Brain Checklist Approach - Smirniotopoulos (RSNA 2009)

7/28/2019 Brain Checklist Approach - Smirniotopoulos (RSNA 2009)

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Critical Imaging Diagnoses:Critical Imaging Diagnoses:When and Where We Make a DifferenceWhen and Where We Make a Difference

James G. Smirniotopoulos, M.D.James G. Smirniotopoulos, M.D.

Radiology and Radiological SciencesRadiology and Radiological Sciences

Uniformed Services UniversityUniformed Services University

Bethesda, MDBethesda, MD

DisclosuresDisclosures

No financial disclosures nor conflict ofNo financial disclosures nor conflict of

interest to reportinterest to report

Im from the Government

and I here to help!

Learning ObjectivesLearning Objectives

Develop aDevelop achecklistchecklistfor imaging tofor imaging to

improve your ability to identify significantimprove your ability to identify significant

findingsfindings

Recognize imaging findings that willRecognize imaging findings that will

acutely change patient managementacutely change patient management

MR and CT Imaging ChecklistsMR and CT Imaging Checklists

Anatomic LocationsAnatomic Locations Sagittal ImagesSagittal Images

Sup. Sag. SinusSup. Sag. Sinus

Corpus CallosumCorpus Callosum

SellaSella RegionRegion

ClivusClivus

Axial ImagesAxial Images Skull,Skull, EpiEpi/Sub Dural/Sub Dural

SASSAS

Cortical Gray MatterCortical Gray Matter

White MatterWhite Matter

Deep Gray MatterDeep Gray Matter

VentriclesVentricles

Morphologic FeaturesMorphologic Features Mass EffectMass Effect

Yes, proportionalYes, proportional

Less than expectedLess than expected

No mass effectNo mass effect

Abnormal WM SignalAbnormal WM Signal Vasogenic EdemaVasogenic Edema

DemyelinationDemyelination

Infiltrating neoplasmInfiltrating neoplasm

Enhancing Ring LesionEnhancing Ring Lesion Necrotic NeoplasmNecrotic Neoplasm

Reactive (e.g. abscess)Reactive (e.g. abscess)

Fluid or InflammatoryFluid or Inflammatory





SellaSella RegionRegion ClivusClivus


SASSAS





Superior Sagittal Sinus ThrombosisSuperior Sagittal Sinus Thrombosis

Venous Infarct: Deeper, white matter, may spare parts of cortex


2/25

Sup. Sag. Sinus ThrombosisSup. Sag. Sinus Thrombosis

DehydrationDehydration

ParaneoplasticParaneoplastic SyndromesSyndromes w/hypercoagw/hypercoag

Spinal AnesthesiaSpinal Anesthesia

PostPost--partumpartum







SASSAS





GliomatosisGliomatosis CerebriCerebri

Gliomatosis cerebri: 2 or more lobes infiltrated by a diffuse astrocytoma

Courtesy of R.D. Zimmerman, NY

Diffuse Astrocytoma of Corpus Callosum:Diffuse Astrocytoma of Corpus Callosum:

Butterfly GliomaButterfly Glioma

Diffuse Astrocytoma of Corpus Callosum:Diffuse Astrocytoma of Corpus Callosum:

Butterfly GliomaButterfly Glioma

CNS Lymphoma:Hyperdense

Glioblastoma:Central Necrosis

Corpus Callosum LesionsCorpus Callosum Lesions


3/25

Lymphoma: hyperdenseLymphoma: hyperdense

Low water content hyperattenuation

PCNSLPCNSL

FLAIR

T2W

T1W Gd+

Low water content restricted diffusion

CNS Lymphoma Micro PathologyCNS Lymphoma Micro Pathology

DENSELY CELLULARDENSELY CELLULAR

Perivascular infiltrationPerivascular infiltration

IncreasedIncreased RETICULINRETICULIN fibersfibers

HIGH N/C (nuclear/cytoplasm)HIGH N/C (nuclear/cytoplasm)

Small RoundSmall Round Blue CellBlue Cell TumorTumor

High attenuation/low signal intensityHigh attenuation/low signal intensity

Small * Round * BlueSmall * Round * Blue--Cell TumorCell Tumor

Perivascular

Infiltrate

RimphomaRimphoma RIM PHOMARIM PHOMA


4/25







SASSAS





Agenesis of the Corpus CallosumAgenesis of the Corpus Callosum






ClivusClivus


SASSAS





Bitemporal Hemianopsia

Mass Lesion Presentation

Bitemporal Hemianopsia

Pituitary AdenomaPituitary Adenoma

Adult PatientAdult Patient

MicroadenomaMicroadenoma

< 10 mm< 10 mm

entirely within glandentirely within gland EndocrineEndocrine SxSx..

ProlactinomaProlactinoma

AcromegalyAcromegaly

GigantismGigantism

Cushing DiseaseCushing Disease

MacroadenomaMacroadenoma

> 10 mm> 10 mm

balloonballoon sellasella

VisualVisual SxSx

if >6 mm aboveif >6 mm above sellasella

bitemporalbitemporal hemianopsiahemianopsia

Met Hemoglobin inSella Region

Macroadenoma

Pituitary MACROPituitary MACRO--AdenomaAdenoma


5/25

Pituitary ApoplexyPituitary Apoplexy

Met Hemoglobin inSella Region

Macroadenoma

Pituitary ApoplexyPituitary Apoplexy

David and Goliath

Did Goliath have Gigantism and/orAcromegaly?

He was a Giant

He was an Angry Giant from HA and ICP

Did he have a Macroadenoma?

David was able to sneak up to him

bitemporal hemianopsia

Tunnel Vision

One stone to the head killed him

Pituitary Apoplexy

Hemorrhage into a macroadenoma






ClivusClivus


SASSAS





CraniopharyngiomaCraniopharyngioma Bright T1WBright T1W MR and CT Imaging ChecklistsMR and CT Imaging Checklists






SASSAS





Bilateral Abducens (CNN6) Palsy


6/25

Bulky Clival Mass

Midline BoneDestruction

ChordomaChordoma ChordomaChordoma






ClivusClivus


SASSAS





Depressed SkullDepressed Skull FxFx







SASSAS





Small EDH, no herniation, can beSmall EDH, no herniation, can be

managed with observationmanaged with observation

Smile of the Quadrigeminal Cistern


7/25







SASSAS





2 y.o. with Lethargy

Child Abuse?Child Abuse?






ClivusClivus


SASSAS





Headache, Kernig & Brudzinski+

HistoryHistory

4242 y.oy.o. woman with acute onset of:. woman with acute onset of:

the worst headache of my lifethe worst headache of my life

NoNo papilledemapapilledema

KernigKernig Sign +Sign +

BrudzinskiBrudzinski Sign +Sign +

Brudzinski sign: Pain and/or rigiditywith simultaneous neck and knee/hip

flexion.

Kernig sign: Pain elicited bystraightening the knee with the

hip/thigh flexed.

ICA AneurysmICA Aneurysm ICA AneurysmICA Aneurysm


8/25







SASSAS





Fever, Kernig +, Brudzinski +

Bacterial glycopeptides cause Breakdown in the BBBand contrast leaks into CSF in the SAS

Subarachnoid Space EnhancementSubarachnoid Space Enhancement

Leptomeningeal Enhancement - Pneumococcal Meningitis

ZulmarieZulmarie RoigRoig, MD and Gil Gonzalez, MD, MGH, MD and Gil Gonzalez, MD, MGH

CSF SpreadCSF Spread -- ZuckergussZuckerguss

Carcinomatous MeningitisEncephalitis

SerpentineSerpentine -- Cortical GyralCortical Gyral

Meningitis







SASSAS





Hx: 23 y.o. w/confusion

HSV EncephalitisHSV Encephalitis


9/25







SASSAS





Hx: 53 y.o. left sided weakness Day 1Day 1 Day 3Day 3

CVA: Progression Over 3 DaysCVA: Progression Over 3 Days

No Sulci

Low attenuationInsular Ribbon Sign

Chronic Infarct

Cerebral InfarctionCerebral Infarction

DWI ADC

2 hrs of Sx 4 hrs of Sx

MCA


DWI ADC


MCA

Hemorrhagic TransformationHemorrhagic Transformation

Reperfusion InjuryReperfusion Injury

Restoration of Systemic pressure into deadRestoration of Systemic pressure into dead

brainbrain

Function of Ischemic VolumeFunction of Ischemic Volume Entire MCA vs. branchEntire MCA vs. branch

Function of TimeFunction of Time

IV TPA up to 3 hrsIV TPA up to 3 hrs

IA up to 6 hrsIA up to 6 hrs

DesmoteplaseDesmoteplase up to 9 hrsup to 9 hrs

Anterior Cerebral ArteryAnterior Cerebral Artery


10/25

PCA InfarctPCA Infarct

DWI







SASSAS





Hx: 13 y.o. w/ Seizures

Proton Density T1W

DysembryoplasticDysembryoplastic NeuroepithelialNeuroepithelial Tumor (DNET)Tumor (DNET)Another Cortical Wedge Lesion MR and CT Imaging ChecklistsMR and CT Imaging Checklists





ClivusClivus


SASSAS





65 y.o. HT had TAH/BSO

Anoxia During SurgeryAnoxia During Surgery

Diffuse patchy abnormal loss of normal attenuation in cortical gray-matter.

Anoxia During SurgeryAnoxia During Surgery

Ischemic gray-matter, cortical (ACA & MCA) and basal ganglia (caudate).

NOTE: Relative sparing of the PCA (occipital lobes and thalami)


11/25







SASSAS





34 y.o. woman w/Coma

3434 yoyo comatose woman, psychiatric pt.comatose woman, psychiatric pt.

Courtesy Aimee Hawley, M.D. MGAFMC

FindingsFindings

IntraaxialIntraaxial

Diffuse Bilateral abnormalitiesDiffuse Bilateral abnormalities

Low attenuation in Cortical Gray MatterLow attenuation in Cortical Gray Matter

Low attenuation in basal gangliaLow attenuation in basal ganglia

EdemaEdema

What Kind?What Kind?

InterstitialInterstitial

CytotoxicCytotoxic

HydrostaticHydrostatic

Lab: Serum Na+ 121Lab: Serum Na+ 121

PsychogenicPsychogenic polydipsiapolydipsia

OverhydrationOverhydration

Athletes drinking too much waterAthletes drinking too much water

IatrogenicIatrogenic

D5W w/o saltsD5W w/o salts

TreatmentTreatment

Fluid restrictionFluid restriction

RingerRingers Lactate or Hypertonic Salines Lactate or Hypertonic Saline

1.8% saline (not 4%NS and NOT D5W)1.8% saline (not 4%NS and NOT D5W)

Water Intoxication







SASSAS





Woman w/confusing symptoms

Multiple SclerosisMultiple SclerosisSmall Ovoid Lesions perpendicular to lateral ventricle


12/25







SASSAS





Acute Pure Motor Hemiplegia







SASSAS





14 yo girl with congenital HIV

TOXOPLASMOSIS14 yo AA girl withcongenital HIV and CD4 count of 50 presents withmental status change, high fever, and two weeks of watery diarrhea

Left thalamicmass lowattenuation withhyperdense rim;hypointense T2rim (collagencapsule); smooth,round rimenhancement,surroundingvasogenicedema, restricteddiffusion

ToxoplasmosisToxoplasmosis

Typical deep gray matter paracentral abscesses with rimenhancement and surrounding edema

Toxoplasmosis: Calcification after TreatmentToxoplasmosis: Calcification after Treatment

Lesions shrinks, vasogenic edema resolves, calcification







SASSAS





71 yo man with HIV/AIDS


13/25

1CNS Lymphoma71 yoAA man with a history ofHIV/AIDS presented with gait instability

Low SI masslesions in theright MCP, leftinsula, and leftthalamuswith

surroundingvasogenicedema

The T1-weighted postgadoliniumimages showpredominantlyringenhancement

with areas ofcentralnecrosis







SASSAS





Medial Lenticular Globus Pallidus

Coma at home after Ice Storm

Toxic and MetabolicToxic and Metabolic

IntrinsicIntrinsic

DiabeticDiabetic KetoacidosisKetoacidosis

Hypoglycemic ComaHypoglycemic Coma

ExtrinsicExtrinsic Toxic ExposureToxic Exposure

COCO

Methanol, Ethylene GlycolMethanol, Ethylene Glycol

SolventSolvent LeukoencephalopathyLeukoencephalopathy

CO Poisoning: Selective forCO Poisoning: Selective for GlobusGlobus PallidusPallidus







SASSAS





Bruns Syndrome Positional HAChronic HAChronic HAAcutely WorseAcutely Worse

Hydrocephalus: Vents > Sulci


14/25







SASSAS





Positional Headaches

33rdrdVentricleVentricle CysticercosisCysticercosis






ClivusClivus


SASSAS










ClivusClivus


SASSAS





Intraventricular MeningiomaIntraventricular MeningiomaMcCainMcCain -- PalinPalin -- SmirniotopoulosSmirniotopoulos

John How didwe Lose?


15/25







SASSAS








No mass effectNo mass effectAbnormal WM SignalAbnormal WM Signal

Vasogenic EdemaVasogenic Edema



Ring LesionRing Lesion Necrotic NeoplasmNecrotic Neoplasm

























Obtunded w/blown pupil

tt tt

f

Brain Herniation SyndromesBrain Herniation Syndromes

C

MU

T T

tt tt

f

Brain Herniation SyndromesBrain Herniation Syndromes

Blown Pupil:

CNN3 (Oculomotor) nerve

ipsilateral to the mass

lesion. Not e CNN4

PupillaryPupillary ReactionReaction


16/25

PupilPupil -- Intrinsic Ocular MuscleIntrinsic Ocular Muscle

Blown Pupil























BP 180/135, HA, Hemiplegia












Long-standing Headache (yrs)

Two Pts: Compare Mass EffectTwo Pts: Compare Mass EffectLong-standing Headache (yrs) New onset Seizures

AVM No Mass Effect GBM Has Mass Effect


17/25













A type of interstitial edema produced byA type of interstitial edema produced byabnormally increased capillaryabnormally increased capillary permiabilitypermiability

Spreads from site of abnormal vessels atSpreads from site of abnormal vessels at~7~7--10 mm/week10 mm/week

May reach a steadyMay reach a steady--statestate cancant estimatet estimateage of lesion from extent of edemaage of lesion from extent of edema

Spreads along association tracts >Spreads along association tracts > corticocortico--spinal tracts >>>spinal tracts >>> commissurescommissures

FingerFinger--likelike pseudopodspseudopods of watery whiteof watery white

mattermatter

Meningioma with extensive EdemaMeningioma with extensive Edema












T1-gad T2

Glioblastoma MultiformeGlioblastoma Multiforme

Neoplastic cellsextend into theedema and

beyond, into thenormal WM


18/25




More than expectedMore than expected








Seizure and Obtundation

Hemorrhage into a PreHemorrhage into a Pre--existing massexisting mass

Acute hemiplegia and confusion in a 68 year old man

Courtesy Doug Phillips, UVA

NOTE: Vasogenic Edema

GBMGBM













Variable and Confusing Sx












Severe HA, HIV+

Lesion w/o Mass EffectLesion w/o Mass Effect -- PMLPML


19/25

Courtesy Jacqueline Bello, M.D.

T2WT2W Geographic hyperintensityGeographic hyperintensity

Looks like vasogenic edema


FLAIRFLAIRGeographic hyperintensity, no massGeographic hyperintensity, no mass

Looks like vasogenic edema but, affects the corpuscallosum


T1T1 w/Gdw/Gd No enhancementNo enhancement

Looks like vasogenic edema

but, no enhancement !Courtesy Jacqueline Bello, M.D.

PMLPML

No Mass, No Enhancement

PProgressiverogressive MMultifocalultifocal LLeukoencephalopathyeukoencephalopathy

WM DiseaseWM Disease -- JCJC Papova/PolyomaPapova/PolyomaVirusVirus

Initials of first patient cultured (1)Initials of first patient cultured (1)

JJohnohn CCunninghamunningham

TxTx forfor HodgkinsHodgkins, died from PML in 1971, died from PML in 1971

LysisLysis of Oligodendrocytesof Oligodendrocytes


Geographic and PeripheralGeographic and Peripheral

Little or No Mass EffectLittle or No Mass Effect

Little or No EnhancementLittle or No Enhancement

Poor Survival of 2Poor Survival of 2--6 months reported6 months reported

Improved survival w/ HAARTImproved survival w/ HAART -- up to 3up to 3--4 years4 years












Severe HA, HIV+


20/25

PMLPML MR and CT Imaging ChecklistsMR and CT Imaging Checklists











T1-gadT2

WHOWHO GrGr 2 Astrocytoma2 Astrocytoma ((gliomatosisgliomatosiscerebricerebri))(edemaedemaw/o contrast enhancement)w/o contrast enhancement)

NOTE: Although this looks like vasogenic edema there is no enhancement.

Vasogenic edema often spares the internal capsule. This is NOT edema secondary toa lesion. This is the tumor itself infiltrating through the white-matter.

GliomatosisGliomatosis CerebriCerebri::

Diffuse AstrocytomaDiffuse Astrocytoma 2 lobes2 lobes

Infiltrates through White Matter TractsInfiltrates through White Matter Tracts

CHO

Cr

NAA ?{

GliomatosisGliomatosis CerebriCerebri


21/25

T1WT1W GdGd+ in Two Astrocytomas+ in Two Astrocytomas

Gr 4 Astrocytoma Gr 2 Astrocytoma

Without Contrast Enhancement, itcant be vasogenic edema?

Neovascularity w/BBB causescontrast Enhancement and

vasogenic edema

Why does it look likeWhy does it look like likelike interstitialinterstitial

vasogenic edema? Microcystic changevasogenic edema? Microcystic change
























Morphologic FeaturesMorphologic Features

Mass EffectMass Effect




Abnormal WM SignalAbnormal WM Signal




Ring LesionRing Lesion

Necrotic NeoplasmNecrotic Neoplasm



Fever, HA, Recent Dental work

AbscessAbscess

Mag. susceptibility fromatomic oxygen inmacrophages


22/25

AbscessAbscess

Viscous Pus and Coagulation Necrosis

Brain AbscessBrain Abscess

MRS Courtesy of Mauricio Castillo - UNC

DWI

Inverted

AA Peaks

Short TE MRS Long TE MRS

AAPeaks

DWI: Necrosis vs. PUSDWI: Necrosis vs. PUS

GBM Abscess

We conclude that viable cell density is the main biological parameter

responsible for restricted diffusion in brain abscess, and it is notinfluenced by the etiological agents responsible for its causation.Magn. reson. med. 2005, vol. 54, no4, pp. 878-885

Ring Lesion DifferencesRing Lesion Differences

GBM Abscess - Toxo












Cyst

Nodule

Fluid Secreting Pilocytic AstrocytomaFluid Secreting Pilocytic Astrocytoma

Neoplasm + thinrim of enhancing

gliosis

5min.


23/25

Fluid Secreting Tumor: Pilocytic AstrocytomaFluid Secreting Tumor: Pilocytic Astrocytoma

NOTE: Fluid has protein not identical to CSF signal nor attenuation

Fluid Secreting Tumor: Pilocytic AstrocytomaFluid Secreting Tumor: Pilocytic Astrocytoma

Fluid Secreting Tumor: Ganglioglioma Enhancement w/o Vasogenic EdemaEnhancement w/o Vasogenic Edema

open ringopen ring

signsign

Absent vasogenic edema signal abnormality ends atedge of enhancement

Open (Incomplete) Ring SignOpen (Incomplete) Ring Sign

DemyelinatingDemyelinating DiseaseDisease

FluidFluid--secretingsecretingCysticCysticNeoplasmsNeoplasms

Masdeau JC, Moreira J, Trasi S, Visintainer P, Cavaliere R, Grundman M:The open ring. A new imaging sign in demyelinating disease.J.Neuroimaging 1996; 6(2):104-107.

Masdeu JC, Quinto C, Olivera C, Tenner M, Leslie D, Visintainer P: Open-ring imaging sign: highly specific for atypical brain demyelination.Neurology 2000; 54(7):1427-1433.

Absent vasogenic edema signal abnormality ends atedge of enhancement & incomplete ring

incomplete ringincomplete ring

Enhancement w/o Vasogenic EdemaEnhancement w/o Vasogenic EdemaInflammatory Breakdown of the blood-brain-barrier froma Demyelinating Lesion


24/25

Absent vasogenic edema signal abnormality ends atedge of enhancement & incomplete ring

3131 yoyo -- Multiple SclerosisMultiple Sclerosis

PerivenularPerivenular

inflammationinflammation

Enhance for 3-8 weeks

open ring signopen ring sign

SummarySummary






ClivusClivus


SASSAS












Enhancing Ring LesionEnhancing Ring Lesion Necrotic NeoplasmNecrotic Neoplasm








ClivusClivus


SASSAS





2 y.o. with Lethargy


DWI ADC


MCA







SASSAS





Medial Lenticular Globus Pallidus

Coma at home after Ice Storm


25/25

T1WT1W GdGd+ in Two Astrocytomas+ in Two Astrocytomas

Gr 4 Astrocytoma Gr 2 Astrocytoma

Without Contrast Enhancement, itcant be vasogenic edema it must be tumor infiltration

Neovascularity w/BBB causescontrast Enhancement and

vasogenic edema

Two Pts: Compare Mass EffectTwo Pts: Compare Mass EffectLong-standing Headache (yrs) New onset Seizures

AVM No Mass Effect GBM Has Mass Effect

Hemorrhage into a PreHemorrhage into a Pre--existing massexisting mass

Acute hemiplegia and confusion in a 68 year old man


NOTE: Vasogenic Edema

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EUXAPIT !

Mahalo !

Dank u wel !

Merci BeaucoupDanke Schn !

Muchas

Gracias

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Brain Checklist Approach - Smirniotopoulos (RSNA 2009)

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Transcript of Brain Checklist Approach - Smirniotopoulos (RSNA 2009)