Neuroimaging for

medical residents

Kanokwan Boonyapisit, M.D.

Department of medicine
Siriraj Hospital
Plain film of skull
Normal sella turcica

Anterior clinoid Posterior clinoid

Dorsum sellae

Floor of sella
 ICP

“loss of dorsum sella sign”

Pituitary tumor

“Double floor sign”

Large intrasella mass

1
3

“ballooning of
sella”
Anatomy
Inferior Medulla
Cerebellar
Pedancle
 Temporal
Basillar a. lobe

Pons

Forth ventricle
 Pituitary
Fossa
Pons

Forth ventricle
 Gyrus rectus of frontal lobe

MCA

Medial
temporal
Amygdala

Midbrain
 Ant limb of
Int. capsule Caudate

Putamen
Sylvian fissure

Thalamus
Posterior
Limb of int. capsule

Occipital lobe
Lateral ventricle

Splenium
 Frontal lobe

Central sulcus

Parietal lobe
CT brain
Computed tomography (CT) scan
• Cross-sectional representation of
anatomy created by a computer-
generated analysis of the attenuation
of x-ray beams passed through a
section of the body
CT scan: indication
• Primary study of choice in
– Evaluation of acute trauma to the brain
and spine
– Subarachnoid hemorrhage,
– CT is complementary to MR in the
evaluation of the skull base, orbit, and
osseous structures of the spine.
CT scan
• Intravenous contrast is often
administered prior to or during a CT
study to
– identify vascular structures
– detect defects in the blood-brain
barrier (BBB), which are associated with
disorders such as tumors, infarcts, and
infections.
• Carried risk for allergic reaction,
nephrotoxicity
 CT scan

• Advantage
• Availability
• Shorter scan time
• Detection of hemorrhage
• Disadvantage
• Contrast media
• Artifacts in posterior fossa or area surrounded by
bone
• Radiation exposure is between 3 and 5 cGy per
study
CT brain check list

• CT brain with/without contrast

• Soft tissue, bony structure, sinus, orbit, mastoid
• Meninges, CSF space surrounding brain
• Brain parenchyma
– Abnormal hyper/hypodensity lesion+location
– Abnormal calcification +location
– Grey-white differentiation +location
– Edema
• Location
• Pressure effects on ventricle
• Midline shift
• herniation
CT brain check list

• Ventricles
– Any pressure effect on ventricles from edema
– Abnormal dilatation of ventricle
• Contrast enhancement
– Location
– Pattern: nodular, gyral, ring, homogeneous,
inhomogeneous
• Others
– Abnormal vascular structure
– Hyperdense MCA
– Empty delta sign
– Pituitary, pineal
CT brain check list
• Diagnosis
– Diagnosis
– Location and SIDE!!!
– Stage: acute, subacute, chronic (if
indicated)
– Other important findings: eg. With
herniation
MRI
Magnetic resonance imaging (MRI)

• Complex interaction between hydrogen

protons in biologic tissues, a static
magnetic field (the magnet), and
energy in the form of radiofrequency
(Rf) waves of a specific frequency
introduced by coils placed next to the
body part of interest
MRI
• Advantage
• Better resolution esp. temporal lobe,
posterior fossa, spinal cord
• MRA/MRV
• Special techniques: DWI
• Disadvantage
• Availability
• Longer scan time
• Interpretation of hemorrhage
MRI of the brain
MRI of the brain

MRS
 Use of MRI in emergency
situation

• Very early case of ischemic stroke

• Cerebral venous sinus thrombosis
• Acute spinal cord compression
Contraindication for MRI scan
• Cardiac pacemaker or permanent pacemaker leads
• Internal defibrillatory device
• Cochlear prostheses
• Bone growth stimulators
• Spinal cord stimulators
• Electronic infusion devices
• Intracranial aneurysm clips (some but not all)
• Ocular implants (some) or ocular metallic foreign body
• McGee stapedectomy piston prosthesis
• Omniphase penile implant
• Swan-Ganz catheter
• Magnetic stoma plugs
• Magnetic dental implants
• Magnetic sphincters
• Ferromagnetic IVC filters, coils, stents—safe 6 weeks after implantation
• Tattooed eyeliner (contains ferromagnetic material and may irritate eyes)
 MRI

T1W T2W

CSF ขาว
CSF ดำ Grey matter เทาอ่ อน
Grey matter เทาเข้ ม White matter เทาเข้ ม
White matter เทาอ่ อน Lesion, edema ขาว
FLAIR (fluid attenuated inversion recovery)

CSF ดำ
Grey matter เทาอ่ อน
White matter เทาเข้ ม
Lesion, edema ขาว
Case 1
• 57 year old woman presented to the
ER with sudden onset left
hemiparesis 2 hours before arriving
at the ER
Answer
CT brain check list

• CT brain with/without contrast

• Soft tissue, bony structure, sinus, orbit, mastoid
• Meninges, CSF space surrounding brain
• Brain parenchyma
– Abnormal hyper/hypodensity lesion+location
– Abnormal calcification +location
– Grey-white differentiation +location
– Edema
• Location
• Pressure effects on ventricle
• Midline shift
• herniation
CT brain check list
• Ventricles
– Any pressure effect on ventricles from edema
– Abnormal dilatation of ventricle
• Contrast enhancement
– Location
– Pattern: nodular, gyral, ring, homogeneous,
inhomogeneous
• Others
– Abnormal vascular structure
– Hyperdense MCA
– Empty delta sign
– Pituitary, pineal
Description
• CT brain without contrast
• Soft tissue, bony structure, sinus, orbit,
mastoid- normal
• Hypodensity lesion in the right frontoparietal
region
• Loss of gray white differentiation/ loss of
sulci in the right frontoparietal region
• Edema in the right frontoparietal region with
pressure effect on right lateral ventricle
• No midline shift
CT brain check list
• Diagnosis
– Diagnosis
– Location and SIDE!!!
– Stage: acute, subacute, chronic (if
indicated)
– Other important findings: eg. With
herniation
Diagnosis
• Acute right middle cerebral artery
infarction
Left hyperdensed
MCA sign
Anterior choroidal a.

Posterior cerebral a.
Case 2

40 years old man

Was sent to ER due to confusion
Answer
Lens shape extra-axial lesion
Soft tissue swelling
Description
CT brain without contrast
Soft tissue swelling at the right
frontal region
Normal orbit and bony structures
Lens-shape, extra-axial hyperdensity
lesion overlying the right frontal lobe
Some pressure effect to the adjacent
brain and ventricles
No midline shift
Diagnosis
Acute epidural (or Extradural)
haematoma at right frontal lobe
Case 3

50 years old man

Was sent to ER due to confusion
Answer
Extra-axial lesion
with pressure
effect
Description
CT brain without contrast
Normal orbit, sinus and bony
structure
Isodensity, extra-axial, concave
lesion overlying left fronto-parietal
area
With midline shift to the left
With pressure effect on the adjacent
brain and obliteration of the left
lateral ventricle
Diagnosis
Subacute subdural haematoma at
left fronto-parietal area with
midline shift
Epidural VS Subdural
haematoma

Epidural haematoma 1=84.22HU

Lucid interval
EDH: typical lens shaped, 60-90HU
Associated fracture
laceration of middle meningeal
artery
Don’t cross suture
2

1
1

EDH cross midline (1)

Brain contusion (2)
Epidural VS Subdural
haematoma

Subdural haematoma
generally more
larger
Collection between
dura and arachnoid
Venous bleeding
May cross suture but
don’t cross midline
Acute SDH: hyperdense
 Subacute
Subdural Isodense SDH
haematoma
Subacute SDH: isodense, +C needed
Chronic SDH: hypodensity=CSF
Case 4

50 years old woman

Was found unconscious and sent to
ER
Answer
Hyperdensity in Subarachnoid space
Description
CT brain without contrast
Normal skull, orbit and paranasal
sinuses
Hyperdensity lesion in the
subarachnoid space especially at left
sylvian fissure and basal cistern
Mild dilatation of the ventricular
system
No midline shift
No clear abnormal hypodensity in
the brain parenchyma
Diagnosis
Acute subarachnoid haemorrhage
Subarachnoid haemorrhage

Cause
Traumatic
Aneurysmal bleeding
AVM
Extension from intraparenchymal
bleed
Unknown
Perimesencephalic cisterns
(excellent outcome, negative
angiogram)
 Subarachnoid
haemorrhage

Non-contrast CT!!!
Axial CT brain : before contrast
injection!!
Case 5

50 years old man

Was found comatose and sent to
ER
Answer
Hyperdensity lesion in middle of pons
Description
CT brain without contrast
Normal skull, orbit and paranasal
sinuses
Hyperdensity lesion occupying middle
of pons with some local pressure
effect
Some hyperdensity lesion surrounding
the brainstem (subarachnoid blood)
(Normal ventricular size)

Diagnosis
Acute pontine haemorrhage
Common sites of hypertensive
hemorrhage

• Basal ganglia
• Thalamus
• Cerebellar
• Pons
How do see bleeding on MRI
• Depends on timing after hemorrhage
 Bleeding on MRI
Biochem Stage Time T1W T2W

OxyHb in Hyperacute Hours Iso 

RBCs
DeoxyHb Acute Hrs to Iso,  
in RBCs days
MetHb in Early Days  
RBCs subacute
Extracell Subacute Days to  
MetHb to chronic months
Ferritin Remote Days to Iso,  
Hemoside indefinite
rin
Hyperacute hematoma

T1W T2W
Acute hematoma

T1W Proton T2W

density
Early subacute hematoma

CT T1W T2W
Remote hemorrhage

T1W T2W Gradient

echo
Case 6

27 years old woman

30 weeks pregnant
Presented with headache and
hemiparesis
Instruction
Describe the non-contrast CT
brain
Diagnosis
Suggest further investigation to
confirm the diagnosis
Answer
Generalized brain
oedema

Hypodensity
lesion at right
parieto-occipital
area

Hyperdensity lesion at the posterior part

of superior sagittal sinus
Description
CT brain without contrast
Normal skull, orbit and paranasal
sinuses
Hypodensity area at right perieto-
occipital area
Hyperdensity lesion in posterior part
of superior sagittal sinus
Generalized brain swelling
Obliteration of lateral ventricles
No midline shift
Diagnosis
Sagittal venous sinus thrombosis
with venous infarction at right
parieto-occipital area

How to confirm the

diagnosis
Cerebral angiogram
MRV
CTV
Venous sinus thrombosis

Empty Delta Sign

Case 7

40 years old man

Weight loss for 6 months
Headache and confusion for 2
weeks
Answer
 Multiple ring
enhancing lesion
Description
Multiple ring-enhancing lesion,
which appears hypersignal on T2W
with surrounding oedema, at right
basal ganglia, left basal ganglia, both
cerebellar hemisphere
Mild dilatation of ventricles
No midline shift
Differential diagnosis
Tumour; metastasis, lymphoma
Infection
Toxoplasmosis
Tuberculosis
Fungus ie Histoplasmosis
Inflammation
Multiple sclerosis
Case 8

40 year old woman

Presented with blurred vision
Answer
Pituitary mass
Description
Enhancing mass at pituitary fossa
with supra sellar extension

Diagnosis
Pituitary macroadenoma with
suprasellar extension
DDx Craniopharyngioma
Special thanks
• Dr. Chotipat Danchaivijitr
• For these beautiful slides and
images