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 The Requisites

Neuroradiology
 SERIES EDITOR James H. Thrall, MD
Radiologist-in-Chief
Massachusetts General Hospital
Juan M. Taveras Professor of Radiology
Harvard Medical School
Boston, Massachusetts

OTHER VOLUMES IN Breast Imaging

THE REQUISITES IN RADIOLOGY SERIES Cardiac Imaging
Emergency Radiology
Gastrointestinal Imaging
Genitourinary Radiology
Musculoskeletal Imaging
Nuclear Medicine
Pediatric Radiology
Ultrasound
Thoracic Radiology
Vascular & Interventional Radiology
 The Requisites

Neuroradiology
Third edition

David M. Yousem, MD, MBA

Professor of Radiology, Director of Neuroradiology
Russell H. Morgan Department of Radiology and
Radiological Science
Johns Hopkins Medical Institution
Baltimore, Maryland

Robert I. Grossman, MD
Dean and CEO
NYU Langone Medical Center
Attending Physician
Department of Radiology
NYU Hospitals Center
Attending Physician
Department of Radiology
Bellevue Hospital Center
Professor
Department of Radiology
Neurosurgery and Physiology & Neuroscience
NYU School of Medicine
New York, New York
 1600 John F. Kennedy Boulevard
Suite 1800
Philadelphia, PA 19103-2899

NEURORADIOLOGY: THE REQUISITES ISBN: 978-0-323-04521-6

© 2010 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in ­evaluating
and using any information, methods, compounds, or experiments described herein. In using such
­information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of ­administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
­knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products liability,
­negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
The Publisher

Previous editions copyrighted 2003, 1994.

Library of Congress Cataloging-in-Publication Data

Yousem, David M.
Neuroradiology : the requisites / David M. Yousem, Robert I. Grossman. – 3rd ed.
   p. ; cm. – (Radiology requisites series)
Robert I. Grossman is first named author on previous edition.
Includes bibliographical references and index.
ISBN 978-0-323-04521-6
1. Nervous system–Radiography. I. Grossman, Robert I. II. Title. III. Series: Requisites in radiology.
[DNLM: 1. Neuroradiography–methods. 2. Central Nervous System Diseases–radiography.
WL 141 Y83n 2010]
RC349.R3G76 2010
616.8′04757–dc22
2010005631

Acquisitions Editor: Rebecca S. Gaertner

Developmental Editor: Stacey Fisher
Project Manager: David Saltzberg
Design Direction: Steven Stave

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Dedication

To the LOML, my OAO.

Thank you for the love and support.
—DMY

To Lisse—great mother, perfect wife, spectacular ophthalmologist.

You did it all!
—RIG
Contributors

Robert Zimmerman, MD
Executive Vice Chairman
Professor of Radiology
Department of Radiology
Weill Cornell Medical College
Director of Diagnostic Imaging
Department of Radiology
New York Presbyterian Hospital-Weill Cornell
New York, New York

vii
Foreword
Neuroradiology: The Requisites is now appearing in its third ­edition Fellows specializing in neuroradiology will also find this to be
and has established itself as one of the widely read books on the a very useful book. The organization follows from methods to
subject. The third edition again captures the philosophy of the anatomic concepts and disease-oriented applications, ­presenting
series for efficient and economical presentation of material while a logical sequence for their mastering of the subject at the
still presenting the important subject matter of neuroradiology at ­fellowship level.
a level and with a clarity of detail that is sure to be well received. Residents and fellows studying for board exams will also like the
Neuroradiology has always been a challenging field to capture in concise nature of the Requisites series, including Neuroradiology:
a textbook because of the multiplicity of methods involved and The Requisites. These books can truly be “studied rather than just
the inherent complexity of the interplay among neuroanatomy, read superficially,” leading to a much more enduring mastery of
physiology, and function that all must be understood in order to the information.
master the practice of neuroradiology. For radiology practitioners, neurologists, and neurosurgeons,
In the time since publication of the second edition of Neuroradiology: The Requisites can serve as a textbook for learning
Neuroradiology: The Requisites, several important advances and trends the subject and as a useful and efficient reference book to help
have continued to transform and reshape the field. Advances in guide their understanding of imaging results and findings in their
technology include the fairly widespread adoption of higher field patients.
MR imaging at 3.0 Tesla, with associated improvements in image When the Requisites series was first established, there was a
quality and increased flexibility in image protocol development. hypothesis and hope that the format would make information read-
Multichannel MR imaging has led to improved image quality and ily accessible to the reader by eliminating extraneous material and
shortened imaging times. MR tractography has opened important covering only those topics deemed most important to clinical prac-
new avenues of research and is increasingly used for patient care. tice by the respective authors. The success of the series of the past
There has been near universal adoption of multislice CT, greatly two decades argues strongly in favor of the approach and format.
facilitating the application of functional CT for the diagnosis and I have every confidence that the third edition of Neuroradiology:
management of stroke. These technologic advances are remark- The Requisites will be equally well received as its two predeces-
able, and, in retrospect, many of them were beyond our imagination sor editions. I again congratulate Drs. Yousem and Grossman for
only a few years ago. their outstanding text. They have truly brought to bear their
Given the continued changes in the practice of medicine authoritative knowledge and experience in neuroradiology for
and neuroradiology, anyone who deals with the nervous system the benefit of the reader, whether beginning resident or sea-
will find the third edition of Neuroradiology: The Requisites to be soned warrior.
an invaluable resource on the subject. The concise nature of
the book will make it particularly appealing to residents dur- James H. Thrall, MD
ing their neuroradiology rotations, where they face the unique Radiologist-in-Chief
problem of going from a minimal knowledge base of neuroradiol- Massachusetts General Hospital
ogy to a working knowledge in a very short period of time. The Professor of Radiology
Requisties series was designed to address this issue by balancing
text and illustrations appropriately and reinforcing concepts with
Harvard Medical School
summary tables and boxes. Boston, Massachusetts

ix
Preface
Somewhere between the first and the second edition of 20 years, Rena Geckle; and my great buddy, Norm Beauchamp.
Neuroradiology: The Requisites, Bob Grossman and I lost our tight At Elsevier, Martha, Linnea, and Rebecca have shepherded me
focus or, some will say, got full of ourselves and the book bal- through the process with minimal pain and maximal assistance
looned to more than 900 pages (with index). There was a lot more and support. On the home front, close friends Scott and Coos,
great stuff in the second edition, but there was also a lot of “non- and loving family members, especially my ever-delighting Ilyssa
requisite” stuff as we covered more subtle and obscure entities. and Mitch and Liz support me. Hard to believe that Mitch was
The third edition marks a return to the essentials of neuroradi- “in utero” for the first edition of the book and is on the way
ology, with the elimination of many of the less common entities to driver’s ed at the time of this third edition. I cannot express
most people will not see outside the quaternary care academic enough love and gratitude to my ever spiritual wife, Kelly, who
medical institutions. We still guarantee passing grades for ABR has recharged my batteries in many, many ways as I pass from
candidates and feel confident that we cover the subject thor- my 40s to my 50s….and beyond. She is my muse, and I love her
oughly, but our goal was to recapture about 200 pages and get the more and more with each passing day. Many days of writing in
book back to “the requisites.” We hoped that we could recreate a our home on Sarkar Cove, Alaska, were punctuated by her offers
book that residents everywhere could read on a 1- month rotation of more coffee, more salmon, more halibut, more granola, more
comfortably, undaunted by the size, and one that still served the brownies. She has kept me happy and happily writing. Thank
practice of most radiologists needing a firm base in neuroradiol- you, my love.
ogy from all venues of practice. Live, love, learn, and leave a legacy.
As I participated in feedback sessions on Aunt Minnie about —DMY
what the third edition should sound like, there was a strong pref-
erence expressed for rolling back much of the humor that dotted
the first and second editions. While I had mixed feelings about Tempus fugit—so true! I still have the image of a young David
that, I recognized that it would be helpful to reduce the size of the Yousem and me in 1994 choosing photographs for the first edition of
book if Bob and my attempts to have a piece of humor on every our book. It was an ice-cold winter, and we were exhausted trying to
page were reduced. Thus, hopefully, the humor that remains finish the manuscript in a timely fashion. I had the highest respect for
will be less intrusive, in good taste, and used to make teaching his work ethic then, and nothing has changed in the past 15 years.
points, not just to demonstrate wit . . . . if there was any there to
Well, not quite. David left Penn and became head of neurora-
begin with. Because this is more “my edition,” people will no
doubt think that it was Bob who had the good sense of humor diology at Johns Hopkins, where he has built a superb academic
and Yousem was the serious dull one, but so be it. The books will section and has embellished his legacy as a leader in the field.
have a different tone, no doubt, but it still is a joint product. My career had a few twists and turns. After not being afforded an
Bob left the third edition to me to revise. I have used his strong interview for the Radiology Chair position at Penn, I was incred-
basis from the previous editions and have updated, trimmed, and ibly fortunate to have been given a better opportunity at NYU.
enhanced, and eliminated material from his original chapters. Starting in 2001 and working with a team of energetic and talented
Nonetheless, because the vast majority of the text is his original individuals, we transformed the department into an ­academic
material Bob Grossman remains a co-author. He also remained a powerhouse in a few short years.
sounding board for me to bounce ideas about the book and to lis- In 2004, the second edition of this book was published. The
ten to me complain and gripe about various aspects of the author- combined sales of our book was more than 50,000 copies! I then
ship process. It’s still a Grossman product. I am happy to have announced to David that I would not be an author of the third
him share the byline. edition. As chair of a department, my focus had shifted. I was
When it came to rewriting Grossman’s stroke chapter, I enlisted delighted that David wanted to continue the effort and was sur-
the support of another Bob, Bob Zimmerman. Bob is well known prised and honored that he asked me to be the coauthor on this
as a great teacher and elder statesman in neuroradiology. Because edition. Truth be told, I contributed little new material; this is
I recognized that this chapter would require the most work David’s book, and he richly deserves the glory. I took pride in cre-
because so much of the evaluation and treatment of stroke and ating part of the foundation on which this work is based. However,
aneurysm has changed since the second edition, I opted to have he will have to find a new partner for the next edition—a young
a fresh face recreate that chapter. Bob Zimmerman came to the “David Yousem” perhaps.
rescue and has written an excellent contribution that dramatically As for me, I had the great good fortune of being chosen Dean
updates the third edition. Thank you, Bob Z. and CEO of NYU Langone Medical Center in 2007. It is a career
As always, I am grateful to my many colleagues that enabled me direction I never imagined, and I am grateful to those individuals
to have the time to write this book, including the many members who made it possible. Most of all, I want to underscore a life les-
of the Neuroradiology Division at Johns Hopkins including fac- son: When you don’t get what you want (and think you deserve),
ulty, fellows, and support personnel. Special people that deserve take a deep breath, believe in yourself, work hard, and keep run-
mention include my ever-supportive chairman, Jon Lewin; my ning—it’s a marathon.
most valuable nonphysician colleague and friend of more than —RIG

xi
Preface to the First Edition
The original intent in writing this book was to create a short, eas- presented; although the chapters may stand alone, we often refer
ily readable text for radiology residents that would fully prepare to previous chapters to avoid overlap that is annoying to the reader.
then for interpreting neuroradiologic studies—The Requisites. We Therefore we entreat you to pass from the basics of imaging tech-
subsequently decided that more than The Requisites would be nec- niques and anatomy, to brain diseases (neoplasms, vascular dis-
essary for those in the practice of radiology and for those clinicians eases, infections, white matter diseases), to neurodegenerative and
and trainees who interact with neuroradiology. With the emer- congenital abnormalities. From there, we discuss the subsites of
gence of certificates of added qualification, the book required neuroradiology: the orbit, sella and central skull base, and temporal
modification, including the addition of a head and neck section bone. The chapters on the head and neck, an area of which neu-
and more tables. However, with the added weight of more infor- roradiologists are often frightened but which is often within their
mation, we were concerned that the text remain eminently read- bailiwick, follow. The chapters on sinonasal pathology, mucosal
able and enjoyable (even for the authors). This was important to diseases, and extramucosal disease present a practical approach
us. We wanted to impart our enthusiasm and passion for neurora- to the head and neck that is digestible by even the most fearful
diology in a light-hearted, entertaining way. radiologist. We conclude the book with classic neuroradiology, with
The reader will find that this book does not have footnotes. two chapters about the spine entitled “Anatomy and Degenerative
This book is not intended to be a reference book, although you Diseases” and “Nondegenerative Disease of the Spine.”
will find an enormous number of statistics and useful data within Our last chapter was the most fun. We discuss that intangible
it. We were more concerned with giving the reader a factual topic, how to look at a case. We strive to provide an approach to
framework for diagnosing diseases and understanding the clini- masses in the extraaxial and intraaxial compartments and to dif-
cal ramifications of neuropathology. We also thought that foot- ferentiating neoplasms from infarcts, from infections, and from
notes are somewhat distracting. On the other hand, we stressed demyelinating processes in the brain and spine. We try to go
to Mosby that we wanted the text to be heavily indexed so that it beyond a description of entities to synthesize all the information
will be easy to find a lesion’s precise location in the book . . . no in the book into a strategy for hitting the home run. We leave the
flipping through pages in a frustrating attempt to find Lhermitte- reader with some useful tables that can be ripped out and surrep-
Duclos here. We also used some abbreviations repeatedly that titiously taken to any examination.
are not constantly identified. They include T1WI, PDWI, and We hope that you relish this text as much as we have enjoyed
T2WI for T1-weighted image, proton density-weighted image, our careers in this rich and vibrant subspecialty.
and T2-weighted image, respectively.
We have designed the chapters to flow from one to the next. We Robert I. Grossman
encourage you to read the book in its entirety in the order that it is David M. Yousem

xiii
Preface to the Second Edition
Neuroradiology has evolved considerably since our first edition We still strove to write a book that you couldn’t put down (lit-
was published in 1994 (thank the Lord—otherwise why would erally and figuratively) that would be engaging to the reader.
you cough up the big bucks for the second time around). We have Frankly, adjusting the humor through the Clinton scandal years
attempted to capture this extended scope while at the same time to the Gore-Bush non-election, to the era of terrorism and war
tried to keep the same inimitable style that appeared to be suc- was as difficult as describing Balo’s concentric sclerosis. We hope
cessful in the first edition. As you can see, the size of the text has that we have created a book that has the proper balance of irrev-
grown in keeping with the field. We believe that the vast major- erential humor, psy-ops, and scientific fact . . . or hearsay.
ity of topics in the book are relevant to the practice and art of We have put our blood, sweat, and tears into this edition (our
neuroradiology. publisher guaranteed the last item). We hope that this book is
Our goal in writing a second edition was to produce a volume as well-received as our first product. Please provide us with any
that was current with respect to neuroimaging, including diagno- suggestions, comments, criticisms, or corrections (be nice, we
sis, pathophysiology, and techniques. We have included diffusion, are very sensitive). DMY may be able to think about a third edi-
BOLD, magnetic resonance spectroscopy, perfusion imaging, etc. tion after his ulcer is healed. RIG has officially retired from writ-
Some of this may not have migrated to common practice, but, ing Neuroradiology textbooks, although he still thinks about
if not, it is pretty close, and clearly important for the reader to Neuroradiology.
understand. We are now in an era of genomics and proteinomics Lastly, you the reader will be the ultimate arbiter of this book’s
and molecular imaging; how do these relate to macroscopic imag- success. Enjoy our baby!
ing tools? Hard questions to be answered by a couple of small
town doctors like us. There is considerable information here, Bob and Dave
more than our friend, the tire-kicking radiologist, may need, but
the board-taking resident or CAQee will be more than satisfied.

xv
Chapter 1
Techniques in
Neuroimaging
INTRODUCTION of ­attenuation of the x-ray beam than air or soft tissue. Metal and
bone will look white on an x-ray film; air is black. By virtue of lower
Central to the effective evaluation of an image is an understand- density, fat also has a lesser degree of x-ray attenuation (Fig. 1-1).
ing of the technical aspects of image production. This not only
includes recently developed methodologies such as magnetic Digital Radiography
resonance (MR) and computed tomography (CT), but also the
traditional techniques of angiography, myelography, ultrasound, Digital radiography has also invaded the workspace. This allows
nuclear scintigraphy, and plain-film radiography. In some cases, collection and storage of data on digital detectors and computers
individuals will limit their careers either to the more invasive rather than merely relying on hard-copy film for plain-film stud-
aspect of neuroradiology (neurointerventionalists) or to the diag- ies. This has led to a debate between hard and soft copy as it
nostic function (cross-sectional imagers). No matter which field relates to expense versus ease of use versus storage needs, and so
one pursues, it is necessary to have a rudimentary knowledge of on. Some manufacturers have switched to silicon flat-panel detec-
the physics behind the modalities used. Since the last edition of tors, with cesium iodide scintillators to improve image quality,
this book, new techniques, such as positron emission tomography/ decrease radiation dose, and allow long-term storage of data. The
CT, diffusion tensor MR imaging, and CT/MR perfusion map- x-ray photons are converted to light by the cesium scintillator,
ping, have become more widely utilized. With these advances, which in turn produces an electrical charge, which is transformed
our understanding of the pathophysiology of neurologic disease into a digital readout on an electronic processor. Digital images
has improved dramatically. may be read on film, computer monitors, or even video screens.
Thus, the innovators have taken a relatively simple technology
PLAIN FILMS and made it as complex as rocket science. The trend has been
from low cost/low tech to high cost/high tech methodology with
The limited role of plain-film radiography (Box 1-1) in neuro- constant software upgrades. Digital radiography has largely been
radiology warrants a brief discussion of the technique. Suffice implemented in such plain-film bastions as the intensive care unit
it to say that with plain-film radiography the x-ray beam serves and mammography unit (where the debate between hard versus
as the source of photon energy and the recipient (film or digital soft also rages). As these areas are often services that are “in the
receiver) is the “detector.” The x-ray beam is generated when red” to begin with, the negative margin only increases.
electrons produced in the cathode of an x-ray tube hit the anode Subtraction angiography is based on the principle that a
(usually tungsten alloy) target. The electron current is mea- baseline film of an area of anatomy without vascular opacifica-
sured in milliamperes (mA), and the potential difference across tion can be subtracted from a film of the same area with vas-
the x-ray tube is the peak kilovoltage (kVp). Increasing the kVp cular opacification, yielding an image of the vascular structures
increases the energy of the electrons flowing toward the anode alone. The administration of iodinated contrast allows one to
and therefore increases the amount and energy of x-rays pro- opacify the blood vessels because of the differential attenua-
duced. The time that the x-ray tube is in operation is multiplied tion of the x-ray beam by iodine compared with the skull and
by the mA to calculate the mAs (milliampere-seconds). Lowering nonopacified ­portions of the brain, head, and neck. Taking
the kVp increases image contrast, but penetration of the photon a “negative image” of the scout film and manually applying
beam decreases. Increasing the mAs yields greater exposure at that to one where the vessels are opacified yields a composite
the cost of higher current and heat load on the x-ray tube. This ­vessel-only study.
has not changed since Roentgen.
Contrast in plain-film radiography is based on the differential
attenuation of the x-ray beam by various tissues. As the density, COMPUTED TOMOGRAPHY
atomic number, and electrons per gram of a tissue increase, the
degree of attenuation of an x-ray beam increases. The greater Parameters and Units
the attenuation of the photons of an x-ray beam, the lighter the
Nobel Prize winner Sir Godfrey Hounsfield developed CT for
image on the film. Thus, metal and bone have a greater degree
clinical use between 1972 and 1973. The first company to intro-
duce a CT scanner was EMI (Electric and Musical Industries,
Ltd), the same company the Beatles used for distributing their
music on the Apple label.
Box 1-1. Current Alleged Utility of Plain Films The principles of differential x-ray beam attenuation apply to
Rule out foreign body (before magnetic resonance scan) CT, except CT uses a highly collimated x-ray beam. The photons
Skull fractures that pass through the patient are collected by CT detectors, which
Acute sinusitis screen show a differential rate of intensity on a gray scale depending on
Rule out opaque salivary gland calculi the degree of absorption along the narrow x-ray beam. The CT
Characterize bony lesions scanner’s x-ray beam is rotated over many different angles so as to
Rule out epiglottitis versus croup in emergency room get differential absorption patterns across various rays through a
Cervical spine fractures single slab of a patient’s body. By a mathematical analysis known
Flexion-extension views for instability as projection reconstruction, one is then able to obtain an absorp-
Spondylolysis tion value for each point (pixel) within a CT slice. To understand
Facial trauma: Gross fractures the concept of a pixel, one must understand how pixel size relates
to the matrix and field of view (FOV).
1
2 Neuroradiology: The Requisites

C D

Figure 1-1. Multimodality imaging of different tissues. A, Plain film of last

night’s entree reveals water (w), air (a), bone (b), lamb (l), fat (f), and paper clips
(metal) (yum!). B, Computed tomography performed with standard algorithm
and filmed at soft-tissue settings shows good differentiation of bone (b), metal
(m), lamb (l), air (a), and fat (f). Note that water (w) and lamb have similar den-
sities at this window setting. C, T1-weighted image shows high-intensity fat
(f), low-intensity water (w), and intermediate-intensity lamb muscle (l). Air (a)
and bone (b) are black. Unfortunately, the paper clips flew into the bore of the
scanner before they could be imaged. D, Items on T2-weighted image include
A B intermediate-intensity fat (f) and lamb muscle (l), bright water (w), black air (a),
and bone (b).

The matrix refers to the number of imaging partitions in the Table 1-1. HU of Central Nervous System Structures on CT
x-y plane of a slice, assuming an axial slice is in the z plane. The
in-plane pixel size is determined by dividing FOV by the matrix Structure HU
dimensions. The FOV is the linear dimension of the space to
be imaged. The machine operator can select both the FOV and Acute blood 56 to 76
the matrix size. The matrix sizes of CT scanners have increased Air −1,000
­several-fold since the original 80 × 80 matrix of the EMI scanner Bone 1,000
in 1972. At present, matrices on the order of 512 × 512 are used. As
Calcification 140 to 200
an example, a 20-cm FOV scanned with a 512 × 512 matrix would
yield pixels that are 0.39 mm (200 mm/512) by 0.39 mm. The Cerebrospinal fluid 0
final dimension one must know in CT imaging is the slice thick- Fat −30 to −100
ness. At present, CT slice thicknesses can be less than 1 mm. The
Gray matter (caudate head) 32 to 41
three-dimensional imaging unit is called a voxel; in the ­example
just given, the voxel size would be 1.0 × 0.39 × 0.39 mm3. For an White matter (centrum semiovale) 23 to 34
18-cm FOV with a 256 × 256 matrix and 8-mm slice thickness, the CT, computed tomography; HU, Hounsfield units.
voxel size would be (180 mm/256) × (180 mm/256) × 8 mm. For
high-resolution imaging, as desired in the temporal bone or orbits,
a large matrix and a small FOV are used with slice thicknesses of relatively limited to air-containing materials (airway, mastoid air
0.5 mm. cells, sinuses) (Fig. 1-1B).
The scale for CT absorption generally ranges from +1,000 to
−1,000, with 0 allocated to water and −1,000 to air (Table 1-1).
The units are termed Hounsfield units (HU), named to honor
Evolution of CT Scanners
the discoverer of the technique. White matter and gray matter CT technology has evolved over several generations, each one
are in the 30 to 50 HU range. Hematomas tend to range from designed to reduce scan time and increase image quality. The
50 to 80 HU, and calcification is generally 150 HU or greater. first-generation CT scanner had a thin x-ray beam and one detec-
These values vary by approximately 10 to 25 HU, according to tor. The second-generation scanners used a fan-shaped beam and
the particular CT machine that is used. Dense bone and metal multiple detectors. The arc of scanner gantry motion improved
are the materials at the highest HU range. High protein con- from 1-degree increments to as much as 30-degree differences.
centrations (clotted blood, tenacious sinus secretions, the lens Third-generation scanners used an even wider fan-shaped beam
of the eye) equate with higher HU values. At values less than and 10 times as many detectors as the second-generation scanner.
0 one finds the structures that show less CT attenuation than The gantry rotated 360 degrees and moved continuously. Fourth-
water. Fat is usually in the −40 to −100 HU range. In neuro- generation scanners used circumferential detectors so that only
radiology, the structures with less CT attenuation than fat are the x-ray tube moved in a 360-degree arc.
 Techniques in Neuroimaging 3

Most CT scanner manufacturers now use “slip ring technol- effects of xenon inhalation may include sedation, bronchospasm,
ogy,” which allows continuous data acquisition and gantry rotation and respiratory depression.
throughout the scanning procedure as the table moves without Iodine-based CT perfusion has also been introduced
stopping and starting for each slice. This procedure, called spiral recently. A large rapid bolus of contrast is infused during con-
scanning, has allowed scan times per slice to be reduced to 1 sec- tinuous rapid scanning of a single slice, and the wash-in and
ond or less. The increased heat capacity of the newer x-ray tubes wash-out of the bolus can be analyzed by a computer to gen-
and the increasing sensitivity of the CT detectors have allowed erate semi-­quantitative images of brain perfusion. Commonly
more rapid image acquisition and more slices before x-ray tube measured parameters are mean transit time (MTT), cerebral
heating becomes prohibitive. Other advances in CT collimation blood volume (CBV), and CBF (CBF = CBV/MTT). On CT
have allowed thinner and thinner slice profiles to be obtained. perfusion images, the differential density between normal brain
At present, 0.5-mm thick sections are often used for evaluation and hypoperfused brain can be accentuated through computer
of fine anatomic structures such as the ossicles in the temporal manipulation to demonstrate areas of ischemia in the brain.
bone or for CT angiography studies. Because the beam is so well The main disadvantages to this technique are the large-bore
collimated, x-ray exposure to the patient is limited to the area ­catheter required (14 to 16 gauge), the rapid injection rate (5 to
of scanning, and if overlapping sections are not used, the overall 10 mL/sec), patient discomfort (one should use nonionic con-
dose to the patient is less than 3 rad to the imaged volume. Of trast to reduce the “barf” factor), the limited number of slice
course, one cannot help but get “scatter radiation,” which may acquisitions that limit the region of study, and the reluctance
affect radiosensitive organs such as the thyroid glands or gonads of clinicians to give iodinated contrast to patients with strokes.
(both of which are hypometabolic in RIG). Helical (spiral) scan- To that end, MR still has an advantage in that only milliosmoles
ning has allowed excellent quality CT angiography studies to be are delivered with gadolinium injections (see discussion of
performed, thus enabling CT to compete with ultrasound and Magnetic Resonance Imaging in this chapter).
MR angiography (MRA) for the evaluation of neck and intracra- CT perfusion CBF maps are noted to be more sensitive to isch-
nial vessels. emia than blood volume or time-to-peak maps. Infarctions may
One of the terms used to define the parameters for helical occur in most patients in areas of the brain with CBF values no
scanning is pitch, which is defined as the table speed times the more than 30% of normal tissue and in 50% of patients where the
tube rotation time divided by the slice width. As an example, if CBF of affected tissue is 30% to 50% that of normal tissue.
a scanner has a table speed of 5 mm/sec and you scan for 0.8 sec- CT technology has really taken off in the past 5 years, and the
onds and have a slice thickness of 3 mm, your pitch would be 5 × sanctity of MR as the premiere means for evaluating intracranial
0.8/3 = 1.33 pitch. In the past the pitch floated between 0.75 and pathology now rests more in the elimination of radiation expo-
1.50, but as table speeds have increased and slice thicknesses sure and increased soft-tissue contrast than in image resolution
has reduced, pitches of 2.0 to 15.0 are not uncommon. Fast table and functionality.
speed is desirable to cover more anatomy in a scan; however, spa-
tial resolution decreases with higher pitch (like Roger Clemens’ Algorithms, Windows, and Contrast Agents
fastball—the faster it moves the more the ball blurs—from a hit-
ter’s standpoint). Different reconstruction algorithms, or kernels, can be used to
Another advantage to helical scanning is that once you have a highlight a particular tissue with CT. Thus, bone disease may
volume of tissue scanned, you can slice it in as many thin sections be best visualized with a bone, edge, or detail algorithm used
or in as many planes as you wish. In general, the best image qual- to accentuate the interface between the bone and the soft tis-
ity is produced when images are reconstructed using at least half sue. Alternatively, the algorithm for data reconstruction can be
the collimator setting. You can play with overlapping images and set to highlight differences in soft-tissue attenuation of struc-
thinner slice reconstructions for CT angiography studies. tures. If you save the raw data from a scan, any number of
The latest refinement in CT technology is the multidetector algorithms can be used retrospectively to analyze (target) the
system. In this scenario, instead of 1 mm × 20 mm detector chan- tissues studied.
nels, you have 1 mm × 1.25 mm channels. The key to optimiz- The images from a given algorithm may be displayed with
ing scanning is deciding which detectors to turn on when. Image different window widths and levels to photograph the pic-
thickness is selected by changing collimation, detector configu- tures in a manner that accentuates differences in CT attenua-
ration, and reconstruction algorithm. In practical terms, with one tion between structures. Window widths refers to the HU range
rotation of the gantry, one is able to perform interweaving heli- selected for gray-scale display, whereas the window level refers
ces producing multiple (current scanners for sale are in the 16- to the center point about which the range is displayed. By using
to 256-slice mode) slices instead of one per rotation. The speed small window widths (80 to 400 HU) and center levels (20 to 80
of data acquisition and patient throughput can be accelerated in HU), you can highlight subtle soft-tissue differences. To visu-
this way; alternatively, thinner slices and higher resolution can alize tissues with wide variations in CT attenuation, as in bone
be achieved. The evolution of CT has thus progressed from 0.5 versus air, a larger width (2000 to 3000 HU) and level (300 to
image per second (single slice with 1 second of scanning and 600 HU) are used.
1 second of table movement), through 2 images per second (heli- Contrast enhancement is often used in cranial CT to opacify
cal imaging with 2 images in 1 second as the table moves), to 64 blood vessels and to detect areas of abnormal blood-brain barrier
images per second (multidetector mode with 64 images in 1 sec- breakdown, where iodinated contrast will seep into the paren-
ond as the table moves). chyma. The factors that determine contrast enhancement of
a lesion include (1) the volume and delivery of the contrast to
the intravascular system, (2) the size of the intravascular space,
CT Perfusion (3) lesion vascularity, (4) permeability of lesion blood vessels, and
Xenon-133 CT is a method for evaluating cerebral perfusion. (5) size of extravascular intralesional space.
The xenon is inhaled in combination with oxygen, and CT scans Occasionally, intrathecal contrast is administered through a
are performed to determine cerebral blood flow (CBF) at mul- lumbar, cervical, cisternal, or ventricular approach to visualize
tiple locations in the brain. Brain xenon concentration is related intracranial pathology. Approximately 3 mL of nonionic con-
to the concentration of xenon absorbed in the bloodstream, the trast material (iodine, 180 mg/mL) can be administered through
brain blood flow, and the time of exposure to xenon. Decreased the cisternal or ventricular approach without risk of deleterious
flow has been documented in patients with meningitis, vaso­ effects (i.e., seizures, headache, nausea, vomiting, and neuralgia).
spasm, head trauma, sickle cell disease, and stroke. Adverse Myelographic doses are discussed later.
4 Neuroradiology: The Requisites

patient lying between the two permanent magnets, the magnetic

Box 1-2. Most Effective Uses of CT in Neuroradiology field is oriented perpendicular to the axis of the supine body.
Ruling out subarachnoid hemorrhage Superconducting magnets require no additional energy input
Acute head trauma once they have been “magnetized,” mainly because they are
Fractures of the face, skull, and spine encased in a liquid helium shell that prevents dissipation of the
Sinusitis energy. The helium keeps the magnet cold enough to maintain
Salivary gland calculus disease its superconductance (i.e., zero resistance). An outer insulating
Subtle bony irregularities layer of supercoolant liquid nitrogen is often used to keep the
Detection of calcification in lesions helium cold. The nitrogen requires constant replenishment or
Odontogenic lesions the magnet “quenches.” The coils of superconducting material
Degenerative disease that produce the magnetic field in a superconducting magnet are
CT angiography (emergency department) generally made of niobium-titanium wire. The static magnetic
CT perfusion (emergency department) field of a superconducting magnet is oriented parallel to the axis
Bony spinal stenosis of the supine patient body.
When MR is contraindicated or unavailable Because of their heavy weight from the iron yoke that sur-
Immediate postoperative evaluation rounds and connects them and the weight of the magnets them-
Temporal bone (external, middle, inner ear) disease selves, the maximum field strength of the permanent magnet
scanner is relatively low, usually 0.5 tesla. A tesla (T) is a unit of
magnetic field strength and is equivalent to 10,000 gauss (G). By
comparison, the earth’s magnetic field is approximately 0.5 G.
Aren’t you impressed now with “low-field strength” (0.15 to
Current Role of CT in Neuroimaging 0.5 T) magnets? They are much stronger than Mother Earth!
What is the role of CT in neuroimaging (Box 1-2)? It remains the Most nonopen superconducting magnets in clinical use range
quickest, most efficient screening technique in patients with head from 1.0 to 3.0 T systems, but scanners with field strengths up to
trauma. It is the most sensitive imaging study for the detection 8.0 T are available and can blow your ears off with the noise they
of subarachnoid hemorrhage (SAH), and is the study of choice for generate. Open magnets range from 0.1 to 1.0 T in strength.
initial evaluation of patients with signs and symptoms suggestive
of SAH. CT angiography has gained ascendancy as the mode for Gradient Coils
screening for aneurysms in patients with SAH in the ED. In a
The concept of gradient coils is important to understanding MR.
similar vein (equally large), CT perfusion has become an emer-
To localize a point in space, the magnetic field at that point must
gency department technique for the evaluation of possible stroke
be unique. The way to alter the magnetic field (which is uniform
patients and for guiding thrombolytic therapy.
in strength) within the bore is to pass current through gradient
The sensitivity of CT for calcification is critical in increas-
coils, which create an organized continuous gradation. That is, for
ing diagnostic specificity, particularly for central nervous system
a z gradient, there is an orderly increase in field strength of the
(CNS) tumors (e.g., craniopharyngioma, oligodendroglioma, neu-
main magnet from one end to the other. Each coordinate axis has a
rocytoma, retinoblastoma, meningioma), metabolic disorders (e.g.,
series of gradient coils, which are essentially loops or half-loops of
parathyroid dysmetabolism), and congenital lesions (e.g., TORCH
wire that carry current. By winding different-shaped coils around
infections, tuberous sclerosis). In the head and neck, chondroid
a cylinder, one is able to achieve an x-, y-, or z-oriented magnetic
and osseous lesions are well depicted on CT and may be confusing
gradient field. Therefore, at any point in the x, y, and z planes a
in their appearances on MR imaging. CT is the best study for bony
unique magnetic vector will be present in the scanner. A proton in
(nonmarrow-replacing) lesions and is indispensable in evaluating
that location in the scanner will precess with a unique frequency
the temporal bone in general and the skull, face, and spine for frac-
that is proportional to the magnetic field it “feels.” By tuning to
tures. It is critical for defining the intricate anatomy of the parana-
a particular frequency one can localize that point and judge the
sal sinuses. In the spine, CT still holds its own in the evaluation of
amplitude of its signal. This is one way that spatial localization is
cervical and lumbar bony spinal stenosis, trauma, and postoperative
achieved with MR. Turning the imaging gradient coils off and on
studies where the hardware precludes adequate MR definition.
is what gives MR its characteristic loud noise.
Obviously the homogeneity (uniformity of magnetic field
MAGNETIC RESONANCE IMAGING strength across an FOV) of a magnetic field affects the image
Summarizing the principles of MR imaging in just a few pages quality. Other coils (called shim coils) are used to correct any
does a disservice to the complexity and elegance of the tech- unwanted localized inhomogeneities to the main magnetic field.
nique, but that is about all we can muster given the constraints Much emphasis in recent years has therefore been placed on
our editors have placed on the length of this tome. Fortunately, those gradient shim coils that allow better homogeneity to the
the anatomy that has been demonstrated with MR is well inte- applied magnetic field. These shim coils should not be confused
grated into the knowledge that has been achieved through CT. with the three gradient coils used to localize a particular region of
However, the contrast mechanisms for the two studies are com- interest within an x-y-z coordinate system.
pletely different. CT relies on differential attenuation of an x-ray The MR manufacturers are in a never-ending battle to
beam, whereas MR relies on a complex interplay of the response upstage each other with the strength of their gradient packages.
of tissues to applied magnetic fields. What this translates to for the physician is shorter times to echo
(TEs), smaller FOVs, faster scanning, and higher resolution.
Magnets We ­encourage these battles with our demands for image quality,
but pay through one of our apertures for the cost.
The two main types of magnets used in clinical imaging are per-
manent magnets and superconducting magnets. Permanent mag-
nets can be thought of as two bar magnets that generate a uniform
Radiofrequency Receiver Coils
magnetic field between them. Typically, the magnets are com- Radiofrequency receiver coils are used to receive magnetic
posed of metallic alloys, with iron used as the material that out- ­signals from the region of interest within the body. In neurora-
lines the two magnets and conducts the magnetic field from one diology, except for the head, neurovascular head and neck, and
bar to the next. Permanent magnets, as the name implies, do not whole body coils, which transmit signal, the surface coils are lim-
require continual energy to maintain the ­magnetic field. With a ited to receiving signal from the imaged volume after the body
 Techniques in Neuroimaging 5

coil stimulates it. Innovations in surface coil technology have led the time it takes for the hydrogen nucleus to recover 63% of its
to the creation of more specialized coils, including those used longitudinal (z-axis) magnetization. At the same time, the trans-
for the spine, temporomandibular joint, shoulder, and knee, verse magnetization in the x-y plane also decays toward zero in an
and even rectal and intravaginal coils. The smaller the surface exponential fashion. This exponential decay is characterized by a
coil, the higher the signal-to-noise ratio (SNR) but the smaller time constant that is termed T2, or spin-spin relaxation time. The
the sensitive volume. One is therefore forced to strike a com- signal created in a proton’s decay is called a free induction decay
promise between sensitivity profile (coverage), SNR, and resolu- (FID). In spin-echo imaging, rather than detecting the FID, a
tion. If the coil is too small, one obtains excellent resolution and 180-degree RF pulse is given at some time (half the TE) after the
SNR but insufficient coverage. If the coil is too large, one obtains initial 90-degree RF pulse. This rephases the spins after another
adequate coverage but insufficient SNR to support the resolu- ½ TE and when all the spins are coherent produces the so-called
tion one desires. This has led to the concept of phased-array coil spin echo. Thus, the TE is the time from the 90-degree RF pulse
and parallel imaging systems, in which signal is obtained from to the echo. The analogy is to a race where the slow and fast run-
several small coils simultaneously or sequentially to scan a large ners start together (in phase), but very soon thereafter the fast
volume. For example, a multicoil spine system may use a linear runners pull ahead of the slow runners. At a certain time (½ TE)
array of four coils, each approximately 6 inches in size, ample to in the race the runners are told to turn around and head back to
cover from C1 to L2. The four coils are electrically isolated from the starting line (180-degree RF pulse). All the runners should
one another (with low-input impedance preamplifiers and over- return across the starting line at the same time (spin echo) if they
lapping fields) and are each connected to a separate MR receiver, have kept up their original pace.
preamplifier, and digitizer. Each coil has limited coverage but Because T1 and T2 relaxation mechanisms are independent of
very high resolution. The four separate images are then com- each other by and large, one can completely lose signal in the x-y
bined (by sophisticated computers) to form one composite image axis without having completely returned all the magnetization to
that has maximal coverage, SNR, and resolution. the z axis. The T2 or transverse (spin-spin) relaxation is due to
dephasing caused by the adjacent hydrogen nuclei, which are not
Larmor Frequency totally in concert with each other. T2 is defined as the time for
63% of the transverse magnetization signal to be lost owing to this
Most of MR consists of proton imaging of the hydrogen nucleus natural dephasing process. By and large, T2 values in the CNS
because it is very abundant within human tissue. The hydrogen are shorter than T1 values. The T1 and T2 values of some normal
nucleus precesses in a magnetic field at its own resonant fre- tissues seen in the CNS are listed in Table 1-2.
quency, called the Larmor frequency. The Larmor frequency of The overriding concept of T2 relaxation is that of phase disper-
the hydrogen nucleus is linearly related to field strength by the sion or incoherence caused by local field inhomogeneity. However,
following equation: phase dispersion may be due to three factors: (1) the magnetic
environment of the hydrogen protons (true T2), (2) the hetero-
Precessional (or Larmor) Frequency = Field Strength × geneity in the main magnet itself (extrinsic variations caused by
Gyromagnetic Ratio magnetic field imperfections and other inhomogeneities produce
phase dispersion characterized by the time constant T2′), and (3)
The gyromagnetic ratio of each nucleus is unique and does the paramagnetic substance-induced field inhomogeneities (blood
not vary in different field strength magnets. At 1 T the Larmor or iron) known as T2″. Now you can understand that various tis-
frequency for hydrogen is 42.6 MHz, whereas at 1.5 T the sues within the human body have varying magnetic susceptibili-
Larmor frequency is roughly 63.86 MHz. To stimulate the ties (affinities to be magnetized), which result in different local
hydrogen nuclei, a radiofrequency (RF) pulse must be tuned to field strengths and which cause phase dispersion as the patient’s
the Larmor frequency of the hydrogen nucleus (its resonant fre- body is placed in the “uniform” magnetic field. To reiterate, con-
quency). As the hydrogen nucleus is put into a magnetic field sider three components: T2 from spin-spin relaxation, T2′ caused
with a gradient of magnetism, the location of a particular hydro- by main field inhomogeneity, and T2″ from susceptibility effects.
gen nucleus can be determined by its resonant frequency within The reciprocal of these relaxation times (relaxation rates), when
that gradient. Again, the frequency varies slightly, depending on summed, can be related by this equation:
where in the field the nucleus resides. The ability to localize
protons by variations in their Larmor frequency as a response to 1/T2* = 1/T2 + 1/T2′ + 1/T2″
a graded magnetic field allows the spatial characterization that
distinguishes MR imaging from nuclear magnetic resonance, or The reason these three factors are worth emphasizing becomes
chemical spectroscopy. clear in a discussion of the differences between spin-echo and
gradient-echo pulse sequences.
Relaxation Times
When a sample containing hydrogen nuclei is placed in a mag-
net, its magnetization aligns along the direction of the magnetic Table 1-2. Representative T1 and T2 Relaxation Times
field (z direction). After stimulation of the hydrogen nuclei by of CNS Structures at 1.5 T
applying a 90-degree RF pulse at the Larmor frequency of its
nucleus, the magnetization vector rotates from the z axis to the Structure T1 (msec) T2 (msec)
transverse x-y plane, where the protons precess at the Larmor fre- Gray matter 980–1040 64–71
quency. According to Faraday’s law of induction, the precessing
­magnetization creates voltage in a properly oriented receiver coil White matter 740–770 64–70
(the same coil that is used to apply the RF pulse when the head CSF >2,000 >300
or body coils are used). One can vary the angle at which the vector Muscle (at 1.0 T) 600 40
is tipped from the z axis by varying the amplitude and duration
of the RF pulse. The hydrogen nuclei then relax by two mecha- Fat (at 1.0 T) 180 90
nisms. The first is termed T1, or spin-lattice relaxation time. As
the nucleus relaxes back to equilibrium after being excited by CNS, central nervous system; CSF, cerebrospinal fluid.
From Berger RK, Rimm AA, Rischer ME, et al: T1 and T2 measurements on
an RF pulse, there is an exponential increase in the amplitude a 1.5-T commercial MR image. Radiology 171:273–279, 1989. Data for 1.0 T from
of the z-direction magnetization until there is complete return of Bushong SC: Magnetic resonance imaging; physical and biological principles, St. Louis,
the magnetization toward its baseline position. T1 is defined as Mosby, 1988.
6 Neuroradiology: The Requisites

Pulse Sequences 180-degree inversion pulse is placed. This parameter can be

set to various values to generate contrast or to null the signal
Conventional Spin-Echo Imaging of a specific tissue in the brain, spine, or head and neck. The
Different pulse sequences have been developed that empha- most frequent uses in neuroradiology are in suppressing fat in
size T1 or T2 relaxation effects. T1-weighted images (T1WI) the orbits, neck, or bone marrow (short tau inversion image
are used for tissue discrimination and in conjunction with recovery) or in suppressing cerebrospinal fluid (CSF) signal
­gadolinium contrast agents because enhancing lesions become in the brain (fluid-­attenuated inversion recovery [FLAIR]).
bright on T1WI. T2-weighted images (T2WI) are very sensitive One can use this technique in a T1-weighted or T2-weighted
to the presence of increased water and can visualize edema to sequence. The values of the TI vary with TR, field strength,
great advantage. T2WI are also most sensitive to differences in and tissue to be suppressed.
susceptibility between tissues. Usually both T1WI and T2WI
are used in routine brain, spine, and neck imaging. The com- Gradient Echo Imaging
bination of signal intensities on the two sequences often allows In gradient echo scanning, the magnetization vector of the pro-
some tissue specificity. However, as you can imagine, the combi- tons also is tipped off the z axis to the x-y coordinate system
nations of bright or dark on these two images are limited, which (usually less than 90 degrees). As opposed to the 180-degree
is why MR specificity is also limited. Proton density-weighted spin-echo pulse, a rephasing gradient pulse follows the ini-
images are variably used and are occasionally helpful from the tial flip-angle magnetization. Therefore, the gradient echo
standpoint of diagnostic specificity. Proton density-weighted scans can be devised to be more susceptible to magnetic field
scans display contrast based on available mobile hydrogen pro- inhomogeneities because of the lack of 180-degree rephasing
ton concentrations. pulse (Table 1-3). Blood products, iron, calcium, and manga-
The most common pulse sequence currently used is the spin- nese deposition are seen more readily with gradient echo scan-
echo pulse sequence. This consists of a 90-degree pulse that flips ning. These scans are part of routine trauma or stroke protocols
the longitudinal magnetization from the z axis to the x-y axis. searching for blood or in cases where calcified lesions are sus-
This is followed by a 180-degree pulse, which rephases the pro- pected. Remember, however, that CT is the study of choice
tons that are dephased because of magnetic field distortions for the detection of calcification. When gradient echoes are
(T2). T2′ and T2″ can be rephased by the spin-echo technique, applied, the most important factors to create T1 or T2 weight-
but gradient echo scanning unmasks these contributions to total ing are the value of the angle of nutation, or flip angle, the TR,
transverse relaxation. and the TE. At low flip angles, more T2 weighting is achieved.
By varying the repetition time (TR), which is the time between The lower the flip angle (5 to 10 degrees) and the longer the
90-degree pulses, and the echo time (TE), one can obtain T1WI TE (>40 msec), the greater the susceptibility sensitivity. The
and T2WI. In general, a short-TR (<1,000 msec), short-TE (<45 cost of extending the TEs to achieve higher susceptibility sen-
msec) scan is T1-weighted. A long-TR (>2,000 msec), short-TE sitivity is a reduction in slices available and in signal. To get
(<45 msec) scan is weighted toward proton density. A long-TR through the brain, longer scan times are needed. However, gra-
(>2,000 msec), long-TE (>60 msec) scan is weighted toward dient echo imaging generally is more rapid than conventional
T2 information. The terms short and long here are relative. The spin-echo imaging and also allows one to obtain bright blood
intensity of a voxel in a spin-echo sequence is determined by from flow-related enhancement, which is used for MRA and
both ­tissue-intrinsic and scanner-extrinsic factors (Boxes 1-3 MRV. Three-dimensional gradient echo scanning is also pos-
and 1-4). sible and allows very thin slices while maintaining high SNR.
Another factor in scanning is the inversion time (TI), The three-dimensional data set may be manipulated into mul-
the length of time before the 90-degree pulse at which a tiplanar reconstructions with relative ease.
At larger flip angles (45 to 60 degrees) and a shorter TR, a
more T1-weighted or proton density-weighted gradient echo
image is achieved. However, other factors, such as spoiler gra-
Box 1-3. Intrinsic Contrast Factors of Tissue dients or steady-state free precession factors, can cause T1
T1 weighting or T2 weighting within a gradient echo scan. Spoiler
T2
Proton density
Blood-brain barrier Table 1-3. Utility of Gradient Echo Scanning
Velocity of movement
Viscosity Feature Advantage Clinical Use
Diamagnetic and ferromagnetic disturbances to magnetic
field Shorter TR Faster Uncooperative patient,
rapid localizer scans
Magnetization transfer
Diffusion coefficient Can be used Higher Better for looking for blood
without180- susceptibility products, calcification
degree pulse sensitivity
Can be used “Echoplanar Fast imaging, functional
with180-degree scanning” studies
Box 1-4. Extrinsic Factors for Contrast Manipulation pulse
TR Flow-related Bright blood Basis of time-of-flight
TE enhancement MRA, CSF flow imaging
Flip angle Less gradient Thinner slices Cervical spine, sella,
Saturation pulses stress temporal bone, MRA,
Velocity-encoding schemes 3DFT images
Spoiler gradients Shorter TE More slices Thin section T1WI-SPGR
Gradient moment nulling
FSE design 3DFT, three-dimensional Fourier transformation; CSF, cerebrospinal fluid;
Contrast administration MRA, magnetic resonance angiography; SPGR, spoiled gradient recalled; T1WI,
T1-weighted image; TE, time to echo; TR, repetition time.
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