Clinical and Experimental Ophthalmology 2009; 37: 30–53 doi: 10.1111/j.1442-9071.2008.01822.


Imaging for neuro-ophthalmic and orbital disease – a review
Andrew G Lee MD,1,2,3 Michael C Johnson MD FRCSC,1 Bruno A Policeni MD4 and Wendy RK Smoker MD FACR3,4
Departments of 1Ophthalmology and Visual Sciences, 2Neurology, 3Neurosurgery and 4Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA

A literature review was performed by content experts in neuro-ophthalmology and neuroradiology using a systematic English-language Medline search (1994–2008) limited to articles with relevance to neuro-ophthalmic and orbital imaging. The information covered in this review includes: (i) the basic mechanics, indications and contraindications for cranial and orbital computed tomography and magnetic resonance (MR) imaging; (ii) the utility and indications for intravenous contrast, (iii) the use of specific MR sequences; (iv) the techniques and ophthalmic indications for computed tomography/MR angiography and venography; and (v) the techniques and indications for functional MR imaging, positron emission tomography scanning and single photon emission computed tomography. Throughout the review accurate and timely communication with the neuroradiologist regarding the clinical findings and suspected location of lesions is emphasized so as to optimize the ordering and interpretation of imaging studies for the ophthalmologist. Key words: computed tomography, diagnostic imaging, magnetic resonance angiography, magnetic resonance imaging, visual pathway.

Ophthalmologists may be the first clinicians to evaluate the patient with an orbital or intracranial

structural lesion. Therefore, it is important for the ordering ophthalmologist to understand the basic mechanics, indications and contraindications for specific imaging studies, such as computed tomography (CT) and magnetic resonance (MR) imaging (MRI). Over the past decade, these imaging techniques have evolved and continue to improve. There are also many techniques that have recently emerged and that are of interest to the ophthalmologist. This monograph provides a summary of the most commonly used imaging techniques in ophthalmology. We update and summarize the recent literature on the various modalities (e.g. MR angiography [MRA], CT angiography [CTA], MR venography [MRV] and CT venography [CTV]) and specific sequences (e.g. fat suppression, fluid attenuation inversion recovery (FLAIR), gradient recall echo imaging [GRE], diffusion-weighted imaging [DWI], perfusion-weighted imaging [PWI] and dynamic perfusion CT [PCT]) used in neuro-ophthalmic and orbital imaging. We also include a discussion of the indications and contraindications for using contrast in CT and MRI. Finally, we briefly review the ophthalmic indications for functional imaging (e.g. functional MRI [fMRI], positron emission tomography [PET] and single photon emission computed tomography [SPECT]). Throughout this review, we emphasize the critical importance of accurate and timely communication of the clinical findings and presumed location of a lesion with the neuroradiologist in order to acquire the best imaging study and receive the best interpretation.

Correspondence: Dr Andrew G Lee, Department of Ophthalmology, 200 Hawkins Drive, PFP, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA. Email: Received 23 January 2008; accepted 26 June 2008. © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists

Neuro-ophthalmic and orbital imaging


An English-language Medline search was performed from 1994 to 2008 for articles on orbital or neuroimaging relevant to ophthalmology, including CT, MRI, angiography (e.g. catheter, MRA and CTA), venography (e.g. MRV and CTV), fMRI, PET and SPECT. Two content experts from ophthalmology (AGL, MCJ) selected relevant titles and abstracts and then reviewed the pertinent papers with two neuroradiology content experts (BAP, WRKS). Publications prior to 1994 were included only if they added significant or new information to the review. The information from the review was collated into a clinical summary of the available radiographic techniques of interest to the ophthalmologist, with indications and contraindications included for each study.

CT scanning
The CT scan, first introduced in 1972, is based on standard X-ray attenuation by tissues of various densities.1 Images are acquired by rapid rotation of an X-ray tube around the patient. The transmitted radiation is measured by a ring of detectors located on the gantry. Data points obtained by the detectors are analysed using a computer and the density, or attenuation value, of the tissue at each point is calculated. The image is reconstructed as a corresponding matrix of picture elements (pixels), with each pixel being assigned a numerical value. These values are then compared with the attenuation value of water and displayed on a scale of arbitrary units called Hounsfield units. This scale assigns water as an attenuation value of zero. Denser material (e.g. lead) blocks, or attenuates, the X-ray beam and less dense material allows the beam to pass through to the detectors. By convention, the denser material (e.g. bone) is ‘brighter’ (positive Hounsfield units) on CT and less dense material (e.g. air) is ‘darker’ (negative Hounsfield units). Early CT scanners acquired images one single slice at a time. During the 1980s, technical advances enabled the X-ray tube to rotate continuously in one direction around the patient. This led to the introduction of helical (or spiral) CT in 1989.2 Data could now be continuously acquired while the patient was simultaneously moved at a constant speed through the gantry. The transmitted radiation took on the form of a helix or spiral. This allowed larger anatomical regions of the body to be imaged during a single breath hold, less overall radiation exposure and reduced movement artefacts. Faster scanning also increased patient throughput. Multislice or multidetector-row CT scanners are the current generation of scanners commercially available. They use the principle of helical scanners, but incorporate multiple rows of detector rings (from 4 to 64) and can therefore acquire multiple slices per tube rotation and increase the area covered in a given time by the X-ray beam.3 The contrast material for CT scanning is iodinated contrast. Prior allergic reaction to iodinated contrast or a history of renal failure may be contraindications to using contrast in CT.4–6 In general, the use of contrast improves the sensitivity and specificity of CT scan interpretation.5 For most conditions in ophthalmology, contrast material should be included when ordering a CT scan. However, there are a few exceptions to this recommendation. For example, a CT scan that is being performed for acute intracranial or intraorbital haemorrhage does not require contrast material. In fact, the non-contrast study is superior for assessing the hyperdensity of acute blood.7 In addition, in cases of trauma (e.g. orbital, facial or

The review identified the following clinical scenarios for which an imaging study might be ordered by an ophthalmologist: (i) unilateral or bilateral visual loss (e.g. transient visual loss [amaurosis fugax], unilateral or bilateral optic neuropathy, junctional scotoma, bitemporal hemianopsia, homonymous hemianopsia or cortical blindness); (ii) efferent pupillary defects (e.g. anisocoria due to Horner syndrome or third nerve palsy) or afferent pupillary defects (e.g. relative afferent pupillary defect or lightnear dissociation of the pupils); (iii) proptosis (e.g. thyroid eye disease, orbital tumours, idiopathic orbital inflammation [i.e. orbital pseudotumour], orbital cellulitis or carotid-cavernous fistula); (iv) diplopia or external ophthalmoplegia; (v) lid abnormalities (e.g. lid retraction, lid lag, ptosis or orbitallid lesion); (vi) oscillopsia (e.g. nystagmus); (vii) ophthalmoscopic abnormalities (e.g. papilloedema, optic atrophy, optic nerve hypoplasia, optic disc head drusen or choroidal folds); and (viii) ocular or orbital trauma (e.g. intraocular/intraorbital foreign body or suspected fracture). In this review we have elected to exclude the neuroimaging evaluation of isolated headache or facial pain as these are beyond the scope of this work. The three main imaging techniques for the brain and orbit are conventional X-rays (e.g. skull film), CT and MR scanning. Although the X-ray has been known since Roentgen, the role of the traditional skull or orbital X-ray has been supplanted in the modern era by current CT and MR techniques. We use the skull X-ray to prescreen patients with a history or suspicion for metallic foreign body prior to MR studies. As a general rule, patients who have an indication for orbital imaging should undergo a CT or an MR study, if not contraindicated, for improved bone or soft-tissue resolution.

© 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists

which can dramatically demonstrate the anatomic relationships between osseous defects and sinus.g. the quality of reconstructed coronal (and sagittal) images has greatly improved and has obviated the need for direct coronal scanning at many institutions.9–11 However. The 2-D source images should always be examined along with the 3-D reconstructions. skull base fracture. © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . In patients with thyroid eye disease. we caution against using 3-D reconstructions exclusively as the software involved in producing these images tends to smooth over abnormalities and may hide subtle pathology. An orbital CT scan differs from a head CT in that the images are typically obtained at a different angle using thinner slices (e. contrast material is unnecessary. sagittal views can also be obtained with computerized reconstruction. 3–4 mm) and can be reconstructed to any slice thickness (we routinely reconstruct at 2 mm). iodinated contrast may even worsen systemic thyroid disease. medial and superior rectus muscle bellies bilaterally. white dots). extraocular muscle enlargement). Because of the ability of current generation scanners to obtain very thin axial slices. For localization purposes. Coronal reconstructions may be the only option in a patient who is unable to extend or flex their neck for direct imaging (e. Coronal views display the anatomical relationships between the extraocular muscles. such as a minimally displaced fracture. the head or both. Finally. trauma. easy to perform. Thyroid eye disease. and the images can be obtained very rapidly. short arrow) and a stranded appearance of the retrobulbar fat (b and c. Figure 1. whereas the axial images show involvement of the tendinous insertion of the medial rectus muscle (b. whereas the coronal image optimally reveals the true extent of disease by demonstrating enlargement of the inferior. Idiopathic orbital inflammation. as thin as 0. it is important to view orbital lesions and anatomy in at least two orthogonal planes. for some disorders such as hydrocephalus.7 mm vs.8 When ordering a CT scan it is important for the ophthalmologist to specify whether the study should include the orbit. contrast material adds little to the examination. or traumatic optic neuropathy). sinusitis) or thyroid eye disease (e. three-dimensional (3-D) reconstructions can be created (using an independent workstation). axial and coronal CT images).32 Lee et al. Non-contrast (a) axial and (b) coronal computed tomography images demonstrate enlargement of the medial rectus muscle bellies compared with those of the lateral rectus on the axial image. but 3-D reconstruction imaging techniques can provide additional information for surgical planning or detailed anatomical analysis. Using the axially acquired data set.g. best appreciated on the coronal image (a. Orbital and head CT scans are widely available.g. sinus disease (e. (a) Coronal and (b. long arrows) typical of idiopathic orbital inflammation. Figure 2.g. relatively inexpensive.g. clinicians would implicitly perform a mental reconstruction of two-dimensional (2-D) images (e. cervical collar or cervical disc disease). optic nerve and surrounding osseous structures very well. Although the most commonly obtained orbital CT planes are axial and coronal. orbital or intracranial disease. In the past. orbital or intracranial foreign body. c) axial post-contrast computed tomography images demonstrate enlargement of all extraocular muscles in the left orbit.

subdural. sinusitis or sinus tumours. despite MR’s superior softtissue resolution.13. acute trauma. 5]. suspected orbital fracture. sphenoid wing agenesis in neurofibromatosis-1. Craniopharyngioma. specific ophthalmic conditions (e. Non-contrast axial computed tomography image demonstrates hyperdense signal intensities consistent with calcifications (arrow) within this suprasellar mass.g. there are circumstances where CT may be very helpful. 3]). and can be obtained more rapidly than MR. However. it is usually preferred ‘after hours’ or in the emergent setting (e. such as in demonstrating calcification and osseous pathology. more widely available.Neuro-ophthalmic and orbital imaging Figure 3. bone destruction or erosion). craniosynostosis syndromes. 6]). intraventricular or intraparenchymal haemorrhage associated with tumour. optic nerve head drusen12 [Fig. CT is often used in conjunction with MRI for cases involving disorders of bone or sinuses (e.g. 33 Figure 4. Optic nerve head drusen. In general. stroke or ruptured aneurysm). As described earlier. arrow) and inferior displacement of the superior extraocular muscles (b. orbital haematoma. Thus. a non-contrast CT scan is excellent for showing the hyperdensity of acute haemorrhage (e. hyperostosis of bone associated with meningiomas. primary bone tumours.g.14 © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . 1]. pituitary apoplexy or intracranial shunt malfunction). Non-contrast axial computed tomography image demonstrates a small calcification at the left optic nerve head (arrow). calvarial or skull base fracture.g. CT can also be used for demonstrating calcification in Figure 5. fibrous dysplasia. As CT scanning is generally easier to perform. subarachnoid. acute stroke. in addition to MR. orbital. double arrows) are identified. Although CT scanning is probably sufficient for many orbital conditions (e. Some clinical scenarios in which an ophthalmologist might order an emergent orbital or head CT scan include the following: (i) acute orbital trauma (e. 2] and orbital tumours [Fig. clivus or other skull base pathology. meningioma or retinoblastoma [Fig. orbital. 4]. because it provides superior soft-tissue discrimination of intracranial anatomy (e. craniopharyngioma [Fig. MR is the examination of choice for almost all other neuro-ophthalmic indications. Schwannoma of V1. CT is not as sensitive as MR for detecting brain pathology. meninges. Chronic. posterior fossa and dural venous sinuses). thyroid eye disease [Fig.g. brain abscess. idiopathic orbital inflammation [Fig. (a) Axial and (b) coronal post-contrast computed tomography images demonstrate a lesion in the superior aspect of the left orbit (white dots).g.g. maxillofacial. non-lytic pressure changes in the bone of the orbital roof adjacent to the tumour (b. cavernous sinus. metallic or wooden foreign bodies.

severe headache (i. MRI is based on detecting the signal from © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . marked obesity exceeding table weight limit. extraconal orbit. (vi) acute papilloedema (e. ‘worst headache of my life’) with or without acute third nerve palsy (e. ferromagnetic aneurysm clip. The left tumour involves all sides of the pterion. 8]). which is based on standard X-ray technology. Whereas the discussion has emphasized situations in which one study may be preferred over the other. a follow-up MR scan may still be required for optimal evaluation of pathology. particularly in children needing sequential or multiple imaging studies. pituitary apoplexy). (a) Axial bone-window computed tomography image demonstrates extensive hyperostosis of the right anterior clinoid process (arrow) and left greater wing of the sphenoid bone (arrowhead). cochlear implant. this issue has now become a public health concern.g. The lesion on the right extends anteriorly to involve the medial basi-frontal region (white dot).15 Further work is needed in this area. (iii) acute bitemporal hemianopsia (e. to rule out intracranial tumour or bleed in the emergent setting). and (vii) acute visual loss.34 Lee et al.g. idiopathic orbital inflammation. Retinoblastoma.g. Figure 7. acute stroke. Calcifications. typical of this tumour. (v) acute. sphenoid wing meningioma with hyperostosis [Fig. This is particularly true for lesions that have both soft-tissue and osseous changes (e.g. orbital cellulitis.g. Because of the widespread use of CT. or traumatic optic neuropathy). 7] or orbital dermoid cyst [Fig. CT and MRI are complimentary and can often provide a more complete picture of the nature of a lesion when used together than could be found using each separately. are identified in (b) (arrow). extending to involve the infratemporal fossa (black dot) and the lateral. Although the widespread availability and rapid scan times of CT make it more useful than MR for patients requiring emergent imaging. acute haemorrhage from tumour or arteriovenous lesion). but a proposed action plan to address radiation exposure risk has recently been published by the American College of Radiology. One major concern with CT scanning is future cancer risk from the associated low-dose radiation exposure. (iv) acute homonymous hemianopsia or cortical blindness (e. Axial (a) and (b) non-contrast computed tomography images reveal a large tumour occupying much of the right globe. (b) Axial post-contrast fat-suppressed T1-weighted magnetic resonance image demonstrates two large meningiomas (arrows). Figure 6.g. Finally. (ii) acute proptosis (e.17 Magnetic resonance imaging Unlike CT. there are also relative and absolute contraindications to MR scanning that might necessitate the substitution with a CT scan (e. headache or diplopia. thyroid eye disease with compressive optic neuropathy. post-surgical or spontaneous retrobulbar haemorrhage).16. Sphenoid wing meningiomas. pacemaker or other metallic foreign body).g. subarachnoid haemorrhage due to ruptured intracranial aneurysm). severe claustrophobia.e.

(c) Coronal precontrast T1-weighted magnetic resonance image demonstrates hyperintense signal within the lesion consistent with fat (arrow). indicative of chronicity. (b) Coronal T2-weighted image demonstrates marked lesion hypointensity. Orbital dermoid. Thinning of the adjacent orbital roof is present (b. homogeneously hyperintense mass in the posterior–inferior aspect of the left globe. (d) Axial post-contrast fat-suppressed T1-weighted magnetic resonance image confirms the presence of fat by demonstrating suppression of the fat signal intensity (arrow).) © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists .Neuro-ophthalmic and orbital imaging 35 Figure 8. These signal intensities reflect the paramagnetic effects of melanin. (Case courtesy Dr HK Lee. Figure 9. (a) Axial and (b) coronal post-contrast computed tomography images demonstrate a lesion of fat density in the superior aspect of the right orbit (white dots). (a) Axial precontrast T1-weighted magnetic resonance image demonstrates a round. Choroidal melanotic melanoma. arrows).

The added value of fluid attenuation inversion recovery (FLAIR). Acute intraparenchymal haemorrhage. Value of fat suppression. Figure 11. (a) Axial T2-weighted magnetic resonance image makes it difficult to determine the extent of high signal periventricular white matter disease because of the adjacent hyperintense signal of cerebrospinal fluid (CSF). (a) Axial noncontrast computed tomography demonstrates an area of significant hyperdensity in the left parietooccipital region in a patient with haemophilia A. Figure 10. © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . (a) Axial postcontrast T1-weighted magnetic resonance image without fat suppression demonstrates no definite optic nerve enhancement in this patient with an inflammatory optic neuropathy. Figure 12.36 Lee et al. (b) Axial post-contrast fat-suppressed T1-weighted image clearly reveals right optic nerve enhancement (arrow). (b) Axial T2-weighted FLAIR image demonstrates suppression of CSF signal permitting optimal visualization of the periventricular white matter lesions (arrows). (b) Axial gradient recall echo magnetic resonance image reveals marked signal hypointensity of this acute haemorrhage.

Isolated vasculopathic cranial neuropathies may not require initial imaging. fourth. PET. 13) or PRES (Fig. optic neuropathy in one eye and superotemporal field loss in fellow eye) Bitemporal hemianopsia Yes MRI head (attention to sella) FLAIR to look for demyelinating white matter lesions. cerebral achromatopsia.24) Yes Homonymous hemianopsia MRI head © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists MRI head Yes Consider CT of sella if an emergent scan is needed (e.g. sixth nerve palsy or cavernous sinus syndrome Yes Internuclear ophthalmoplegia. 19). meningioma or craniopharyngioma [Fig.g. SPECT or MRS) Cortical visual loss or visual association cortex (e.g.36 with permission) Preferred imaging study Not necessary Yes Contrast material Comment Clinical indication Optic nerve drusen Bilateral optic disc swelling Transient monocular visual loss (amaurosis fugax) due to ischaemia Demyelinating optic neuritis Depends on clinical situation Yes (enhancing lesions suggest acute disease) Yes CT scan of the orbit may show calcification (Fig. alexia. 5] or aneurysm) Retrochiasmal pathway. Include a FLAIR sequence MRI brainstem MRI brainstem (with or without MRA) Yes Yes Localize nystagmus Facial nerve compression at root exit zone 37 . male or elderly Carotid Doppler study might be first line and may still require follow-up catheter angiography MRI head and orbit Neuro-ophthalmic and orbital imaging Inflammatory. skew deviation Nystagmus Hemifacial spasm MRI head with attention to the skull base. DWI may be useful if acute ischaemic infarct (Fig. simultagnosia. calcification in tumours and hyperostosis may be better seen on CT Rule out demyelinating or other brainstem lesion.Table 1. infiltrative or compressive optic neuropathy Yes MRI head and orbit Junctional scotoma (i. 22). 4) MRI head (with MRV)CT scan might be first-line study in emergent setting MRA or CTA of neck for carotid stenosis or dissection Orbital ultrasound is less costly and more sensitive than a CT scan for optic disc head drusen12 Consider concomitant contrast MRV to exclude venous sinus thrombosis (Fig.e. See Table 3 for third nerve palsy evaluation with MRA or CTA MRI head (brainstem) Yes Rim calcification in aneurysm. CT is superior in traumatic optic neuropathy for canal fractures Junctional lesions are typically mass lesions MRI head (attention to chiasm and sella) (Figs 23. If structural imaging negative and organic loss consider functional imaging (e. supranuclear or nuclear gaze palsies. Consider DWI in ischaemic infarct. optic ataxia. Balint’s syndrome) Third. especially in atypical patients of pseudotumour cerebri who are thin. dorsal midbrain syndrome (Fig. 14). pituitary or chiasmal apoplexy) or if imaging for calcification (e. prosopagnosia. MRI has prognostic significance for development of multiple sclerosis (Fig.g. If structural imaging negative and organic loss consider functional imaging such as PET Retrochiasmal pathway. Neuro-ophthalmic indications and recommended imaging study (modified from Lee et al. 21) Fat suppression to exclude intraorbital optic nerve enhancement (Fig. 25).

diffusion-weighted imaging. 1) Orbital cellulitis and orbital disease secondary to sinus disease Idiopathic orbital inflammation CT orbit and sinuses CT or MRI of orbit (with fat suppression) CT or MRI of orbit Yes Yes Iodinated contrast may interfere with evaluation and treatment of systemic thyroid disease Depends on clinical situation MRI and/or CT with CTA may be useful adjunct to a CT alone. Rule out carotid dissection. posterior reversible encephalopathy syndrome.g. subperiosteal haematoma. glaucoma) © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists † When the presumed lesion is in the lung. magnetic resonance imaging. CTA.37. orbital bruit. MRA. etc.g.38 ‡Imaging the entire pathway (MRI head and neck down to T2 with MRA neck) may be necessary if further localization cannot be performed because of difficulties with hydroxyamphetamine availability. Colour flow Doppler studies may be useful for detecting reversal of orbital venous flow Carotid-cavernous sinus or dural fistula (Fig. computed tomography. gazeevoked visual loss) Orbital trauma (e. SPECT. Isolated post-ganglionic lesions are often benign Clinical indication Horner syndrome: preganglionic Horner syndrome: post-ganglionic Yes Thyroid eye disease MRI head and neck to second thoracic vertebra (T2) in chest with neck MRA† MRI head and neck to level of superior cervical ganglion (C4 level) with MRA neck‡ CT or MRI of orbit Bone anatomy is better seen on a CT scan especially if orbital decompression is being considered (Fig. especially if possible concomitant cavernous sinus thrombosis is present Beware fat suppression artefacts Orbital tumour (e. CT scan may be superior if looking for hyperostosis or calcification CT is superior to MRI for bone fractures CT is superior for visualizing fracture or bone fragment CT or MRI may show enlarged superior ophthalmic vein. contrast-enhanced axial CT may be sufficient for localization. PRES. arterialization of conjunctival and episcleral vessels. PET. optic nerve glioma or sheath meningioma) (Figs 26.g. Lee et al. May require catheter angiogram for final diagnosis and therapy. 17) (e. mediastinum or anterior aspect of the neck. single photon emission computed tomography. orbital emphysema) Traumatic optic neuropathy CT scan of orbit with direct coronal Not generally necessary Not generally necessary Yes CT of optic canal (thin sections) CT or MRI of head and orbit (with contrast-enhanced MRA) Include head imaging if lesion could extend intracranially. magnetic resonance venography. continued Preferred imaging study Yes Contrast material Comment Rule out lateral medullary infarct. carotid dissection.38 Table 1. . fracture. CT. MRV. MRI with contrast is superior at determining intracranial extent of primary optic nerve tumours (e. FLAIR. orbital foreign body. computed tomography angiography. MRI. magnetic resonance spectroscopy.g. DWI. apical lung neoplasm. proptosis or enophthalmos. magnetic resonance angiography. MRS. brachial plexus injury. fluid attenuation inversion recovery.27). positron emission tomography.

for evaluation of optic nerve sheath meningioma or optic neuritis). hyperintense. Without fat suppression.0 T) is increasing worldwide because of the potential technical benefits associated with stronger magnets.e.g. more in-depth neuroradiology publications for further information. Other than fat.00005 T. pituitary apoplexy). Unlike CT.g. periventricular white matter lesions in multiple sclerosis).g.e. which relies on the density of tissue (i. because specific sequences can suppress the normal hyperintense signal of fat on T1WI (i. This hyperintense signal artefacts could be misinterpreted as abnormal enhancement and the ophthalmologist should be suspicious of orbital MR reports describing ‘abnormal enhancement’ in this area (e. The detailed physics of MRI is beyond the scope of this review and the reader is referred to other. postcontrast imaging with fat suppression is an established protocol.g. open MRI scanners for orbital and neuroimaging when high-field scanning is available. because it is a paramagnetic substance.21–24 We caution against the exclusive use of low-field.0 T on research systems). For comparison. At many centres. FLAIR).g.26 We summarize the basic parameters of MRI in the following text. the most important T1 hyperintense substances are subacute haemorrhage (e. particularly in the orbit.g.e. The importance of these suppression sequences is they eliminate or reduce the hyperintense fat and water signal from normal tissues in order to enhance visualization of underlying pathology. this may translate into either higher patient throughput or improved diagnostic accuracy for many neuroradiological applications. braces or metallic eyelash mascara) and at the air–bone interface of adjacent paranasal sinuses (e. there are very few substances that are hyperintense on precontrast T1WI.18 The MR signal is generated from the interaction of hydrogen protons (mostly in water) within the powerful magnetic field. 9) or intracranial melanoma metastases. Although ophthalmologists do not have to order T1WI or T2WI .g.5 and 3.g. Ophthalmologists should be aware that inadequate or incomplete fat suppression can be caused by metallic artefacts (e. Most patho- 39 logical lesions tend to be hyperintense on T2WI. The ophthalmologist must be familiar with local scanning protocols to avoid misdiagnosis.0 T (up to 8. T2WI are typically better for demonstrating intracranial or other pathology. hyperdense.19 There are also proponents of expanding low-field (<0. Clinically. Proton density imaging will not be discussed as its use is becoming more and more limited in orbital and neuroimaging. In MRI.Neuro-ophthalmic and orbital imaging resonance within a large magnetic field. they should make sure that fat suppression is used for all post-contrast orbital T1WI (e. ischaemia (e. especially if there is no clinical correlation and there is visible metallic artefacts on the ipsilateral side. but this is still debated. Wernicke encephalopathy) and neoplasms. Fortunately. This property is helpful when evaluating choroidal melanomas (Fig. the earth’s magnetic field is approximately 0. optic neuritis with optic nerve enhancement [Fig. the two most common pulse sequences are T1. high signal area at the inferior rectus muscle adjacent to very low signal air in the maxillary sinus).and T2-weighted images (T1WI and T2WI).5 T) MR technology because of its cost savings and open format. Hyperintense T2 pathologies include demyelinating lesions (e. increased chemical shift resolution. the language of MR is signal intensity (i. These benefits include an increased signal-to-noise ratio. 3. longer scan times and difficulties with contrast enhancement. Careful review of other sequences might confirm that the abnormal signal is indeed © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . it is important for ophthalmologists to recognize the MRI appearance of common tissues in the brain and orbit. However. ‘fat suppression’ or ‘fat saturation’) or the normal hyperintense signal of CSF on T2WI (i. The two most important tissue appearances are the hyperintense T1 signal of fat (‘bright on T1’). In distinction.27 Melanin is hyperintense on T1WI and very hypointense on T2WI. Current MRI scanners used in clinical practice are typically 1. Normal anatomy is best demonstrated on T1WI. inflammatory disease. toxic or metabolic disorders (e. 8d) and lipomas.25. stroke). there is no radiation exposure with MRI. isodense or hypodense) to determine the attenuation of signal. For the ophthalmologist.20 The disadvantages to using low-field MRI include reduced image quality. particularly when contrast is used. Unlike CT scanning. ‘inflammatory pseudotumour’ or ‘enhancement in the inferior rectus muscle’).g. 10]). and the hyperintense T2 signal of cerebrospinal fluid (CSF) (‘bright on T2’). proteinaceous fluid (e. such as orbital dermoid cysts (Fig. increased sensitivity to various contrast agents and improved vessel-versus-tissue contrast. the ophthalmologist does not need to specifically ask for T1WI and T2WI as they are typically acquired as part of the standard MR examination of the orbit and brain. melanoma).e. fat suppression and DWI.g.g. Fat suppression techniques can also confirm the content of fat-containing lesions. isointense or hypointense). Fat suppression sequences allow better visualization of underlying pathological lesions on T1WI of the orbit. The static magnetic field created by the MRI scanner is expressed in the unit Tesla (T). The number of high-field scanners (e. The ophthalmologist cannot always rely on fat being hyperintense on T1WI or CSF being hyperintense on T2WI.g. sinus mucoceles or craniopharyngioma) and melanin (e. the overlying hyperintense fat signal might obscure underlying contrast enhancement (e.

MRA. CA). The MRI scan is superior to CT for most neuro-ophthalmic indications. 11]). but there are reports of rare reactions that can be severe or even fatal. thyroid eye disease. free gadolinium. head. skin rash. Gadolinium contrast material in MRI As with CT. 4. but CT is superior to MRI for calcification. have also shown promise in detecting subarachnoid haemorrhage. or if the patient cannot undergo an MRI scan. Lee et al. and then order the best study tailored to the lesion location (e. Magnevist. define the differential diagnosis (‘what is the lesion’). special MR sequences. computed tomography. See Table 3 for catheter angiography.e. Call the radiologist if there is any doubt about localization. In most cases. posterior reversible encephalopathy syndrome. review the films directly with them. Topographically localize the lesion clinically (‘where is the lesion’). fluid attenuation inversion recovery for white matter lesions. MultiHance. MRA or CTA. Decide if contrast is needed. MR with gadolinium was considered the ‘procedure of choice’ in patients with renal insufficiency who required a contrast study. Transmetallation (i. Unlike the iodinated contrast used for CT. NSF is characterized by thickening and hardening of the skin. MR scanning with intravenous contrast material improves detection of pathology by demonstrating areas of blood–brain barrier breakdown. along with T1WI and T2WI. in combination with FLAIR and T2WI. a relatively new disorder related to gadolinium contrast has emerged called nephrogenic systemic fibrosis (NSF). MRV. Evolving GRE techniques. or if additional studies might show the lesion. MRV. or traumatic brain injury. computed tomography angiography. magnetic resonance angiography. CA.g. 8. can also show blood products effectively. Ask the radiologist if the area of interest has been adequately imaged. typically over the extremities and trunk.g. non-contrast CT still remains the preferred study for suspected subarachnoid haemorrhage. Clinically. Even trace amounts of haemorrhage may be detected because of the profound signal loss caused by the paramagnetic effects of deoxyhaemoglobin and methaemoglobin. intra. MRA and CTA recommendations for third nerve palsy.28–31 With regard to CSF intensity. the FLAIR sequence improves visualization of subtle adjacent or underlying pathological hyperintensity on T2WI (e. acute haemorrhage. Fortunately. contrast selection. 2. CTA. CT is faster and less prone to motion artefacts in a distressed. establish the urgency of the imaging request. hives and facial swelling). © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . The gadolinium paramagnetic metal ion enhances the local magnetic field and increases signal intensity. 6. orbit or neck). Although CT is considered superior to MR for demonstrating acute haemorrhage (e. Gadolinium contrast agents are chelated to form a larger. Omniscan). MRI. Decide whether a CT or an MRI scan is indicated or not. ProHance. Omniscan and OptiMark). image study of choice. indications or the final report.g. bone. if an emergent scan is needed. Unfortunately.36 with permission) 1.g. breaking the bond between artefacts. magnetic resonance imaging. Although most reports relate to a specific gadolinium agent (i. CT.40 Table 2. Caution is necessary for both iodinated contrast and gadolinium contrast in patients with renal failure and contrast may be contraindicated in these settings. confused or agitated patient with intracranial haemorrhage. or in trauma cases. If the imaging shows either no abnormality or an abnormality that does not match the clinical localization then call the radiologist or better yet. periventricular white matter demyelination [Fig. contrast material should be ordered for both CT and MRI studies.g. the contrast material used for MR is a paramagnetic material called gadolinium. the Food and Drug Administration has issued a ‘black box’ warning about NSF and gadolinium agents approved in the USA (e.or extraaxial intracranial haemorrhage (Fig. 3. unlike iodinated contrast material. If the clinical picture suggests a specific lesion or localization and initial imaging is ‘normal’ consider repeating the imaging with thinner slices and higher magnification of the area of interest especially if the clinical signs and symptoms are progressive.e. magnetic resonance venography. such as GRE. 28.35 NSF is a disorder seen weeks to months following gadolinium contrast administration in patients with kidney failure. itching. Recognize that the lack of an imaging abnormality does not exclude pathology. more stable complex around the more toxic. Up until very recently. subarachnoid haemorrhage). gradient recall echo for haemorrhage.32. if artefacts might be obscuring the lesion. PRES. conventional angiography. the approximate age of a haematoma may be determined. Contrast may not be necessary in acute haemorrhage. This stable complex is excreted via the kidneys. diffusion-weighted imaging for stroke or PRES) depending on clinical indication. fat suppression for orbital post-contrast study. Order special imaging for specific vascular indications (e. By using GRE. serious side-effects from gadolinium are uncommon.g.34 GRE MR sequences are useful for demonstrating haemorrhage associated with arteriovenous or cavernous malformations. 12). 5. 9. However.g. sweating. Guidelines for ordering imaging studies in ophthalmology (modified from Lee et al.33 Ophthalmologists may have to specifically ask for FLAIR sequences in cases of suspected demyelinating disease as it may not be routinely performed as part of a standard MR protocol at some radiology facilities.5 The most common allergic reactions are typically mild (e. 7. Order specific imaging sequences (e.

(b) Corresponding diffusion-weighted imaging reveals iso. the toxic metal gadolinium and the chelate). (a) Axial T2-weighted fluid attenuation inversion recovery image demonstrates hyperintense signal changes in both occipital lobes in a hypertensive patient (arrow). unless there is a clear contraindication to the admin- istration of contrast. differential diagnosis and the urgency of the imaging request to the neuroradiologist on the requisition. Ordering the right imaging study at the right time The ophthalmologist should communicate the clinical findings. especially in patients with renal disease. suspected lesion location. gadolinium should probably be ordered for virtually all MR scans performed for neuro-ophthalmic indications.30 These authors described © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . Wolintz et al. might be the mechanism for NSF. Gadolinium is very safe in nonrenal failure patients and does not produce crossreaction in patients with allergies to iodinated contrast or fluorescein dye. The American College of Radiology recommends against using Omniscan for patients with any stage of renal disease and caution is advised for all other gadolinium agents in patients with ‘moderate to severe’ renal disease.29 The main point for ophthalmologists is that ordering MRI with gadolinium is no longer a ‘no risk’ procedure. free gadolinium ion. 41 Figure 14. which is designed to block the toxic.Neuro-ophthalmic and orbital imaging Figure 13. Acute right occipital lobe infarction.and hypointense (arrow) signal changes consistent with vasogenic oedema. there is no proven therapy for NSF. Posterior reversible encephalopathy syndrome. Despite these new concerns. Unfortunately. (b) Corresponding apparent diffusion coefficient map shows an area of decreased signal intensity (arrow) confirming an acute ischaemic stroke. (a) Diffusionweighted imaging demonstrates restricted diffusion (‘bright’ signal intensity) in the right occipital lobe (arrow) in a patient presenting with a complete left homonymous hemianopsia. described common requisition errors when ordering ophthalmological studies.

† the following prescriptive errors: (i) failure to apply a dedicated study.62 ‡Vasculopathic patients (e. MRA.42 Lee et al. CTA. hypertension or diabetes). Patients without vasculopathic risk factors or vasculopathic patients who do not improve or who progress over a few months time should undergo a neuroimaging study (MRI with MRA or CTA). with complete external dysfunction and no internal dysfunction may be observed for improvement without neuroimaging. as it is very likely to be due to an ischaemic third nerve palsy. (iii) assumption that a striking imaging abnormality accounted for the clinical abnormality. Catheter angiography is recommended if (i) worsening of extraocular muscle or iris sphincter impairment continues beyond 14 days.g. Figure 15. (ii) inappropriate use of a dedicated study. (c) Mean transit time image from a perfusion study demonstrates a very large area of prolonged transit involving the entire right middle cerebral artery cortical distribution (box) that is not yet completely infarcted (i. magnetic resonance angiography.63 with permission) Isolated third nerve palsy Complete internal dysfunction Incomplete internal dysfunction No internal dysfunction Complete external dysfunction Highest risk MRI with MRA or CTA Angiography may still be needed† Uncertain but probably lower risk MRI with MRA or CTA Consider angiography† Low risk Initial observation‡ MRI with MRA or CTA if no improvement Incomplete external dysfunction Highest risk MRI with MRA or CTA Angiography may still be needed† Moderate risk MRI with MRA or CTA Consider angiography† Uncertain risk MRI with MRA or CTA Consider angiography† No external dysfunction Minimal if any risk No imaging for aneurysm required Minimal if any risk No imaging for aneurysm required Not applicable Catheter angiography should still be considered for patients in whom the risk of aneurysm is higher than the risk of angiography. In patients with high suspicion for aneurysm a CTA might be the initial study and then if negative an MRI (with or without an MRA) might be performed to exclude non-aneurysmal causes for a third nerve palsy.65 (iii) no recovery of function occurs within 12 weeks. (ii) iris sphincter impairment progresses to anisocoria >1 mm. magnetic resonance imaging.30 Table 1 lists the common ophthalmic © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . The following interpretive errors were also reported: (i) failure to detect the lesion because of misleading clinical infor- mation. and (iv) failure to consider the lack of clinical specificity of imaging abnormalities. Table 3. or (iv) signs of aberrant regeneration develop. and (iv) omission of specialized sequences. (a) Axial T2-weighted fluid attenuation inversion recovery image shows an area of pathological T2 hyperintensity in the right basal ganglia (arrow). (iii) omission of intravenous contrast. computed tomography angiography. (b) Diffusion-weighted imaging (DWI) reveals corresponding restricted diffusion in the same area as well as a smaller area more posteriorly (arrows). This represents ‘at-risk’ brain and is consistent with a large DWI/perfusion-weighted imaging mismatch. MRI. At many centres CTA is the superior study for evaluation of aneurysm compared with MRA. the ischaemic penumbra). Stroke with perfusion mismatch. (ii) rejection of a clinical diagnosis because an expected imaging abnormality was absent. This remains a practice option depending on the individual center and clinical scenario.e. Recommended neuroimaging for acute isolated third cranial nerve palsy based on degree of internal and external dysfunction and risk of aneurysm (modified from Lee et al.

DWI may still show hyperintensity. differentiating epidermoid from arachnoid cysts).e. evidence of acute cerebral emboli in a patient with embolic retinal arterial occlusion.g. DWI can detect hyperacute ischaemic stroke even before abnormalities are detected on conventional T1WI. DWI shows hypointensity and the corresponding signal changes on ADC are hyperintense. The mobility of water within intracranial tissue is called the apparent diffusion coefficient (ADC). but there are typically hyperintense signal abnormalities on T2WI and FLAIR images. subacute and chronic.42 It is usually encountered in the setting of hypertension (e.40 In vasogenic oedema the diffusion of water molecules is increased. DWI can differentiate the various phases of cerebral infarction: hyperacute.44–48 In addition to DWI/ADC. Diffusion-weighted imaging is an MRI technique that is based on the microscopic random Brownian motion of water. PWI.41. 14).or hypointense signal. brain abscess or vasculitis).39.39.e.g. 43 indications for ordering an imaging study and Table 2 summarizes our recommendations for contacting the neuroradiologist to discuss the clinical indications. (b) Three-dimensional computed tomography angiography image reconstructed on a Vitrea workstation (same patient) optimally demonstrates the aneurysm sac (white dot) as well as the aneurysm neck (arrow). cyclosporine or tacrolimus) can produce a similar radiographic picture. In contrast. cortical visual impairment. in cytotoxic oedema the movement of water from the extracellular to the intracellular compartment produces restricted diffusion.44–50 PWI allows measurement of capillary perfusion in a region of interest by signal tracking after bolus injection of a paramagnetic contrast agent and requires ultrafast © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . but ADC values appear normal. multiple sclerosis) and neoplastic lesions (e. the most common applications for using DWI/ADC are acute ischaemic homonymous hemianopsia (Fig. These include DWI.g.g. Thus. eclampsia or amphetamine use). In certain pathological states.g. Alzheimer dementia). T2WI and FLAIR sequences. but immunosuppressive medications (e. For the ordering ophthalmologist. In the hyperacute phase there is restricted diffusion (i. hyperintense or ‘bright’ on DWI).39. One scenario in which the ophthalmologist might have to decide whether oedema is vasogenic or cytotoxic in nature is in posterior reversible encephalopathy syndrome.31. Posterior reversible encephalopathy syndrome typically affects the posterior brain (e. so the ADC is hypointense and the DWI is hyperintense. suspected lesion location and urgency of the study. During the acute phase there is also restricted diffusion and hypointense signal changes on ADC. The combination of DWI and ADC can define specific pathology of water diffusion. Posterior communicating artery (PCoA) aneurysm. Thus. often with normal T2WI and FLAIR signal intensity. hyperintense on DWI) and corresponding hypointense signal changes on ADC.Neuro-ophthalmic and orbital imaging Figure 16. occipital lobes) and can produce homonymous hemianopsia or cortical visual impairment (Fig. DWI and ADC can discriminate between reversible vasogenic oedema and irreversible cytotoxic oedema. differential diagnosis.g. Current imaging techniques Ophthalmologists should be aware of a number of current MR techniques and sequences that have been developed to image acute stroke and other central nervous system (CNS) pathology. PCT and constructive interference in the steady state (CISS). acute. 13). so the ADC shows hyperintense and the DWI shows iso. These changes in water molecular diffusion can be measured as signal intensity in vivo with DWI.g. PWI provides additional information that is useful in assessing the utility of interventional (catheter) thromblytic therapy for treatment of acute ischaemic stroke.43 Other DWI/ADC applications include assessment of inflammatory (e. diffusion becomes restricted (i. or top of the basilar syndrome with acute brainstem ischaemia producing a progressive ophthalmoplegia. (a) Maximum intensity projected image from a circle of Willis magnetic resonance angiography demonstrates a small PCoA aneurysm (arrow) in a patient with a left pupil-involving third nerve palsy. Finally. degenerative (e. In the subacute phase. in the chronic phase. demyelinating (e.

(c) Anterior and (d) lateral maximum intensity projection images show narrowing of the mid-cervical left ICA (arrows). crescent-shaped intramural haematoma with a diminutive anterior flow void in the left ICA (large arrow). Internal carotid artery (ICA) dissection. small arrows). (d) Catheter angiography (same patient) shows the direct high-flow cartoid cavernous fistula (white dot) draining into the superior ophthalmic vein (large arrow) and inferior petrosal sinus (small arrow). large arrow) as well as marked enlargement of the right cavernous sinus (b and c. Figure 18. (b) Axial and (c) coronal magnetic resonance angiography images also reveal the dilated SOV (b. Figure 17. Carotid-cavernous fistula.44 Lee et al. hyperintense. (a) Axial fat-suppressed T1-weighted magnetic resonance image demonstrates a normal-appearing flow void in the right ICA (small arrow) and a posterior. © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . (a) Axial T1-weighted magnetic resonance image demonstrates a markedly enlarged right superior ophthalmic vein (SOV) (arrow). (b) Parasagittal T1-weighted image clearly reveals the cranio-caudal extent of the intramural haematoma (arrows).

52 For example. but there remains a significant. cavernous sinus invasion and vascular abnormalities. albeit small (~1%).e. epilepsy. CNS neoplasms. The current widespread use of MRA and CTA has significantly reduced the use of invasive catheter angiography for initial evaluation of vascular pathology. There are two basic types of MRA: (i) time-of-flight (TOF) MRA. cranial nerves.51 It provides information about cerebrovascular haemodynamic parameters.Neuro-ophthalmic and orbital imaging 45 between PCT and MR diffusion/perfusion imaging abnormalities in acute stroke has been demonstrated. Contrast-enhanced magnetic resonance venography image demonstrates occlusion of the right transverse (arrow) and sigmoid sinus with extension into the right internal jugular vein in a patient presenting with bilateral disc oedema. Post-processing.15 The morbidity and mortality of modern catheter angiography has been declining with better techniques. Technical advances have allowed 3-D rotational reconstructions that eliminate the need for multiple oblique views and thereby decrease the amount of contrast needed. within 6 h for anterior circulation and within 9 h for posterior circulation). such as windowing and filtering.56 PCT also shows promise in distinguishing benign from malignant lesions by determining tissue perfusion characteristics. time to peak. the duration of radiation exposure and the overall length of the procedure. CTA. risk of severe complications (e. On conventional MR. following intravenous injection of iodinated contrast. a specific treatment decision for intervention could be made. Perfusion studies are also becoming an important diagnostic tool in a variety of other conditions. fastmoving blood appears dark on all sequences as a ‘flow void’. MR sequences. Both TOF and PC MRA can acquire data using either a 2-D or a 3-D scan. and (ii) phase-contrast (PC) MRA.63 The technique of MRA relies on the flow-sensitive nature of the MR signal. DWI remains the sole imaging technique with the ability to assess a stroke within minutes of onset and is unlikely to be replaced by CT in the near future. and potentially salvageable tissue (i. 15). These sequences have inherent flow compensation that greatly reduces the artefacts caused by CSF pulsations.34 The volume difference of DWI and PWI (also termed DWI/PWI mismatch) gives an approximate measure of hypoperfused (but not yet infarcted).55 Nevertheless. MRA. such as constructive interference in steady state (CISS). and other developmental and degenerative CNS disorders.57 Finally. These reconstructions also have the advantage of being better able to delineate the neck of an aneurysm and thereby provide a more accurate assessment of the coil size needed for embolization. are acquired using a CT scanner capable of operating in the necessary cine mode.g. mean transit time and cerebral blood flow. Venous sinus thrombosis. ischaemic stroke). recent developments in MR pulse sequences.59–61 Digital subtraction catheter angiography depicts iodinated contrast-filled vessels without interference from background tissues. the ischaemic penumbra) (Fig.54 Good correlation © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists .53 Dynamic perfusion CT imaging is also showing progress in providing valuable information in acute stroke and tumour differentiation. such as cerebral blood volume. especially if a vessel occlusion is demonstrated by MRA. have allowed higher-resolution imaging of labyrinthine structures. Background images of the brain are taken as ‘mask images’ and then ‘subtracted’ from the images after injection of contrast material.g. perineural spread of tumour.62. can improve the appearance of the final images. The addition of contrast enhances the MRA acquisition and optimizes visualization of possible dural venous sinus disease and is also useful for evaluating carotid Figure 19. if the DWI/PWI mismatch is greater than 20% and the onset of symptoms is within a certain time window (e. MRV and CTV Ophthalmologists should also be aware of other imaging techniques for assessing vascular lesions. A DWI/PWI mismatch represents an indication for thrombolysis based on potential reversibility of DWI lesions.and extra-axial lesions. Sequential images. such as arteriovenous malformations.58 The detailed anatomical information provided by CISS sequences is of particular value in planning surgical interventions for both intra.

Figure 20. a technically easier and faster study to acquire and less motion artefacts. These include the lack of ionizing radiation exposure. Utility of magnetic resonance spectroscopy (MRS). We believe that TOF MRA is a more robust technique than PC MRA for evaluating vascular abnormalities of interest to ophthalmologists (e. ovoid white matter hyperintense lesions oriented perpendicular to the lateral ventricles (arrow). For patients with partial or © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . Pathological diagnosis was a World Health Organization Grade IV astrocytoma (glioblastoma multiforme).63 An imaging approach for assessing an isolated third nerve palsy is summarized in Table 3 using a risk tolerance method. Axial post-contrast fat-suppressed T1-weighted magnetic resonance image demonstrates left optic nerve enhancement (arrow).g.62. Optic neuritis. iodinated contrast). Axial T2-weighted fluid attenuation inversion recovery magnetic resonance image demonstrates multiple. Magnetic resonance angiography has some advantages over CTA. gadolinium vs. Figure 21. the neuroradiologist should examine the actual source images regardless of which technique is used. stenosis. aneurysms or arteriovenous malformations).46 Lee et al. In either case. The advantages of CTA over MRA are increased spatial resolution. The degree of completeness of external ophthalmoplegia (external dysfunction) and the presence or absence of pupil involvement (internal dysfunction) can be used to determine the initial imaging strategy for an isolated third nerve palsy.e. characteristic of MS plaques. a less nephrotoxic contrast material (i. increased signal-to-noise ratio and easier post-processing techniques.64 One of the ‘highest stakes’ situations for which the ophthalmologist might need to decide between invasive (catheter) versus non-invasive (MR or CT) angiography is in the evaluation of third cranial nerve palsy. Figure 22. (a) Axial post-contrast fat-suppressed T1-weighted magnetic resonance image demonstrates a small right parietal ring-enhancing lesion (arrow). Multiple sclerosis (MS). (b) MRS shows marked choline elevation and low Nacetylaspartate consistent with a malignant neoplasm.

68 However. Vasculopathic patients (e.Neuro-ophthalmic and orbital imaging Figure 23. painful pupil-involved third nerve palsy. whereas an MRI combined with a CTA examination would require two different scanners.62. The published sensitivity of both MRA and CTA for detecting an aneurysm leading to a third nerve palsy is as high as 98%. The advantage of MRA over CTA in the evaluation of a patient with a third nerve palsy is that an MRI combined with an MRA is likely easier to obtain as both examinations can be performed using the same scanner.63.63 The sensitivity and specificity of both MRA and CTA for ophthalmic indications are probably equivalent. as it is very likely to be due to an ischaemic third nerve palsy. MRA or CTA offer less invasive methods of evaluation than catheter angiography for detecting aneurysms (Fig. Craniopharyngioma. However. as the ‘gold standard’ for detecting cerebral aneurysms remains catheter angiography. 16). CTA may be superior to MRA in some instances and at some institutions.g. or subarachnoid haemorrhage). we recommend its consideration for highly suspicious cases.66–68 The size of an aneurysm needed to produce a third nerve palsy is likely to be within the detection limit of most scanners used for MRA and CTA (usually 5 mm in size). normal pupil function) may be observed for improvement without neuroimaging. complete external dysfunction of the third cranial nerve with pupil involvement. even in the face of a negative MRA or CTA (e. poor MRA or CTA visualization of the entire posterior communicating artery. In some cases. the clinician must weigh the risks of catheter angiography in © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . Pituitary macroadenoma. incomplete or poor-quality study. MRI with MRA preceded or followed by CTA may be necessary. homogeneously enhancing sellar mass with significant suprasellar extension (arrows) in a patient with bitemporal hemianopsia.g.62.e. Patients without vasculopathic risk factors or vasculopathic patients who do not improve or who progress over a few months time should undergo a neuroimaging study. other risk factors for aneurysm. 47 Figure 24. most ophthalmologists will likely prefer the combination of MRI/MRA rather than CT/CTA when assessing a patient with a third nerve palsy. hypertension or diabetes) with complete external dysfunction and no internal dysfunction (i. (a) Sagittal and (b) coronal post-contrast fat-suppressed T1weighted images demonstrate a complex sellar mass with suprasellar extension that contains both a heterogeneously enhancing solid component (arrows) and a large rim-enhancing cystic component (white dots). (a) Sagittal and (b) coronal post-contrast fat-suppressed T1weighted images reveal a large. depending on the amount of experience with this technique. As an MR scan is superior to a CT scan for assessing non-aneurysmal causes of third nerve palsy.63 Newer scanners and improved techniques have increased resolution enough to reliably detect aneurysms as small as 2–3 mm. As always.

contrastenhanced MRV and CTV. MRI combined with MRA plays a dominant role in the initial diagnosis. carotid dissection.and postcontrast MRI with a contrast-enhanced MRV. In such cases.72 When comparing contrast-enhanced MRA with digital subtraction angiography for evaluation of carotid stenosis. stenosis or occlusion). significant cardiovascular or renal disease) against the likelihood of finding an aneurysm. Figure 25. it can fail to demonstrate the dissection if the haematoma is eccentric and does not cause lumen narrowing.77 A number of venographic techniques have been developed to better define sinus anatomy.82 An important pitfall on MRV is that flow gaps in a hypoplastic non-dominant transverse sinus can be misinterpreted as areas of venous thrombosis.48 Lee et al.71 MRA usually demonstrates irregularity and narrowing of the artery at the dissection site. but in about one-third of cases it is normal. transient monocular visual loss (i. the use of MRA or CTA may also be helpful in patients with hemispheric transient ischaemic attacks. These include PC MRV. Pineal germinoma. it is important to evaluate the ipsilateral jugular vein.84 The commonly measured metabolites in MRS include N-acetylaspartate © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . age >70 years. CTV is another method for detecting cerebral venous thrombosis. ionizing radiation exposure. In cases of suspected acute arterial dissection. A standard head CT can show direct and indirect signs of venous thrombosis. and both have a slightly higher sensitivity and specificity than Doppler ultrasonography. For the ophthalmologist. homonymous hemianopsias. The normal pineal calcification is seen in the centre of the mass and the calcified habenular commissures are seen displaced anteriorly (arrows).76 Non-contrast MRI of the brain is more sensitive than non-contrast CT for showing parenchymal abnormalities and the presence of intraluminal thrombus in the sinus.g.77 CTV can provide very detailed imaging of the venous system. Symptoms of cerebral venous sinus thrombosis may mimic those of idiopathic intracranial hypertension.83 Disadvantages to CTV include the use of iodinated contrast material. and is at least as accurate for detecting thrombosis. symptomatic atherosclerotic cerebrovascular disease. with MR spectroscopy Magnetic resonance spectroscopy (MRS) is another evolving MR technique that is based on detecting various proton MR spectra.77 Our preferred technique for evaluating cerebral venous sinus thrombosis is a pre. The haematoma can be more readily distinguished from adjacent fat surrounding the artery with the use of fat suppression techniques (Fig. However. The major ophthalmic indication for performing a venogram is to exclude dural venous sinus thrombosis in patients presenting with papilloedema from increased intracranial pressure (Fig. as it will be smaller on the side of the hypoplastic sinus. amaurosis fugax). 81. or in patients with completed cortical strokes. CTA can also be used to diagnose dissection.75 Finally. or suspected carotid artery disease (e.g. Other MR findings include the absence of a flow void and the presence of altered signal intensity in the thrombosed sinus. its improved imaging capability.74 Multidetector CTA.e. This is especially problematic on non-contrast TOF MRV. dural or carotidcavernous fistula (Fig. a patient with other significant comorbidities (e. especially in the trauma setting. and difficulty in reconstructing maximum intensity projection (MIP) images because of problems subtracting bone adjacent to the venous sinuses. which is both rapid and widely available.73 CTA has a similar sensitivity and specificity to MRA.69. which is superior to TOF MRV.70 Precontrast T1WI may demonstrate a hyperintense. Contrast-enhanced MRV reduces artefacts that are commonly seen with noncontrast PC MRV. and to correlate findings with the brain MRI. MRA had a pooled sensitivity of 95% and specificity of 90%. other indications for ordering a CTA or an MRA include evaluation for an arteriovenous malformation. non-contrast TOF MRV. crescent-shaped intramural haematoma with an eccentric flow void of the patent lumen at the dissection site.78–80 Depiction of the dural sinuses and small-vessel visualization is also improved with contrast-enhanced MRV compared with TOF MRV. Axial non-contrast computed tomography image reveals a hyperdense pineal mass in a patient with findings of dorsal midbrain syndrome. has even replaced conventional catheter angiography in the evaluation of carotid stenosis at some institutions.74. 18). 17). 19).

Choline is a component of cell membranes and increased Cho might suggest increased membrane synthesis (e. gliomatosis cerebri]) and decreased in hypermetabolic states. inflammatory and mitochondrial disorders.g. can also be assessed. The coronal image confirms the circumferential nature of the enhancement and optimally shows the normal-size nerve centred within the enhancement (b. as well as involvement of the proximal optic nerve (arrow).g. meningiomas] or markedly decreased NAA [e. NAA is a neuronal and axonal integrity marker and a reduction of the NAA peak on MRS is an indication of neuronal/axonal dysfunction (e. gammaaminobutyric acid. such as glutamate. Localized increases in neuronal activity from task-related brain activation produce increased cerebral blood flow and decreased deoxyhaemoglobin and this can be imaged with fMRI.g. myoinositol and fatty acids. creatine and phosphocreatine (Cr). certain neoplasms have no NAA [e. These functional studies might be particularly useful when structural imaging appears normal despite clinical findings that suggest underlying brain dysfunction. fMRI has many potential advantages because it is non-invasive. As the Cr level often remains stable even in disease states. (a) Axial and (b) coronal post-contrast fat-suppressed T1-weighted magnetic resonance images. it can be used as a control for MRS with levels of other metabolites expressed as a ratio to Cr (e. Presurgical mapping of brain function. CT and MR). hypercellular tumours). arrow).g. PET and SPECT As opposed to structural imaging studies (e. and has relatively high spatial and © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . including localization of visual functions.88. ischaemia or certain tumours [e. 20} or metastases]). A pattern of enhancement of the left optic nerve sheath is nicely demonstrated on the axial image (a. neoplastic. The spectrum of MRS applications in neuro-ophthalmology has been expanding and includes differentiating ischaemic. (a) Axial T1-weighted magnetic resonance image demonstrates fusiform enlargement and kinking of the intraconal left optic nerve (arrow). trauma or brain neoplasms). Creatine may be elevated in hypometabolic states (e. a brief description of the technology is useful. glutamine. Optic nerve sheath meningioma.Neuro-ophthalmic and orbital imaging Figure 26.g. Optic nerve glioma. 49 Figure 27.84–87 fMRI. ischaemia. Although an ophthalmologist is unlikely to be ordering MRS. therefore. The normal brain derives energy from aerobic metabolism of glucose and. a feature that distinguishes this lesion from an optic nerve glioma. has provided new insights into brain physiology. arrows).g. (b) Axial post-contrast fat-suppressed T1-weighted image reveals homogeneous enhancement.g.g. cholinecontaining phospholipids (Cho) and lactate.g. increased Cho/Cr ratio in certain brain neoplasms). metabolic disturbances. actively proliferating or solid. a significant lactate peak on MRS might indicate anaerobic metabolism (e.89 The signal change of blood oxygenation level-dependent mechanisms can be imaged on fMRI. functional imaging studies show information about the physiology and metabolic function of brain. glioblastoma multiforme {Fig. radiation necrosis. fMRI is based on changes in T2 signal due to deoxyhaemoglobin. Lipid and myoinositol are markers of gliosis and myelin damage and might be elevated in specific disease states. does not require the injection of contrast agents. demyelinating. Other metabolites. (NAA).

movement disorders and migraine. such as in clinical drug trials. 14. 2): S108–13. Technical advances in multi-slice spiral CT. Radiology 2005. Neurosci Biobehav Rev 1993. 4: 1–8. Rosand J. Zagoria RJ. Surv Ophthalmol 2000. as well as sensitivity.96–98 Except for ocular adnexal lymphoma.101. Flohr TG. 8. 6. Eur Radiol 2004. Ophthalmologists should also be aware of evolving techniques in vascular imaging (i. GRE and DWI. Noguchi T. Bruder H. 12. 3. Schoepf UJ. Smith EE. 14: 902–7. Udupa JK. 10. unless there is a clear contraindication. contrast material should be ordered for neuro-ophthalmic indications. Klotz E. MRA and CTA) as they are reducing the need for catheter angiography at many institutions. PET is more expensive and less widely available than SPECT.99.93. The combination of the two modalities improves specificity. CT still has a role for assessing acute haemorrhage. CONCLUSIONS Ophthalmologists need to be aware of the basic mechanics. Kurz-Levin MM. 15: 259–72. 77 (Spec No. Once again. MRI is superior to CT for most intracranial neuro-ophthalmic indications. regional blood flow and glucose metabolism).94 However. Multi-detector row CT systems and image-reconstruction techniques. Kalender WA. Radiographics 1999. cyclosporine-related cerebral blindness). 2. 235: 756–73. The use of PET/CT (combined PET and CT) is now being used. 4.g. 11. Kransdorf MJ. Kalender WA. we stress the critical importance for the ordering ophthalmologist to provide the radiologist with the pertinent clinical findings. Schulte AV. Morcos SK. ix. However. Neuroimaging Clin N Am 1994. Radiology 1990. Peterson JJ. hydrocephalus. Finally. in tumour imaging. These sequences include fat © 2008 The Authors Journal compilation © 2008 Royal Australian and New Zealand College of Ophthalmologists . Vock P. a useful differential diagnosis and the suspected location of a lesion in order to obtain the best study and interpretation. stroke.94. Thomsen HS. 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