CNS Prestn for MBBS Student 2016BRT
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Transcript of CNS Prestn for MBBS Student 2016BRT
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SBikash Raj Thapa, MD
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Imaging modalities Simple radiography
-cheap preliminary screening -accuracy speci!city is lo"
#S$%- Ine&pensi'e( porta)le( multiplanar-dynamic( no-radiation Choice in neonates*in+ants
Computeried tomography- basic choice hge stroke( head injury( screening
MRI tissue characteriation is )etter .ngiography- mainly +or inter'entional radiology Radionuclide scan- is superseded )y CT MRI /ositron emission tomography 0/1T2
- e&pensi'e a'aila)le in 'ery ad'ance centre- /1T tracer like car)on, nitrogen, o&ygen- Demonstrates di3erence in +ocal )rain meta)olism- Major use in oncology
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N1#R4S4N4$R./56
NIC# .ssist in diagnosis%
/78( IC5(hydrocephalousetc
Monitorcomplications and
inter'entions%'entriculoperitoneal shunts
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C1NTR.8 N1R74#S S6ST1M
C.8CI9IC.TI4N, 56DR4C1/5.8#S
B.SICS 49 T#M4RS, IN9.RCTS,
IN91CTI4NS 4N CT S/IN1
D*D% C488./S1 71RT1BR.1% TB
D*D% M1T.ST.TIC SC81R4TIC 81SI4NS
4ST14M618ITIS
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Hypodense lesions
:; In+arct
; 1dema
?; Meta)olicencephalopathy
@; 5ypertensi'eencephalopathy
A; 1ncephalitis
; 8ipoma
Hyperdense:; Intracranial calci!cations; Cysts% Colloid?; 1ndocrinal%
hypoparathyroidism@; Neurocutaneous syndromesA; .rterio'enous lesions
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Ring enhancing lesions
Metastasis
A)scess
Glio)lastoma In+arction
Contusion
Demylinating disease Radiation necrosis
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INTR.CR.NI.8C.8CI9IC.TI4NS
ormal intracranial calci!cationscan )ede!ned as all age-related physiologic andneurodegenerati'e calci!cations that areunaccompanied )y any e'idence o+ disease and
ha'e no demonstra)le pathological cause; /IN1.8 $8.ND% 60% adult; >14mm: neoplasm 5.B1N#8.% 30% C54R4ID /81#S% 10% B.S.8 $.N$8I.
D#R. /1TR4C8IN4ID 8I$.M1NTS SSS
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CR"#$C%R%&R"'
(R")*"
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Classi!cation o+ head injury
+rimary in,ury%
Those occurring as a direct result o+initial traumatic e'ent;
econdary in,ury:
These are conseEuences o+ primaryinjuries
9reEuently more de'astating than theprimary injury
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+rimary in,uries%
Skull F, scalp hematoma* lacerations 1&tracere)ral hemorrhage
1pidural hemorrhage
Su)dural hemorrhage Su)arachnoid hemorrhage
Intraa&ial lesions% Di3use a&onal injury Cortical contusions Deep cere)ral gray matter injury Brainstem injury Intra'entricular* choroid ple&us hemorrhage
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Secondary lesions%
Cere)ral herniations
Traumatic ischemia, in+arction
Di3use cere)ral edema 5emorrhages
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Imaging Strategy
Imaging o+ acute head trauma is per+ormedto detect treata)le lesions )e+ore secondaryneurologic damage occurs;
Currently, this is )est per+ormed )y CT +orse'eral reasons%
it is Euick "idely a'aila)le
5ighly accurate in the detection o+ acute intra-
a&ial and e&tra-a&ial hemorrhage, as "ell asskull, temporal )one, +acial, and or)ital +ractures;
Monitoring eEuipment is easily accommodated;
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Skull 9ractures%
Types% 8inear F
Depressed F( ping-pong*pond +racture0ne")orn2
Comminuted F
Compound F
$ro"ing F% 0leptomeningeal cyst2
Can in'ol'e% Cranial 'ault Base o+ the skull
Sutural diastases
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1pidural hematoma
:->G pt imaged +or cra'iocere)ral trauma 1tiology- F that lacerates MM. or dural 'enous sinus 8ocation%
Bet"een skull dura 0)icon'e& shape2
Temporoparietal region commonest site H?G unilateral Do not cross suture Secondary herniation common
#maging% Bicon'e& e&tra-a&ial collection May )e heterogeneous due to hyperdense )lood
and hypodense serum or due to acti'e )leeding Chronic- /eripheral enhancement representing
dura and mem)rane +ormation )et"eenhematoma adjacent )rain parenchyma;
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.&ial CT scan demonstrates a )icon'e&, high-attenuation,e&tra-a&ial collection causing mass e3ect on the right +rontallo)e and mild midline shi+t 0su)+alcial herniation2; Note ho"the epidural hematoma does not e&tend )eyond the right
coronal suture
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ubdural Hematoma
Most lethal o+ all head injuries Mortality rates upto ?-?G Stretching and tearing o+ )ridging cortical 'eins
as they cross sd space common
disruption o+ penetrating )ranches o+ super!cialcere)ral arteries less common
8ocation% Bet"een dura and arachnoid 9rontoparietal con'e&ities middle cranial +ossa
Jidespread than 1D5 Crescentic shaped, cross suture, e&tend into interhemispheric
!ssure DoesnKt cross midline ?G unilateral
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Su) .rachnoid hemorrhage
Traumatic; Spontaneous S.5%
Ruptured arterial aneurysm 0A-G2
.rterio'enous mal+ormation 0:G2 4ther rare causes%
Tumor )leeding Mycotic aneurysm Cortical throm)osis Dural .7 !stula .rterial Dissection
No cause identi!a)le in angiogram
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Noncontrast a&ial CT scans in t"o di3erent patientsdemonstrate high-attenuation material "ithin the sulci and
right syl'ian !ssure consistent "ith su)arachnoidhemorrhage;
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5ydrocephalus
Denotes an increase in the 'olume o+ CS9and thus o+ the cere)ral 'entricles;
Obstructive and non-obstructive 0on
the grounds o+ "hether or not there iso)struction o+ CS9 path"ays in the'entricles or in the su)arachnoid space2
Communicating and non-communicating 0addressing "herethe o)struction is located2;
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4)structi'e hydrocephalus
passage o+ CS9 "ithin the 'entricular system or in thesu)arachnoid space is impaired at some point communicating o)structi'e hydrocephalus
passage o+ CS9 +rom the 'entricular system and into thesu)arachnoid space is unimpeded )ut a)sorption o+ C9S 'iaarachnoid granulations is impaired
su)arachnoid haemorrhage ormeningitis e&tra-a&ial CS9 spaces 0e;g; Syl'ian !ssures and sulci2 are also
distended
non-communicating obstructive hydrocephalus o+ten merely re+erred to o+ as obstructie hydrocephalus due to o)struction o+ CS9 out Lo" at any point 0e;g; aEueduct
stenosis,colloid cyst o)structing the +oramen o+ Monro2 up-stream 'entricles are dilated and e&ert mass e3ect upon
adjacent )rain 0e;g; e3acement o+ sulci2
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Non-o)structi'e hydrocephalus
o+ten re+erred to as e-acuodilatation o0 the entricles
CS9 can pass out o+ the 'entricles andinto the )asal cisterns "ithoutimpediment, and is readily a)sor)ed
'entricles are enlarged due to loss o+adjacent )rain parenchyma
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Characteristics o+5ydrocephalus
7entricular enlargement disproportionate to thedegree o+ sulcal "idening
1nlargement o+ temporal horns
/eri'entricular Luid secondary totransependymal CS9 permeation
1nlarged =rd'entricle 0out"ard )o"ing o+ thelateral "all2 "ith large suprapineal andchiasmatic receses and in+erior )o"ing o+ the
LoorIn children < years the head circum+erence is
o+ten the )est distinguishing +eature )et"eenhydrocephalus and atrophy;
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M1.S#R1M1NTS
9rontal horns 0Monro2% > yrs : yrs:?
7entriculohemispheric ratio% ==G in adults >G in children
Third 'entricle
?mm% children Amm% @yrs Hmm%O@yrs
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Normal CT Brain5ydrocephalicBrain
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Colloid cyst
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STR4P1
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4n CT @G o+in+arcts are seen"ithin =-@ hrs and
'irtually all areseen in hours;
.D7% 5ge stroke0MRI con+using2
MRI- Di3usionrestriction 0DJI2"ith reduced .DC
has )een o)ser'edas early as =minutes a+ter theonset o+ ischemia;
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Imaging protocal Nonenhanced scanning must )e per+ormed as
soon as possi)le a+ter the stroke is suspected;
and the key role of nonenhanced CT is thedetection of hemorrhage or other possi)lemimics o+ stroke 0eg,neoplasm, arterio'enous
mal+ormation2;
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CT 9indings in In+arction
Hyperacute: 12 hrsQ Normal ?-@GQ 5yperdense artery 0dense MC. sign2Q 4)scuration o+ the lenticular nucleusQ loss o+ gray-"hite inter+aces 0insular ri))on sign
"cute: 12-24 hrsQ 8o" density )asal gangliaQ sulcal e3acement
1 to 3 ays:Q Increasing mass e3ectQ Jedge-shaped lo" density area in'ol'ing gray and "hite
matterQ /ossi)le hemorrhagic trans+ormation
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"ial unenhanced C(images in a proimalsegment o0 the le0t *C"
in a 3-year-old man a5and a distal segment o0the le0t *C" in a 62-year-old 7oman b58obtained 2 hours a0terthe onset o+ righthemiparesis and aphasia,sho" areas o+hyperattenuation 0arro"2suggesti'e o+ intra'ascular
throm)i
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"ial unenhanced C(image obtained in a ?=-year-old man sho"s
hypoattenuation ando)scuration o+ the le+tlenti+orm nucleus 0arro"s2,"hich, )ecause o+ acuteischemia in the
lenticulostriate distri)ution,appears a)normal incomparison "ith the rightlenti+orm nucleus
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"ial unenhanced C(image8 obtained in a A=-year-old "oman
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Drawings (top) illustrate the territories(blue) of the ACA, middle cerebral artery (MCA)
, and posterior cerebral artery. CT scans (bottom) show established infarctions of
these arteries
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C7.
Intracere)ral
hematoma)asal nucleiregion "ithmass e3ect
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IN91CTI4NS
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Congenital * neonatal in+ections
Meningitis
/yogenic parenchymalin+ections
1ncephalitisTu)ercular and +ungal in+ections
/arasitic in+ections
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C*9
DN. 'irus Most common cong C!" infection
0also cause cardiac anomalies, hepatosplenomegaly2
/redilection +or peri'entricular su)ependymal germinal matri& Jidespread peri'entricular tissue necrosis and su)seEuent
dystrophic calci!cation;
/lain !lm microephaly "ith egg shell- like peri'entricularcalci!cation
#S*CT*MRI encephaloclastic lesions, peri'entricular ca,su)ependymal para'enticular cyst, 'entriculomegaly
MRI- delayed myelination, encephalomalacia, migrational
disorder 0lissencephaly, polymicrogyria, pachygyria2
P i t i l l ifi ti i CMV i f ti
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Periventricular calcification in CMV infection
Fink K R et al Radiographics !"#"$%"''#'*
!"! by #adiolo$ical %ociety of &orth America
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($$+'"*$#
T; gondii, o)ligate intracellular parasite
Multi+ocal, scattered lesions 0)asal ganglia,corte&, peri'entricular location and "hitematter2
No migrational disorder
Triad 0imaging2
hydrocephalus 0due to ependymitis-leads toperiaEueductal necrosis-aEueductalstenosis2
)*l chorioretinitis
intracranial calci!cations
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.&ial unenhanced CT imagere'eals a peripherallycalci!ed lesion 0arro"2 in theright caudate head that is a
seEuela o+ pre'iousto&oplasmosis in+ection; Thelo"-attenuation mass lesion"ith surrounding edema inthe region o+ the le+t )asalganglia is +rom a ne" +ocuso+ to&oplasmosis;
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M1NIN$ITIS
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Role o0 C( in meningitis
to identi+y contraindicationso+ a lum)ar puncture to identi+y complications that reEuire prompt
neurosurgical inter'entions such as symptomatichydrocephalus, su)dural empyema, and cere)ral a)scess;
CT scans may re'eal the causeo+ meningeal in+ection; $torhinologic structures and congenital and posttraumatic
calarial de0ects can also )e e'aluated CT cisternography may depict CS9 leaks, "hich may )e the source
o+ in+ection in cases o+ recurrent meningitis
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onenhanced C( scan !ndings may )e normal 0O?G o+ patients2
e3acement o+ )asilar con'e&ity cisterns )y inLammatorye&udates
mild 'entricular dilatation and e3acement o+ sulci cere)ral edema and +ocal lo"-attenuating lesions;
Contrast-enhanced C( scans Meningeal ependymal enhancement 5elp in detecting complications o+ meningitis, such as
su)dural empyema 7enous throm)osis, in+arction
Cere)ritis*a)scess 7entriculitis;
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#nenhanced a&ial CT imagesho"s high-attenuationmaterial in the )asilar
cisterns
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Cerebritis and deelopingabscess 0ormation in apatient 7ith bacterialmeningitis . (his contrast-
enhanced8 aial computedtomography scan sho7s asmall8 ring-enhanced8hypoattenuating lesion inthe le0t basal ganglia anda le0t subdural
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"bscess in a patient 7ithbacterial meningitis. (hiscontrast-enhancedcomputed tomographyscan sho7s a ring-enhancing8hypoattenuating massabscess5 7ith peripheraledema and mass e=ect.
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&ilateral subduralempyema in a patient7ith bacterial meningitis.(his computedtomography scan
demonstrates theimportant diagnostic0eatures o0 meningitis:prominent enhancemento0 the margin andincreased attenuation o0the empyema.
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CNS tu)erculosis
5ematogenous dissemination usually +rom pulmonaryin+ection
*eningitis- most common mani+estation +arenchymal lesions
Caseating granuloma
#sually solitary, multiple in :*= Cortical, su)cortical, )asal ganglia lesions; Cere)ellum in
children (ubercular abscess
indistinguisha)le +rom caseating granuloma* pyogenica)scess
thinner smoother "all multiloculated larger0O=cm2 surrounding edema is less than that in pyogenic a)scess
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Multiple )ilateral ring-enhancing lesions0tu)erculomas2 in the +rontal and parietal lo)es
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/arasitic in+ections
NCC
1chinococcosis
.me)iasis /aragonimiasis
Spargonimiasis
Malaria
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Neurocysticercosis
8ar'al +orm o+ T; solium
Most common C!" #arasite
location
Brain parenchyma- corticomedullary junction
Intra'entricular in
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C( scan o0 the brain#n parenchymal CC8 the arious stages are as 0ollo7s: 9esicular stage is characteried )y a small, rounded, lo$-density area
in the )rain parenchyma, "ithout edema or enhancement "ith contrast;Sometimes the scole& can )e seen as a hyperdense dot inside the
hypodensity;
Colloidal esicular stage is characteried )y a hypodense or isodenselesion "ith edema and a ring-enhancing #attern a+ter administration o+contrast; This is the acute encephalitic +orm, mani+ested as a reaction )ythe host;
>ranular nodular stage-%C( sho"s isodense cyst "ith hy#erdensecalci%ed scole& ;
odular Calci!ed stage is characteried )y a dead cysticercus; InN1CT, a small calci%ed nodule $ithout mass e&ect or enhancementis typical; 5o"e'er, perilesional edema may occur around already
calci!ed cysts 0may )e upto ? yrs2 and is related to symptom relapse;
(ransitional stages bet7een these stages also can be seen; thepattern on C( scan is a combination o0 2 stages.
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NCC
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Brain tumors
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Classi!cation )y histology "5>lial tumors- .strocytomas
4ligodendroglioma
1pendymalChoroid ple&us tumors-C//*C/C
&5 euronal and mied neuronal/glial tumors-ganglioma
gangliocytoma central neurocytoma
C5 *eningeal and mesenchymal tumors-meningioma
hemangio)lastomahemangiopericytoma
5 +ineal cell tumors- pineo)lastoma pineocytoma
%5 %mbryonal tumors- neuro)lastoma retino)lastoma /N1TS
?5 Hematopoetic tumors- lymphoma leukaemia plasmacytoma
>5 +itutary tumors H5 Cyst and tumor li@e lesions
R i d J54 l i! ti
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Re'ised J54 classi!cation
Su)di'ides into > grades 0II72 )asedon speci!c histologic 0eatures o+tumor such as cellularity, nuclear
atypia, mitotic acti'ity,pleomorphism, 'ascular hyperplasia,and necrosis;
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BR.IN T#M4#RS
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Most common
CNS tumor in adult% Metastasis /rimary CNS neoplasm% $BM Non-glial% Meningioma Neonates% Teratoma
$erm cell tumor% $erminoma Site o+ Sch"onnoma% 7esti)ular di'ision o+ 7III N7 Sellar*parasella% /ituitary adenoma /osterior +ossa tumor in adult% Metastases Tumor to calci+y% 4ligodendroglioma
Spinal e&tradural tumor% Metastasis Benign spinal neoplasm% 7erte)ral hemangioma Intramedullary spinal tumors in adults % ependymoma Intramedullary spinal tumors in children% .strocytoma
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In diagnosis o+ )rain tumors +ollo"ingpoints are important-
age
anatomic location character o+ tumor
perilesional edema
CT density and MR signalcharacteristics
contrast enhancement
$8I4M.*N1#R4$8I.8
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$8I4M.*N1#R4$8I.8Tumours
$lial cells% ?-: 0trillion2 neurons
.mong /rimary )rain tumours %appro& U are glioma
.mong glioma% O V are astrocytoma
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$lio)lastoma multi+orme
Most common and malignant o+ all
primary intracranial tumours 0 ?Gastrocytomas2
Rapidly enlarging malignantastrocytic tumor characteried )ynecrosisand neovascularity
Common in older age O?yrs( Rare
)elo" =yrs 'ocation:
o Supratentorial "hite matter mostcommon
Q 9rontal, temporal, parietal lo)es
Q 4ccipital lo)es relati'ely sparedo Cere)ral hemispheresO )rainstem O
cere)ellum
o Brainstem, cere)ellum - common inchildren
Jorst prognosis
C(:*ar@edi t t l
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intratumoralheterogenicity 7ithcentral lo7 densityregion s/o necrosis or
cyst 0orm5 is present inAB o0 all >&* 5emorrhage peripheral
oedema 0Fingers oedema2 is common
1nhancement is strong
inhomogenous "ith thickirregular rimenhancement
*R:T: sho"s poorlydelineated mi&ed signalmass "ith necrosis or cyst
+ormation "ith markedinhomogenousenhancement
T< sho"s heterogenousmass "ith mi&ed signal,central hemorrhage necrosis
(hic@8 irregular-enhancing rindo0 neoplastic tissue surrounding
necrotic core
S d + $BM
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Spread o+ $BM% 7ia)le tumor e&tends +ar )eyondsignal a)normalitiesW
Common
.long compact "hite matter tracts- coronaradiata, corticospinal tracts, corpus callosum&utter
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+#%
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Tu)ercular spine
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Tu)ercular spine common in N1/.8
:-=G -osseous in'ol'ement
O?G a3ects spinal column
commonest +orm o+ skeletal TB;
Dorsal spine - most commonly
in'ol'ed Most Common !rst = decades;
R.DI484$6
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R.DI484$6/lain radiography
signs % Reduced disc space Blurred paradiscal
margins Destruction o+ )odies 8oss o+ tra)ecular
pattern Increased
/re'erte)ral so+ttissue shado"
Su)lu&ation*dislocation
Decreased 8ordosis*kyphosis
Roentgen triad: primary 'ertebral lesion
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Roentgen triad: primary 'ertebral lesion,disc space narrowin$ and para'ertebral
abscess
(uberculouspondylitis
+yogenicpondylitis
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p y p y
4nset Insidious' chronic Acute
/rogress Slo" Rapid
Site Thoraco-lum)ar 8o"er lum)ar
ray changes At #resentation (-) $ks aft#resentation
&one sclerosis 8ack sclerosis *resent
+eriosteal reaction 8ittle or a)sent *resent
Multi+ocalin'ol'ement
Multiple contiguous'erte)rae
T"o or one
isc inolement 8ate 1arly
+osterior elementin
More +reEuent 8ess
Su)ligamentousspread
common *-
/araspinal mass +arge Small
Calci!cation ,allmark Rare
Spinal de+ormity Common 0kyphosis2 Not so
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7erte)ral Metastasis
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$eneral In+ormation
Metastatic disease is the most commontumor a3ecting the spinal column;
.ppro&imately AG o+ all spinal tumors
are metastatic in nature; /rimary carcinoma o+ the prostate,
)reast, lung, thyroid gland or intestinal
tract;
T"o types o+ spinal
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o ypes o sp ametastases
:; 4steoclastic * 4steolytic 0destruction o+ )one2 9reEuently associated "ith 'erte)ral )ody collapse; May )e mistaken +or plasma cell myeloma;
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7erte)ral Metastases o+ C?
ifferential dia$nosis for i'ory
'ertebral body
* Metastases
* +ymphoma* a$et disease
* +ess common -nfection (low $rade
i.e. T) or -diopathic se$mental
sclerosis
i l di h
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Con'entional Radiographs Con'entional radiography is relati'ely insensiti'e to )one
metastases;
?G destruction o+ the )one mineral content is necessary+or detection, thus it is not apparent on con'entionalradiographs the early stages o+ disease;
.s a rule, lesions need to )e X < cm to )e detected;
Con'entional radiography is still the pre+erred imagingmethod to determine )eha'ior 0i;e;2 sclerotic, osteolytic ormi&ed;
4steolytic metastases can mimic%o 4., Su)chondral cysts or Schmorl nodes o+ the spine
Sclerotic metastases may mimic other sclerotic )one lesionssuch as%o Tu)erous sclerosis, Mastocytosis or 4steopoikilosis
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Sclerotic metastases o+ 8< Common signs o+ spinal
metastases +ound oncon'entional radiographsinclude%
Destruction o+ thepedicle
.ssociated so+t-tissue
mass
MRI
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MRI
Imaging method of choice +or e'aluatingsuspected metastatic spinal pathology;
.pparent di3usion coeYcient 0ADC2'alues calculated +rom di3usion-"eighted
MR images is a relia)le +actor todistinguish vertebral metastasesfrom normal vertebrae;
MRI can also help detect metastaticlesions beforechanges in )onemeta)olism make the lesions detecta)leon )one scintiscans
Criteria #n0ection (umour
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o pattern o0ertebral inole
"t least 2 arounda=ected disc
Isolated* non contiguous
+ortion o0ertebral inole *ostlyendplates( postelements relati'elyspared
Body, typically pedicles
isc inolement Des Spared 0eception% +rostateca2
*arro7 signal T: lo", T< high,normal di3usion
T: lo", T< high, restricteddi=usion
%pidural
component
$ranulation tissue(
etends seeralleels a)o'e )elo"
?ocal mass( limited to le'el
a3ected 0eception% lymphoma2
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82/83
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