NEURORADIOLOGY

dr. Farhan Anwary, Sp.Rad

Bagian/SMF Radiologi
FK Unpad / RS dr. Hasan Sadikin
Bandung

NEURORADIOLOGY (NEUROIMAGING)
Plain Film
CT Scan
(Computed tomography)
MRI
(Magnetic Resonance
Imaging)
Angiography / DSA (Digital
Subtraction Angiography)
Sonography / USG / Color Doppler
Nuclear Medicine

PLAIN FILM/CONVENTIONAL
RADIOLOGY
SKULL : -

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

Normal, Radiographic, Anatomy

LATERAL VIEW
Sutures
Calvarium
Sella
Dorsum sellae
Sinus sphenoidalis

STRAIGHT POSTEROANTERIOR
VIEW

Coronal - lamdoid suture

Orbital roof, petrus ridge,
internal auditory canal,
cribriform plate - crista galli,
maxillary sinus, nasal cavity,
upper lateral rim orbita

CALDWELL VIEW
Lesser - greater wings
Foramen rotundum ( V2 )
Orbital rim
Zygoma - zygomaticofrontal
suture
Floor of anterior cranial fossa
Frontal sinus

TOWNE VIEW
Occipital, parietal, frontal
Sagital suture
Posterior clinoid processes dorsum sellae
Internal auditory canal

WATERS VIEW
Maxillary - frontal sinuses
Orbital margin zygomaticofrontal suture
Zygomatic process
Body, ramus, condyle,
coronoid process

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

I . SINGLE LUSCENT DEFECT IN THE

SKULL

DDX : Normal variant

Pacchionian
granulation
Parietal foramina

DDX : Abnormal solitary luscent skull

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

II. MULTIPLE LUCENT DEFECTS

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

III. INCREASED SKULL DENSITY

A. Diffuse increased skull density

DDX :

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

B. Focal increased skull density

DDX : -

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

IV. INTRACRANIAL CALCIFICATION

A. Physiologic can occur in
1. Pineal
2. Habenula
3. Basal ganglia
4. Choroid
5. Dura

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

B. Phatologic calcifications
2. Infection : CMV, toxoplasmosis,
cysticercosis
3. Vascular :
a. Atherosclerotic disease
b. Aneurysm
c. Arteriovenous malformation
4. Pathologic basal ganglia
calcification

B. Phatologic calcifications
5. Neurocutaneous
syndromes
a. Neurofibromatosis
b. Sturge-Weber
syndrome
c. Tuberous sclerosis

C. Basal Ganglia Calcifications

DDX :
Endocrine : hypothyroidism,
pseudohypoparathyroidism
Infectious : CMV, toxoplasmosis,
cysticercosis
Toxic/Anoxic : CO, lead, radiation
Congenital : Tuberosclerosis,
Fahr's disease

V. Large Sella
DDX :
Tumor : Adenoma,
craniopharyngioma, optic nerve
glioma
Aneurysm
Increase intracranial pressure
Empty sella

CEREBROVASCULAR DISEASE
I. Cerebral Infarction
a. Etiology
1. Atherosclerosis (large
vessels)
2. Atherosclerosis (small
vessels)
3. Hypoxia / anoxia
4. Dissection

CEREBROVASCULAR DISEASE
I. Cerebral Infarction
a. Etiology
5. Fibromuscular dysplasia
6. Vasculitis
7. Basal arteriovascular occlusiv disease
8. Venous thrombosis
9. Miscellaneous; vasospasm, trauma

b. Imaging in ischemia / infarction :

-

Vascular distribution
Evidence of cytotoxic edema
Involvement of cortex
Hemorrhagic transformation

c. IMAGING : CT, MR, MRA,

Angiography

II. Spontaneous Intracranial

Hematoma;
Intraparenchymal hematoma
DDX : Causes of intraparenchymal hematoma
1. Aneurysm rupture
2. Arteriovenous malformation rupture
3. Hypertension
4. Tumor

DDX : Causes of intraparenchymal

hematoma
5. Blood dyscrasia
6. Anticoagulant
7. Drug abuse
8. Infarct
9. Amyloid angiopathy
10. Idiopathic

III. Spontaneous Intracranial

Hemorrhage;
Subarachnoid and extra-axial
1. Subarachnoid hemorrhage (SAH)
2. Extra-axial hemorrhage (SDH, EDH)

IV. Intracranial Aneurysm

V. Cerebrovascular Malformations
1. Capillary telangiectasis
2. Cavernous angioma (hemangioma)
3. Venous angioma
4. Arteriovenous malformation (AVM)
5. Occult cerebrovascular malformation
(cryptic AVM)
6. Vein of galen aneurysm

CRANIAL TRAUMA
1. Imaging
Skull film, CT, MRI
2. Type of Injuries
a. Direct
b. Indirect
c. Skull fractures

CRANIAL TRAUMA
3. Types of the Hemorrhages
a. Appearance of hemorrhage by
CT
b. Appearance MR
c. Extra axial hemorrhage

Extra Axial Hemorrhage

1. Epidural hematomas
2. Sub dural hematomas
3. Sub arachnoid hemorrhage
(S.A.H)
4. Intra ventricular hemorrhage
5. Intra parenchymal hemorrhage

DDX : Parenchymal Hematoma

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

INTRACRANIAL MASSES
1. Radiografic Characteristic of Lesion
a. Intrinsic CT density
b. Contrast enhancement
BBB
(ring, gyriform, homogenous)
c. Multiple lesions
d. MR appearance

DDX : Intracranial Mass

(TEACH )
Tumor
Edema
Abcess, AVM, aneurysm
Cyst
Hematoma

A. Primary Tumor
1. Glioma
a. Astrocytoma
b. Ependymoma
c. Oligodendroglioma
d. Ganglioglioma
2. Meningioma
3. Lymphoma
B. Metastatic Tumor

DIFFERENTIAL DIAGNOSIS BY LOCATION

DDX : Enhancement pattern of focal cerebral
parenchymal lesions
A. Cerebral parenchymal lesion
Ring :

- Glioma

Meta
Abcess
Resolving hematoma
Resolving infarction
Homogenous :

- Lymphoma
- Aneurysm

DDX : Intraventicular Mass Lesion

Meningioma, Astrocytoma, Choroid
plexus papilloma, Colloid cyst, Meta,
Ependymoma, Subependymoma,
AVM, Oligo, Lymphoma

DDX : Pineal Region Mass

Germ cell tumor, Pineal cell
tumor
Germinoma, Pineoblastoma,
Teratoma, Glial cell tumor,
Dermoid, Epidermoid,
Choriocarcinoma, Meta

DDX : Juxta Sellar and Supra

Sellar
Adenoma
Craniopharyngioma
Aneurysm
Meningioma
Uncommon : Meta,
Arachnoid cyst, Glioma

DDX : CPA Mass

Acoustic neurinoma
Trigeminal neurinoma
Meningioma
Arachnoid cyst
Epidermoid
Aneurysm
Meta

INTRACRANIAL INFECTIONS
DISEASE

I. Focal Lesions
A. Pyogenic brain abcess
B. Atypical brain abcess
C. AIDS : Toxo, Lympho, TB,
Abcess

II.

Encephalitis
Congenital : TORCH
Toxo, CMV, Rubella, Herpes

III. Meningitis

WHITE MATTER DISEASE

A. Demyelinating Diseases
DDX :

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

B. Dysmyelinating Diseases
- Leucodystrophies

IMAGING OF THE SPINE

I. Approach
1. Primarily a bony lesion
2. Primarily a joint-space lesion
3. Primarily a lesion involving the soft
tissues with the neural canal or exit
foramina
4. Congenital abnormality may involve
dysplastic changes of both osseous and
neural components

II. Primarily an Osseous

Lesion
1.
2.
3.
4.
5.
6.
7.

Primary bone tumor

Secondary bone tumor
Inflammatory bone disease
Hematologic or vascular
Trauma
Metabolic
Congenital anomaly

III. Primarily a Joint-space

Lesion
1. Degenerative disc disease
2. Trauma (iatrogenic)
3. Disc-space infection

IV. Primarily a Lesion Involving

Soft Tissues of Canal or
Foramina
1. Intramedullary
2. Intradural and
extramedullary
3. Extradural

V. Congenital Anomalies
1. Scoliosis
2. Vertebral anomalies
3. Dysraphism
4. Syrinx
5. Tumors
6. Neurofibromatosis
7. Spinal stenosis

TERIMA KASIH

dr. Farhan Anwary, Sp.Rad