the CSF findings?
CTCSF shows
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DWI
CSF shows
pleocytosis & in
conjunction with
confusion, temp &
elev WBC need to R/
O encephalitis. WhatMR seq is shown &
what abn is seen?
DWI
DWI seq is on top row, what seq is on bottom row &which seq is most helpful in this condition & why ?
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DWI
FLAIR
which seq is most helpful in this condition & why ?
DWI
DWI seq is most helpful for encehalitis esp for herpes simplexenceph (HSE) as early dx is important for rx with antiviral as
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DWI
FLAIR
p ( ) y p
acyclovir. DWI + in mesiotemporal region (typical for HSE)befor
changes are apppreciated on CT or FLAIR. What other test would be
helpful?
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EEG:EEG:
PLEDs over the right temporal lobe.PLEDs over the right temporal lobe.
CSF: HSV1 pos.CSF: HSV1 pos.
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Neoplastic Disease
Case History # 1
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Case HistoryLL
75 yo WM was adm 7/06 withcontinuous seizures of the R side.
One and half yrs ago he sufferedbilateral occipital & cerebellar strokefollowing aortic surgery & 8 moslater he was Dx with lung CA.
CT & MR of head on this admshowed L occipital hypodensity inPCA distribution.
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DWI seq is + in < 1hr after CVA .
This MR seq was done < 2hrs, which is it?
What brain structures are involved?
What dx is likely & why? Stroke,neopl etc.
Cyotoxic edema seen with stroke involvesboth cortex & white matter vs vasogenic
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DWI 1-5-05
1st adm
Brain struct. Invol: cerebellum, occipital lobe
Both are in distribution of post. Circulation.
Stroke best dx bec of + DWI early & edema
type.
What is type of edema? (cytotoxic v vasogenic)
both cortex & white matter vs vasogenic
edema seen with neoplasm where only
white matter is involved.
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CT 7-28-06 11/2 yrs later
Current adm
What is image type & describe the
lesion?
Is attenuation incr/decreased or both?
What type of edema is seen?
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CT 7-28-06 11/2 yrs later
This CT scan shows a L occipital lesion withfinger- like extension of edema seen with
neolpasm (vasogenic) edema.
The signal is mixed with increased signal
suggesting neolplasm . CVA is always
decreased signal unless complicated by
Vasogenic edema spares the cortex
but involves white matter & manifest
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FLAIRDWI
7-28-06
but involves white matter & manifest
increased signal on FLAIR.
This MR shows____edema?
How does this differ from cytotoxic
edema seen with infartion?
This non-enhanced (L) &enhanced (ctr/R)T1W MR
shows a feature of ring
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T1 Gado 7-29-06
shows a feature of ring
enh.seen mainly with neopl,
abscesses & subacute inf.
How were this pts. CT
abnormalities helpful in dx?
Given this hx the likely dx is?
T1W non-gado
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Diagnosis
Dx in 1-05 Cerebellar & L occipital lobe
infarction (early + DWI with cytoxic
edema)
Dx in 7-06Metastasis to L occipital lobe
from lung CA (small area of incr sig on CT,
vasogenic edema on CT/MR with ringenhancement on gad study
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Message
Apprecite vasogenic vs cytotoxic edema
need to enhance image to avoid misdx
unusual features for CVA: (-)DWI, atten
on CT, vasogenic edema
mets to occipital lobe can mimic PCA
infarct
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Demyelinating disease
Case history #1
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DWI ADC FLAIR T2 GRE
Acute
cva,abscess
Acute
cva,abscess
Subacute-
chronic process
ie MS plaque,neopl,cva
Blood
producrts& Caie
SAH,microbld,
ICH
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