34

Section 2: Brain, peripheral nervous system, muscle

Chapter 34

Diagnostic tests and procedures

DIAGNOSTIC TESTS

the examination of free water movement. Restricted free water

movement is detected early, paralleling the development of
cytotoxic edema. The imaging sequences used are fast and not
as easily disturbed by inappropriate patient movement. A
normal SPECT scan is shown in Figure 345. SPECT scanning
can be used for evaluating neoplasms (Fig. 346) and dementia (Fig. 347).

Most neuroradiologic examinations of the central nervous

system (CNS) consist of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and single-photon emission computed tomography (SPECT). Figure 341 shows normal contrast-enhanced
CT anatomy. Figure 342 shows a normal MRI brain scan.
MRI is more sensitive than CT for detection of neoplasms
(Fig. 343). Small infarcts are also more easily visualized by
MRI, especially if they are located in the cerebellum (Fig.
344) or brainstem. With diffusion-weighted imaging (DWI),
ischemic lesions can be demonstrated early. DWI is based on

Imaging of precerebral and cerebral vessels

Duplex sonography allows for the evaluation of vessel anatomy,
along with measurement of the direction and velocity of blood
ow. The degree of stenosis is calculated from the blood ow
Text continued on page 172

mc

ac

sf

mc

tca

tp
ba

fm

cpd

pc

ec

ba

lgb

aw

cq

ac

fh

csp

l
lc 3
th

pg

tn

cs

cp
st
ss

f
cc
sf

cv

sp

bv

cv

st
tr

f
o

Fig 341
Normal contrast-enhanced CT anatomy. Figures A through F show normal CT scans at various levels in the brain. 3, 4, third and fourth ventricles;
ac, anterior cerebral artery; ba, basilar artery; bv, body of lateral ventricle; c, caudate nucleus; cc, corpus callosum (genu); cp, cerebral peduncle;
csp, cave of septum pellucidum; cv, internal cerebral vein; f, falx; fh, frontal horn of lateral ventricle; fm, foramen of Monro; i, infundibulum of pituitary; mc, middle cerebral artery; o, white matter tracts; p, pons; pc, posterior cerebral
artery; pg, pineal gland; sf, sylvian ssure; sp, septum between lateral ventricles; th, thalamus; tp, temporal horn; tr, trigone of lateral ventricle.

168

(From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]: Grainger and Allisons Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed. London.
Harcourt, 2001.)

Chapter 34: Diagnostic tests and procedures

ec

fl
cc

cs
th

pof

pvs

tl

aca

gp

cf

tha

cn

pm

fm

cc

34

gf

pg

3
tl

oc
ba
p

Fig 342
Normal MRI. A, T2-weighted sagittal images through the midline. B, Corneal T2-weighted images through the hippocampi. C, Coronal
T1-weighted images through the level of the third ventricle. 3,4, third and fourth ventricles; a, amygdala; aca, anterior cerebral artery; ba, basilar artery; cc, corpus callosum; cf, calcarine ssure; ch, cerebellar hemisphere; cn, caudate nucleus; cs, central sulcus; ec, external capsule; fh, frontal
horn; fh, frontal lobe; fm, foramen of Munro; gf, gyrus fusiformis; gp, globus pallidus; h, hippocampus; mca, middle cerebral artery; oc, optic chiasm; oh, occipital horn; p, pons; pg, parahippocampal gyrus; pm, putamen; pof, parieto-occipital ssure; pvs, perivascular spaces; sf, sylvian ssure; t, tectal plate; th, temporal horn; tha, thalamus; tl, temporal lobe.
(From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]: Grainger and Allisons Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed. London.
Harcourt, 2001.)

Fig 343
Oligodendroglioma. A, CT after intravenous contrast
medium shows a large left frontal tumor that involves
the cortex. It is predominantly solid with irregular enhancement, but there are also cysts and coarse calcication. B, Follow-up after 2 years with CT.
T2-weighted MRI (C) and T1-weighted postcontrast
MRI (D) show more extensive cyst formation and calcication than on the rst scan. The calcication is
much less apparent on MRI and appears as nonspecic low signal areas. Posterior inltration of the tumor is, however, best seen on MRI (C). Note that the
patient had undergone a left frontal craniotomy after
the rst scan.
(From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]:
Grainger and Allisons Diagnostic Radiology: A Textbook
of Medical Imaging, 4th ed. London. Harcourt, 2001.)

169

34

Section 2: Brain, peripheral nervous system, muscle

Fig 344
Top of the basilar syndrome. T2-weighted MRI show multiple infarcts in the basilar and posterior cerebral artery territories including the left
thalamus (A), both occipital lobes (B) and cerebellar hemispheres (C). Note the absence of ow void in the distal basilar artery in B (arrow).
(From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]: Grainger and Allisons Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed. London.
Harcourt, 2001.)

Fig 345

Fig 346

99mTc

201

(From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]: Grainger and
Allisons Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed.
London. Harcourt, 2001.)

(Courtesy of Professor Donald M. Hadley, Glasgow.)

HMPAO single-photon emission computed tomography scan

of the brain: axial (left) and sagittal (right) images. A, anterior; R, right;
L, left; P, posterior.

170

Tl single-photon emission computed tomography scan in a 40-yearold man with a left frontotemporal mass on MRI. This reveals the high
uptake typical of high-grade glioma, which was conrmed on biopsy to
be a glioblastoma.

Chapter 34: Diagnostic tests and procedures

34

Fig 347
Single-photon emission computed tomography scans of normal subject (A); patient with Alzheimers disease showing bilateral parietal lobe abnormalities more marked on the right side (B); patient with frontotemporal dementia, showing bilateral frontal lobe abnormalities (C); patient with progressive supranuclear palsy, showing bilateral anterior abnormalities (D); patient with corticobasal degeneration, showing asymmetrical right frontoparietal abnormality (E); patient with Creutzfeldt-Jakob disease, showing multifocal cortical abnormalities (F).
(From Tallis R, Fillit H: Brockelhurstss Textbook of Geriatric Medicine and Gerontology, 6th ed. London, Churchill Livingstone, 2003.)

171

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Section 2: Brain, peripheral nervous system, muscle

Fig 348
Imaging of precerebral and cerebral vessels. A, Color-coded Doppler sonography of the internal carotid artery close to the bifurcation in a patient
with pronounced atherosclerotic changes and stenosis causing slowing of blood ow and turbulence (green and blue signals). B, Contrastenhanced magnetic resonance angiography showing a tight stenosis of the internal carotid artery (arrow). C, Conventional angiography showing a
very tight stenosis of the internal carotid artery (arrow).
(From Crawford, MH, DiMarco JP, Paulus WJ [eds]: Cardiology, 2nd ed. St. Louis, Mosby, 2004.)

Anterior
communicating
artery
Posterior
communicating
artery

Anterior cerebral
artery
Middle cerebral
artery
Basilar artery

Vertebral artery

velocity. Color-coded Doppler signals help visualize the direction of blood ow (Fig. 348 )
Conventional angiography (see Fig. 348C) allows good
visualization of the aortic arch and the origins of the neck arteries but has a potential risk of nephrotoxicity, allergic reactions,
and thromboembolism.
MRA (Fig. 349) is useful for detection of carotid artery
stenosis (see Fig. 348B) and suspected carotid or vertebral artery dissection. MRA is also useful for evaluating the aortic arch
(Fig. 3410) and the intracranial circulation (Fig. 3411).
ELECTROENCEPHALOGRAPHY

External carotid
artery
Internal carotid
artery

Common carotid
artery

Fig 349
Magnetic resonance angiogram showing the arterial supply to the
brain.
(From Crawford, MH, DiMarco JP, Paulus WJ [eds]: Cardiology, 2nd ed.
St. Louis, Mosby, 2004.)

172

Electroencephalography (EEG) is a measure of the electrical

activity generated by the central nervous system. It is useful to
document abnormalities of the brain that are not associated
with detectable structural alterations in brain tissue. It also provides a continuous measure of cerebral function over time.
Electroencephalographic signals are generated by the cerebral
cortex. Different parts of the cortex generate distinct uctuations. The uctuations also differ with eye opening and in the
sleep and waking states. Figure 3412 shows an electroencephalogram of a normal subject; an electroencephalogram of a
brain-dead patient is shown in Figure 3413.

Chapter 34: Diagnostic tests and procedures

Eyes
open

34

Eyes
closed

Fp1-F3
F3-C3
C3-P3
P3-01
Fp2-F4
F4-C4
C4-P4
P4-02
Fp1-F7
F7-T3
T3-T5
T5-01
Fp2-F8

Fig 3410
Contrast-enhanced MRA of aortic arch. A three-dimensional gradientecho sequence has been acquired during the rst pass of an intravenously injected gadolinium bolus. It shows the origins of the great vessels. Note also that there is background opacication of the pulmonary
vessels.
(From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]: Grainger and
Allisons Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed.
London. Harcourt, 2001.)

ACCM
A1

M2

PCOM

BA
P1

T4-T6
T6-02

1 sec

300 V

Fig 3412
CS
M1

P2

F8-T4

A posteriorly predominant 9-Hz alpha rhythm is present when the eyes

are closed and is attenuated by eye opening in the electroencephalogram of this normal subject. Electrode placements in this and Figure
34-13 are as follows. A, earlobe; C, central; F, frontal; Fp, frontopolar;
O, occipital; P, parietal; Sp, sphenoid; T, temporal. Right-sided placements are indicated by even numbers and left-sided placements by
odd numbers.
(From Goetz CG, Pappert EJ: Textbook of Clinical Neurology, Philadelphia,
WB Saunders, 1999)

petr CA

Fig 3411
Three-dimensional TOF MRA of the intracranial circulation, axially collapsed maximum intensity projection. A1, precommunicating segment
of anterior cerebral artery; ACOM, anterior communicating artery; BA,
basilar artery; CS, carotid siphon; M1, rst (horizontal) segment of middle cerebral artery; M2, M2 segments of middle cerebral artery; P1,
precommunicating segment of posterior cerebral artery; P2, P2 segment of posterior cerebral artery; PCOM, posterior communicating
artery; petr CA, petrous segment of internal carotid artery.
(From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]: Grainger and
Allisons Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed.
London. Harcourt, 2001.)

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Section 2: Brain, peripheral nervous system, muscle

Fp1-C3
C3-O1
Fp1-T3
T3-O1
Fp2-C4
C4-O2
Fp2-T4
T4-O2
T3-CZ
CZ-T4
10 kOhm resistor
Dorsum of hand
ECG

1 sec

20 V

Fig 3413
Electrocerebral silence in the electroencephalogram of a brain-dead patient following attempted resuscitation after cardiopulmonary arrest.
See Figure 34-12 for electrode placements.
(From Goetz CG, Pappert EJ: Textbook of Clinical Neurology. Philadelphia, WB Saunders, 1999.)

174