BASIC
NEURORADIOLO
GY
Sianny Suryawati
Radiology Department, Faculty of Medicine
Wijaya Kusuma University, Surabaya
2015
Outline
Normal Imaging Anatomy of Brain
Basic Features of Brain Lesions
Brain Tumor
Cerebrovascular Disease
Traumatic Brain Injury
Normal Imaging Anatomy of
Brain
Skull and Meninges (Dura, Pia)
Vasculature: Veins and Arteries
Surface Anatomy-Lobes, gyri, Sulci
Histologic-Broadmans
Functional-motor, sensory, speech
White Matter
Cross sectional imaging
Anterior circulation
Internal Carotid
Arteries
Posterior Circulation
Vertebral arteries
Superficial and Deep Arterial Supply
to the Cerebral Hemispheres
Neuroradiology Modalities :
Plain Film
CT
US
MRI
Interventional
Angiography
Myelography
Biopsy
Nuclear Medicine
CT Basics
CT Basics
Neuroradiology
The BASICS of CT
CT History
Protocol
Terminology
Contrast
Radiation Safety
Cases
SIR GODFREY N. HOUNSFIELD
1979 Nobel Laureate
in Medicine
CT History
1972 First clinical CT scanner
Used for head examinations
Water bath required
80 x 80 matrix
4 minutes per revolution
1 image per revolution
8 levels of grey
Overnight image reconstruction
CT History
2004 64 slice scanner
1024 x 1024 matrix
0.33s per revolution
64 images per revolution
0.4mm slice thickness
20 images reconstructed/second
CT Basics
Neuroradiology
The BASICS of CT
CT History
Protocol
Terminology
Contrast
Radiation Safety
Cases
CT Protocolling
What happens when an exam is
requested?
A requisiton is completed.
The requested exam is protocolled according to
history, physical exam and previous exams.
The patient information is confirmed.
The exam is then performed.
Images are ready to be interpreted in
Uncomplicated exam 5-10 minutes after completion
Complicated exams with reconstructions take at least 1
hour but usually 1-2 hours.
CT Protocolling
CT head protocols
With or Without contrast
CT Brain
CT Brain with posterior fossa images
CT Angiogram/Venogram
CT Perfusion
CT of Sinuses
CT of Orbit
CT of Temporal bones
CT of Mastoid bones
CT of Skull
CT of Face
CT Protocolling
Variables
Plain or contrast enhanced
Slice positioning
Slice thickness
Slice orientation
Slice spacing and overlap
Timing of imaging and contrast administration
Reconstruction algorhithm
Radiation dosimetry
CT Protocolling
Patient Information
Is the patient pregnant?
Radiation safety
Can the patient cooperate for the exam?
CT Basics
Neuroradiology
The BASICS of CT
CT History
Protocol
Terminology
Contrast
Radiation Safety
Cases (Stroke)
CT Terminology
Exams using Ionizing radiation
Plain film
CT
1/10 of all exams
2/3 OF RADIATION EXPOSURE
Fluoroscopy
Angiography, barium studies
Nuclear medicine
V/Q scan, bone scan
CT Terminology
Attenuation
Hyperattenuating (hyperdense)
Hypoattenuating (hypodense)
Isoattenuating (isodense)
Attenuation is measured in Hounsfield units
Scale -1000 to 1000
-1000 is air
0 is water
1000 is cortical bone
CT Terminology
What we can see
The brain is grey
White matter is usually dark grey (40)
Grey matter is usually light grey (45)
CSF is black (0)
Things that are brite on CT
Bone or calcification (>300)
Contrast
Hemorrhage (Acute ~ 70)
Hypercellular masses
Metallic foreign bodies
CT Terminology
Voxel
Volume element
A voxel is the 2 dimensional representation of a 3
dimensional pixel (picture element).
Partial volume averaging
CT Terminology
CT Terminology
Window Width
Number of Hounsfield units from black to white
Level or Center
Hounsfield unit approximating mid-gray
CT Terminology
CT Artifacts
CT Terminology
Digital reading stations are the standard of care in
interpretation of CT and MRI.
Why?
Volume of images
Ability to manipulate and reconstruct images
Cost
CT Terminology
DICOM
Digital Imaging and Communications in Medicine
DICOM provides standardized formats for images, a
common information model, application service
definitions, and protocols for communication.
CT Basics
Neuroradiology
The BASICS of CT
CT History
Protocol
Terminology
Contrast
Radiation Safety
Cases
Contrast
Barium
Iodinated
vascular
Biliary, Urinary
CSF
Gadolinium
Contrast
Types of iodinated contrast
Ionic
Nonionic - standard of care
No change in death rate from reaction but number
of reactions is decreased by factor of 4.
If an enhanced study is needed, patient needs
to be NPO at least 4 hours and have no
contraindication to contrast, ie allergy or renal
insufficiency.
Contrast
What are the risks of iodinated contrast?
Contrast reaction
1 in 10,000 have true anaphylactic reaction
1 in 100,000 to 1 in 1,000,000 will die
Medical Issues
Acute renal failure
Lactic acidosis in diabetics
If on Glucophage, patient must stop Glucophage for 48
hours after exam to prevent serious lactic acidosis
Cardiac
Extravasation
Contrast
Who is at risk for an anaphylactic reaction?
Patients with a prior history of contrast reaction
Patients with a history asthma react at a rate of 1 in 2,000
Patients with multiple environmental allergies, ie foods,
hay fever, medications
Amin MM, et al. Ionic and nonionic contrast media: Current status
and controversies.
Appl Radiol 1993; 22: 41-54.
Contrast
Pretreatment for anaphylaxis
50 mg Oral Prednisone 13, 7 and 1 hour prior to exam
50 mg oral Benedryl 1 hour prior to exam
In emergency, 200 mg iv hydrocortisone 2-4 hours prior to
exam
Contrast
What are the risk factors for contrast induced
acute renal failure?
Pre-existing renal insufficiency
Contrast volume
Dehydration
Advanced age
Drugs
Multiple myeloma
Cardiac failure
Contrast
Considerations in patients with renal insufficiency
Is the exam necessary?
Is there an alternative exam that can answer the
question?
Decrease contrast dose
Contrast
Pretreatment for renal insufficiency
Hydration
Mucomyst
600 mg po BID the day before and day of study
Prevention of radiographic-contrast-agent-induced reductions in
renal function by acetylcysteine.
Tepel M, et al. N Engl J Med 2000 Jul 20;343(3):180-4
Contrast
Contrast induced renal failure
Elevated creatinine 24-48 hours after contrast which
resolves over 7-21 days.
Can require dialysis
Mehran, R. et al. Radiocontrast induced renal failure:Allocations
and outcomes.
Reviews in Cardiovascular Medicine Vol. 2 Supp. 1 2001
CT Basics
Neuroradiology
The BASICS of CT
CT History
Protocol
Terminology
Contrast
Radiation Safety
Cases
Radiation Safety
Diagnostic CT Scans: Assessment of Patient,
Physician, and Radiologist Awareness of Radiation
Dose and Possible Risks
Lee, C. et al. Radiology 2004;231:393
Radiation Safety
Deterministic Effects
Have a threshold below which no effect will be seen.
Stochastic Effects
Have no threshold and the effects are based on the dose x
quality factor.
Radiation Safety
Terminology
Gy = Gray is the absorbed dose (SI unit)
The equivalent of 1 joule/kg of tissue
Rad = radiation absorbed dose
Sv = Sievert is the dose equivalent (SI unit)
Absorbed dose multiplied by a quality factor
Rem = radiation equivalent man
Radiation Safety
Relative values of CT exam exposure
Background radiation is 3 mSv/year
Water, food, air, solar
In Denver (altitude 5280 ft.) 10 mSv/year
CXR = 0.1 mSv
CT head = 2 mSv
CT Chest = 8 mSv
CT Abdomen and Pelvis = 20 mSv
-The equivalent of 200 CXR
Radiation Safety
Effects of X rays.
Absorption of photons by biological material leads
to breakage of chemical bonds.
The principal biological effect results from
damage to DNA caused by either the direct or
indirect action of radiation.
Radiation Safety
Tissue/Organ radiosensitivity
Fetal cells
Lymphoid and hematopoietic tissues; intestinal
epithelium
Epidermal, esophageal, oropharyngeal epithelia
Interstitial connective tissue, fine vasculature
Renal, hepatic, and pancreatic tissue
Muscle and neuronal tissue
Radiation Safety
Estimated Risks of Radiation-Induced
Fatal Cancer from Pediatric CT
David J. Brenner, et al. AJR 2001; 176:289296
Additional 170 cancer deaths for each year of
head CT in the US.
140,000 total cancer deaths, therefore ~ 0.12%
increase
1 in 1500 will die from radiologically induced cancer
Radiation Safety
3094 men received radiation for hemangioma
Those receiving >100 mGy
Decreased high school attendance
Lower cognitive test scores
Per Hall, et al. Effect of low doses of ionising radiation in infancy on
cognitive function in adulthood: Swedish population based cohort
study
Radiation Safety
Hiroshima and Nagasaki
There has been no detectable increase in genetic
defects related to radiation in a large sample
(80,000) of survivor offspring, including: congenital
abnormalities, mortality (including childhood
cancers), chromosome aberrations, or mutations in
biochemically identifiable genes.
William J Schull, Effects of Atomic Radiation: A Half-Century of
Studies from Hiroshima and Nagasaki, 1995.
Radiation Safety
Hiroshima and Nagasaki
However, exposed individuals who survived the acute
effects were later found to suffer increased incidence of
cancer of essentially all organs.
William J Schull, Effects of Atomic Radiation: A Half-Century of
Studies from Hiroshima and Nagasaki, 1995.
Radiation Safety
Hiroshima and Nagasaki
Most victims with high doses died
Victims with low doses despite their large numbers are
still statistically insignificant.
Radiation Safety
Comparison of Image Quality
Between Conventional and LowDose Nonenhanced Head CT
Mark E. Mullinsa, et al.
AJNR April 2004.
Reduction of mAs from 170 to 90
Radiation Safety
What does all this mean?
1 CXR approximates the same risk as:
1 year watching TV (CRT)
1 coast to coast airplane flight
3 puffs on a cigarette
2 days living in Denver
1 Head CT is approximately 20 CXR
Health Physics Society on the web--http://hps.org
Radiation Safety
The pregnant patient
Can another exam answer the question?
What is the gestational age?
Counsel the patient
3% of all deliveries have some type of spontaneous
abnormality
The mothers health is the primary concern.
Radiation Safety
"No single diagnostic procedure results in a
radiation dose that threatens the well-being of the
developing embryo and fetus." -- American College of
Radiology
"Women should be counseled that x-ray exposure
from a single diagnostic procedure does not result
in harmful fetal effects. Specifically, exposure to
less than 5 rad has not been associated with an
increase in fetal anomalies or pregnancy loss." -American College of Obstetricians and Gynecologists
Conclusion
CT Terminology
Attenuation (density) in Hounsfield units
Digital interpretation is standard of care
CT has risks
Contrast
Radiation exposure
CT Basics
Neuroradiology
The BASICS of CT
CT History
Protocol
Terminology
Contrast
Radiation Safety
Cases
Normal
CT
1 day
1 year
2 years
Normal CT
Older person
Normal CT
Older
Person
Normal Enhanced CT
