NEURORADIOLOGY

DIL part 1
K. Agyem MD, G. Hall MD, D. Palathinkal MD, Alexandre Menard
March/April 2015
 GOALS
• Upon completion of these modules, you will have
reviewed some basic neuroanatomy, learned a
standard approach to CT head interpretation, and
reviewed some common intracranial pathologies
including bleeds, strokes and tumors.

• I suggest getting through modules 1 and 2 during

this 1 hour time allotment. Modules 3-5 can be
used as references as the pathologies are
discussed during this neuro session.
 Overview
• Introduction to Neuroimaging - DIL part 1

• Basic Brain Anatomy - DIL part 1

• Standardized Approach to Image Interpretation - DIL part 2

• Common Pathology

• Bleeds (Hemorrhages) - DIL part 3

• Strokes (Infarcts) DIL part 4

• Masses (Tumors) part 5

 INTRODUCTION

• The primary imaging modalities for

neuroradiology include computed tomography
(CT) and magnetic resonance imaging (MRI).
 INTRODUCTION
• CT (computed tomography)

• Initial screening study for neurological pathology.

• Can be performed without or with intravenous

contrast.

• Pros: easily accessible, relatively inexpensive, fast

(great for emergency cases).

• Cons: not very sensitive or specific for certain

pathologies, radiation to patient.
 INTRODUCTION
• MRI

• Often used to further evaluate findings made by CT.

• Can also be performed without or with contrast.

• Pros: More sensitive and more specific than CT for many

pathologies, useful problem-solving tool, no radiation.

• Cons: Certain metal implants are contraindications,

claustraphobia, expensive, less available, time
consuming, and also not senstive or specific for certain
pathologies.
 INTRODUCTION

• The following two slides will show you examples

of a CT and an MRI, so you can start to recognize
the type of study being performed. We have to
start somewhere!
 CT

CT Without Contrast CT With Contrast

Axial
 CT

• Features of a CT:

• Bones are white

• Grey matter is
lighter than white matter

• CSF is black

Axial
 CT

• When you add IV contrast,

notice a few things happen:

• Choroid plexus enhances

• The vessels are now bright

CT With Contrast
Axial
 MRI

T1 MRI T2 MRI
Axial
 MRI

• Features of a T1 MRI:

• Bones are black

• Grey matter
is darker than white matter

• Grey-white differentiation is
more distinct than on CT

• CSF is black

T1 MRI
Axial
 MRI
• Features of a T2 MRI

• Bones are black

• Grey matter is
brighter than white matter

• CSF is white

• Maybe you can

remember that water is
white for T2's. Water
white. WW. 2W's. T2.
T2 MRI
Axial
 MRI

• In addition to T1 and T2, there are many other

MRI sequences that are beyond the scope of this
session.
 CROSS SECTIONAL
CONVENTIONS

• All CT's and MRI's are displayed in the same

manner when you view them on a screen.

• The following slide will describe the standard

convention.
 CROSS SECTIONAL
CONVENTIONS
• When you are looking at a
transverse axial image, you
should be familiar with the
conventional orientation.

• Image right = patient's left

• Image left = patient's right

• Image top = patient's anterior

• Image bottom = patient's

posterior

Axial
 MULTIPLE PLANES
• Cross-sectional imaging is great because we can
display it in different planes. This can be very
helpful to localize a finding to a precise anatomic
location.

• The common planes are TRANSVERSE AXIAL,

CORONAL, and SAGITTAL.

• The next slide shows examples.

 MULTIPLE PLANES
• The green slice cuts through
the patient like a loaf of
bread.

• This results in the transverse

axial plane you're used to
seeing.

http://commons.wikimedia.org/wiki/File:Human_anatomy_planes.jpg
 MULTIPLE PLANES
• The blue slice produces the
coronal plane.

http://commons.wikimedia.org/wiki/File:Human_anatomy_planes.jpg
 MULTIPLE PLANES

• The red slice cuts the patient

down the midline and produces
the sagittal plane.

http://commons.wikimedia.org/wiki/File:Human_anatomy_planes.jpg
 MULTIPLE PLANES

Transverse Axial Coronal Sagittal

 MULTIPLE PLANES
• You've likely noticed that
throughout this module,
whenever there is a CT or MRI
displayed, the plane of imaging
will be written in the bottom
right corner.

• This will help to orient you as

you go through the cases.

• For example, this one is

labelled "axial."

Axial
 MULTIPLE WINDOWS
• Images can be acquired in a certain manner to better
display certain structures. Once an image has been
obtained, the radiologist can further modify these
settings. Part of what is being altered is the "window."

• Look at this example of a CT with brain windows

compared to the one beside it with bone windows.

• Notice how much better you can assess the brain on

the left. Imagine trying to assess the brain on the right!
MULTIPLE WINDOWS

Brain Windows Bone Windows

Axial
 OVERVIEW
• Introduction to Neuroimaging

• Basic Brain Anatomy

• Standardized Approach to Image Interpretation

• Common Pathology

• Bleeds (Hemorrhages)

• Strokes (Infarcts)

• Masses (Tumors)
 ANATOMY
1. Lobar Anatomy

2. Major Fissures

3. Ventricular System

4. Basal Ganglia

5. White Matter Tracts (Corpus Callosum and Internal Capsule)

6. Brainstem

7. Cerebellum

8. Dural Folds (Falx and Tentorium)

9. Major Vessels (Circle of Willis)

FRONTAL LOBE

Axial
FRONTAL LOBE

Axial
FRONTAL LOBE

Axial
FRONTAL LOBE

Axial
FRONTAL LOBE

Axial
FRONTAL LOBE

Axial
FRONTAL LOBE

Axial
FRONTAL LOBE

Axial
FRONTAL LOBE

Coronal
FRONTAL LOBE

Coronal
FRONTAL LOBE

Sagittal
FRONTAL LOBE

Sagittal
TEMPORAL LOBE

Axial
TEMPORAL LOBE

Axial
TEMPORAL LOBE

Axial
TEMPORAL LOBE

Axial
TEMPORAL LOBE

Coronal
TEMPORAL LOBE

Coronal
TEMPORAL LOBE

Sagittal
TEMPORAL LOBE

Sagittal
PARIETAL LOBE

Axial
PARIETAL LOBE

Axial
PARIETAL LOBE

Axial
PARIETAL LOBE

Axial
PARIETAL LOBE

Sagittal
PARIETAL LOBE

Sagittal
PARIETAL LOBE

Sagittal
PARIETAL LOBE

Sagittal
OCCIPITAL LOBE

Axial
OCCIPITAL LOBE

Axial
OCCIPITAL LOBE

Axial
OCCIPITAL LOBE

Axial
OCCIPITAL LOBE

Sagittal
OCCIPITAL LOBE

Sagittal
 MAJOR FISSURES

• Central Sulcus - separates frontal and parietal

lobe.

• Parieto-occipital sulcus - separates parietal and

occipital lobes.

• Lateral Sulcus (Sylvian fissure) - separates the

frontal and parietal lobes from the temporal lobe.
CENTRAL SULCUS

Axial
 CENTRAL SULCUS

Separates
the frontal
and parietal
lobes

Axial
PRECENTRAL GYRUS

Axial
 PRECENTRAL GYRUS
The part of the
posterior frontal
lobe that lies
immediately
anterior to the
central sulcus.

This is the where

the primary motor
cortex resides.

Axial
POSTCENTRAL GYRUS

Axial
 POSTCENTRAL GYRUS

The part of the

anterior parietal
lobe, immediately
posterior to the
central sulcus.

This is where the

primary
somatosensory
cortex resides.

Axial
CENTRAL SULCUS

Sagittal
CENTRAL SULCUS

Sagittal
PRECENTRAL GYRUS

Sagittal
PRECENTRAL GYRUS

Sagittal
POSTCENTRAL GYRUS

Sagittal
POSTCENTRAL GYRUS

Sagittal
PARIETO-OCCIPITAL
SULCUS

Sagittal
PARIETO-OCCIPITAL
SULCUS

Separates the
parietal and
occipital lobes

Sagittal
SYLVIAN FISSURE

Axial
 SYLVIAN FISSURE

Separates
the frontal
and parietal
lobes from
the temporal
lobe

Axial
SYLVIAN FISSURE

Coronal
SYLVIAN FISSURE

Coronal
SYLVIAN FISSURE

Sagittal
SYLVIAN FISSURE

Sagittal
 VENTRICULAR SYSTEM
• Ventricular System

• Right and left lateral

ventricles

• Paired interventricular
foramen

• Third ventricle

• Cerebral aquaduct
http://commons.wikimedia.org/wiki/File:Blausen_0896_Ventricles_Brain.png

• Fourth ventricle

• Central canal
VENTRICULAR SYSTEM

Sagittal
 VENTRICULAR SYSTEM

• Lateral ventricle

• Third ventricle

• Fourth Ventricle

Sagittal
LATERAL VENTRICLES

Axial
LATERAL VENTRICLES

Axial
LATERAL VENTRICLES

Axial
LATERAL VENTRICLES

Axial
LATERAL VENTRICLES

Coronal
 LATERAL
VENTRICLES

Coronal
 LATERAL
VENTRICLES

Coronal
 LATERAL
VENTRICLES

Coronal
 LATERAL
VENTRICLES

Coronal
 LATERAL
VENTRICLES

Coronal
 LATERAL
VENTRICLES

Coronal
 LATERAL
VENTRICLES

Coronal
 LATERAL
VENTRICLES

Sagittal
 LATERAL
VENTRICLES

Sagittal
THIRD VENTRICLE

Coronal
THIRD VENTRICLE

Coronal
 THIRD VENTRICLE
Also note the
lateral
ventricles
draining via the
bilateral
interventricular
foramen into
the third
ventricle.

Coronal
THIRD VENTRICLE

Sagittal
THIRD VENTRICLE

Sagittal
CEREBRAL
AQUEDUCT

Axial
CEREBRAL
AQUEDUCT

Axial
CEREBRAL
AQUEDUCT

Sagittal
CEREBRAL
AQUEDUCT
Recall that the
third ventricle
drains via the
cerebral
aqueduct into
the fourth
ventricle

Sagittal
FOURTH VENTRICLE

Sagittal
FOURTH VENTRICLE

Sagittal
FOURTH VENTRICLE

Axial
FOURTH VENTRICLE

Axial
 BASAL GANGLIA
• Caudate Nucleus

• Lentiform nucleus = globus pallidus + putamen

• Thalamus

• There are other parts of the basal ganglia not

covered, including: Substantia Nigra, Subthalamic
Nucleus, Red Nucleus.
CAUDATE

Axial
CAUDATE

Axial
CAUDATE

Axial
 CAUDATE

Specifically,
this is the
part of the
caudate
nucleus
called the
"head."

Axial
CAUDATE

Coronal
CAUDATE

Coronal
CAUDATE

Coronal
CAUDATE

Coronal
LENTIFORM
NUCLEUS

Axial
LENTIFORM
NUCLEUS

Axial
 LENTIFORM
NUCLEUS
Recall that the
lentiform
nucleus is
comprised of
the putamen
and the globus
pallidus

Axial
THALAMUS

Axial
THALAMUS

Axial
INTERNAL CAPSULE

Axial
INTERNAL CAPSULE
 INTERNAL CAPSULE

The internal
capsule is a
white matter
tract that
separates the
lentiform
nucleus from
the caudate
nucleus and
thalamus

Axial
CORPUS CALLOSUM

Axial
 CORPUS CALLOSUM

White matter
tract that
connects the
two cerebral
hemispheres.

Axial
CORPUS CALLOSUM

Axial
CORPUS CALLOSUM

Axial
CORPUS CALLOSUM

Coronal
CORPUS CALLOSUM

Coronal
CORPUS CALLOSUM

Coronal
CORPUS CALLOSUM

Coronal
CORPUS CALLOSUM

Sagittal
CORPUS CALLOSUM

Sagittal
MIDBRAIN

Axial
MIDBRAIN

Axial
MIDBRAIN

Coronal
MIDBRAIN

Coronal
MIDBRAIN

Sagittal
MIDBRAIN

Sagittal
MIDBRAIN

Do you
remember the
name of the
CSF tract that
passes
through the
midbrain?

Sagittal
MIDBRAIN
Do you
remember the
name of the
CSF tract that
passes
through the
midbrain?

It's the
cerebral
aqueduct!

Sagittal
PONS

Axial
PONS

Axial
PONS

Coronal
PONS

Coronal
PONS

Sagittal
PONS

Sagittal
MEDULLA

Axial
MEDULLA

Axial
MEDULLA

Coronal
MEDULLA

Coronal
MEDULLA

Sagittal
MEDULLA

Sagittal
CEREBELLUM

Axial
CEREBELLUM

Axial
CEREBELLUM

Axial
CEREBELLUM

Axial
CEREBELLUM

Axial
CEREBELLUM

Axial
CEREBELLUM

Axial
CEREBELLUM

Axial
CEREBELLUM

Coronal
CEREBELLUM

Coronal
CEREBELLUM

Sagittal
FALX CEREBRI

Axial
FALX CEREBRI

Axial
FALX CEREBRI

Axial
FALX CEREBRI

Coronal
TENTORIUM
CEREBELLI

Coronal
TENTORIUM
CEREBELLI

Coronal
MAJOR VESSELS

http://commons.wikimedia.org/wiki/File:Circle_of_Willis_en.svg
MAJOR VESSELS
The vessels we
will review on
imaging are the
ones highlighted.

http://commons.wikimedia.org/wiki/File:Circle_of_Willis_en.svg
CIRCLE OF WILLIS -
ICA
ICA = Internal
Carotid Artery

Axial
CIRCLE OF WILLIS -
ICA
ICA = Internal
Carotid Artery

Axial
CIRCLE OF WILLIS -
MCA
MCA = Middle
Cerebral Artery

Axial
CIRCLE OF WILLIS -
MCA
MCA = Middle
Cerebral Artery

Axial
CIRCLE OF WILLIS -
ACA
ACA = Anterior
Cerebral Artery

Axial
CIRCLE OF WILLIS -
ACA
ACA = Anterior
Cerebral Artery

Axial
CIRCLE OF WILLIS -
ACOM
ACOM =
Anterior
Communicating
Artery

Axial
CIRCLE OF WILLIS -
ACOM
ACOM =
Anterior
Communicating
Artery

The ACOM
connects the
left and right
ACAs.

Axial
CIRCLE OF WILLIS -
PCOM
PCOM =
Posterior
Communicating
Artery

Axial
CIRCLE OF WILLIS -
PCOM
PCOM =
Posterior
Communicating
Artery

PCOM connects
the anterior and
posterior
circulation.

Axial
BASILAR ARTERY

Axial
BASILAR ARTERY
The basilar
artery is the
distal
continuation of
the vertebral
arteries,
supplying the
posterior
circulation.

Axial
CIRCLE OF WILLIS -
PCA

Axial
CIRCLE OF WILLIS -
PCA
PCA = Posterior
Cerebral Artery

The PCAs loop

backwards
around the
midbrain.

Axial
CIRCLE OF WILLIS -
PCA
PCA = Posterior
Cerebral Artery

Axial
CIRCLE OF WILLIS -
PCA
PCA = Posterior
Cerebral Artery

Axial
 End of module 1
• Introduction to Neuroimaging - DIL part 1

• Basic Brain Anatomy - DIL part 1

• Standardized Approach to Image Interpretation - DIL part 2

• Common Pathology

• Bleeds (Hemorrhages) - DIL part 3

• Strokes (Infarcts) DIL part 4

• Masses (Tumors) part 5