NEURORADIOLOGYNEURORADIOLOGY

dr. Farhan Anwary, Sp.Rad

Bagian/SMF RadiologiFK Unpad / RS dr. Hasan Sadikin

Bandung

NEURORADIOLOGY (NEUROIMAGING)

Plain Film CT Scan (Computed tomography) MRI (Magnetic Resonance

Imaging) Angiography / DSA (Digital

Subtraction Angiography) Sonography / USG / Color Doppler Nuclear Medicine

PLAIN FILM/CONVENTIONAL RADIOLOGY

SKULL : - Lateral view- Sella- Straight posteroanterior view- Caldwell view- Towne view- Basal (submentovertex) view- Waters view

Normal, Radiographic, Anatomy

LATERAL VIEW

Sutures Calvarium Sella Dorsum sellae Sinus sphenoidalis

STRAIGHT POSTEROANTERIOR VIEW

Coronal - lamdoid suture

Orbital roof, petrus ridge,

internal auditory canal,

cribriform plate - crista galli,

maxillary sinus, nasal cavity,

upper lateral rim orbita

CALDWELL VIEW

Lesser - greater wings Foramen rotundum ( V2 ) Orbital rim Zygoma - zygomaticofrontal

suture Floor of anterior cranial fossa Frontal sinus

TOWNE VIEW

Occipital, parietal, frontal Sagital suture Posterior clinoid processes -

dorsum sellae Internal auditory canal

WATERS VIEW

Maxillary - frontal sinuses Orbital margin -

zygomaticofrontal suture Zygomatic process Body, ramus, condyle,

coronoid process

BASAL (SUBMENTOVERTEX) VIEW

Odontoid Middle fossa Foramen ovale ( V 3 ) Foramen spinosum ( mma ) Sphenoid sinus

I . SINGLE LUSCENT DEFECT IN THE SKULL

DDX : Normal variant Pacchionian granulation Parietal foramina

DDX : Abnormal solitary luscent skull defect ( “Help Me” ) Hemangioma Epidermoid, dermoid Leptomeningeal cyst Paget's : osteoporosis circumscripta Post surgical Metastatic (solitary) Eosinophilic granuloma Encephalocele

II. MULTIPLE LUCENT DEFECTS IN THE SKULL

DDX : - Metastases - Myeloma - Hystiocytocis - Hyperparathyroidism - Cushing's - Osteomyelitis - Radiation

III. INCREASED SKULL DENSITY

A. Diffuse increased skull density

DDX : - Osteopetrosis - Hematologic; anemias, myelofibrosis- Fibrous dysplasia- Paget's disease- Acromegaly - Metastasis - Dilantin - Hypervitaminosis D

B. Focal increased skull density

DDX : - Osteoma- Hyperostosis frontalis- Meningioma- Fibrous dysplasia- Paget's disease- Metastasis- Calcified cephalhematoma

IV. INTRACRANIAL CALCIFICATION

A. Physiologic can occur in

1. Pineal

2. Habenula

3. Basal ganglia

4. Choroid

5. Dura

B. Phatologic calcifications

1. Tumorsa. O1igodendriglioma (90%)b. Craniopharyngioma (70%)c. Ependymoma (60%)d. Choroid plexus papilloma (25%)e. Low-grade astrocytoma (20%)f. Meningioma (10%)g. Other (Dermoid, pineal tumor, lipoma)

B. Phatologic calcifications

2. Infection : CMV, toxoplasmosis, cysticercosis

3. Vascular :a. Atherosclerotic disease b. Aneurysm c. Arteriovenous malformation

4. Pathologic basal ganglia calcification

B. Phatologic calcifications

5. Neurocutaneous

syndromes

a. Neurofibromatosis

b. Sturge-Weber

syndrome

c. Tuberous sclerosis

6. Post trauma

C. Basal Ganglia Calcifications

DDX : Endocrine : hypothyroidism,

pseudohypoparathyroidism Infectious : CMV, toxoplasmosis,

cysticercosis Toxic/Anoxic : CO, lead, radiation Congenital : Tuberosclerosis,

Fahr's disease

V. Large Sella

DDX : Tumor : Adenoma,

craniopharyngioma, optic nerve glioma

Aneurysm Increase intracranial pressure Empty sella

CEREBROVASCULAR DISEASE

I. Cerebral Infarction

a. Etiology1. Atherosclerosis (large vessels)2. Atherosclerosis (small vessels)3. Hypoxia / anoxia4. Dissection

CEREBROVASCULAR DISEASE

I. Cerebral Infarction

a. Etiology

5. Fibromuscular dysplasia

6. Vasculitis

7. Basal arteriovascular occlusiv disease

8. Venous thrombosis

9. Miscellaneous; vasospasm, trauma

b. Imaging in ischemia / infarction :

- Vascular distribution- Evidence of cytotoxic edema- Involvement of cortex- Hemorrhagic transformation

c. IMAGING : CT, MR, MRA, Angiography

II. Spontaneous Intracranial Hematoma;

Intraparenchymal hematoma

DDX : Causes of intraparenchymal hematoma

1. Aneurysm rupture

2. Arteriovenous malformation rupture

3. Hypertension

4. Tumor

DDX : Causes of intraparenchymal hematoma

5. Blood dyscrasia

6. Anticoagulant

7. Drug abuse

8. Infarct

9. Amyloid angiopathy

10. Idiopathic

III. Spontaneous Intracranial Hemorrhage;

Subarachnoid and extra-axial

1. Subarachnoid hemorrhage (SAH)

2. Extra-axial hemorrhage (SDH, EDH)

IV. Intracranial Aneurysm

V. Cerebrovascular Malformations

1. Capillary telangiectasis

2. Cavernous angioma (hemangioma)

3. Venous angioma

4. Arteriovenous malformation (AVM)

5. Occult cerebrovascular malformation (cryptic AVM)

6. Vein of galen aneurysm

CRANIAL TRAUMA

1. ImagingSkull film, CT, MRI

2. Type of Injuries a. Directb. Indirectc. Skull fractures

3. Types of the Hemorrhages

a. Appearance of hemorrhage by

CT

b. Appearance MR

c. Extra axial hemorrhage

CRANIAL TRAUMA

Extra Axial Hemorrhage

1. Epidural hematomas

2. Sub dural hematomas

3. Sub arachnoid hemorrhage

(S.A.H)

4. Intra ventricular hemorrhage

5. Intra parenchymal hemorrhage

DDX : Parenchymal Hematoma

Aneurysm rupture AVM rupture Hypertension Hemorrhagic infarct Hemorrhagic tumor Bleeding diathesis Amyloid angiopathy

INTRACRANIAL MASSES

1. Radiografic Characteristic of Lesion

a. Intrinsic CT density

b. Contrast enhancement BBB (ring, gyriform, homogenous)

c. Multiple lesions

d. MR appearance

DDX : Intracranial Mass (‘TEACH’ )

Tumor Edema Abcess, AVM, aneurysm Cyst Hematoma

A. Primary Tumor

1. Gliomaa. Astrocytomab. Ependymomac. Oligodendrogliomad. Ganglioglioma

2. Meningioma 3. Lymphoma

B. Metastatic Tumor

DIFFERENTIAL DIAGNOSIS BY LOCATION

DDX : Enhancement pattern of focal cerebral parenchymal lesions

A. Cerebral parenchymal lesion “Ring” : - Glioma

- Meta- Abcess- Resolving hematoma- Resolving infarction

Homogenous :

- Lymphoma- Aneurysm

DDX : Intraventicular Mass Lesion

Meningioma, Astrocytoma, Choroid

plexus papilloma, Colloid cyst, Meta,

Ependymoma, Subependymoma,

AVM, Oligo, Lymphoma

DDX : Pineal Region Mass

Germ cell tumor, Pineal cell

tumor

Germinoma, Pineoblastoma,

Teratoma, Glial cell tumor,

Dermoid, Epidermoid,

Choriocarcinoma, Meta

DDX : Juxta Sellar and Supra Sellar

Adenoma Craniopharyngioma Aneurysm Meningioma Uncommon : Meta,

Arachnoid cyst, Glioma

DDX : CPA Mass

Acoustic neurinoma Trigeminal neurinoma Meningioma Arachnoid cyst Epidermoid Aneurysm Meta

INTRACRANIAL INFECTIONS DISEASE

I. Focal Lesions

A. Pyogenic brain abcess

B. Atypical brain abcess

C. AIDS : Toxo, Lympho, TB,

Abcess

II. Encephalitis

Congenital : “ TORCH “

Toxo, CMV, Rubella, Herpes

III. Meningitis

WHITE MATTER DISEASE

A. Demyelinating Diseases

DDX : - Primary : MS- Viral- Toxic and Metabolic- Post therapy- Vascular / SAE

B. Dysmyelinating Diseases

- Leucodystrophies

IMAGING OF THE SPINE

I. Approach1. Primarily a bony lesion

2. Primarily a joint-space lesion

3. Primarily a lesion involving the soft tissues with the neural canal or exit foramina

4. Congenital abnormality may involve dysplastic changes of both osseous and neural components

II. Primarily an Osseous Lesion

1. Primary bone tumor2. Secondary bone tumor3. Inflammatory bone disease4. Hematologic or vascular5. Trauma6. Metabolic7. Congenital anomaly

III. Primarily a Joint-space Lesion

1. Degenerative disc disease

2. Trauma (iatrogenic)

3. Disc-space infection

IV. Primarily a Lesion Involving Soft Tissues of Canal or Foramina

1. Intramedullary

2. Intradural and

extramedullary

3. Extradural

V. Congenital Anomalies

1. Scoliosis

2. Vertebral anomalies

3. Dysraphism

4. Syrinx

5. Tumors

6. Neurofibromatosis

7. Spinal stenosis

dr. Farhan Anwary, Sp.Rad

TERIMA KASIH