BPNA Distance Learning Course

Unit 0: Introduction to Paediatric Neurology

Section 2: Principles of Neuroimaging

(Recommended working time: 3 hours)

August 2017
 Unit 1: Introductory Unit
Section 2: Principles of Neuroimaging

Principles of Neuroimaging

Aim: By the end of this section, you will be able to recognize the scope of
neuroimaging in paediatric neurology. Throughout the units of this distance
learning course you will encounter many examples of neuroimaging
demonstrating different diseases of the nervous system. This section will provide
you with the skills to begin interpreting these images.

Learning Outcomes:
By the end of this section, you will be able to:

1. Identify major neurological landmarks on cranial MR/CT images.

2. Describe the range of neuroimaging modalities and their relative strengths
and weaknesses.
3. Consider factors that might affect the choice and interpretation of
neuroimaging studies in a given clinical situation.
4. Determine the most appropriate imaging modality for given clinical
situation: before requesting a neuroimaging study consider precisely what
diagnosis you are hoping to confirm/exclude – ‘What is the question?’
5. Determine which neuroimaging technique will best answer your ‘question’.

Resources/References:
To complete this section you will need to arrange a visit to your radiology
department to see the radiologist or senior radiographer.

The following texts and websites are useful but not essential resources:

Neuroanatomy Brain Atlas: www.med.harvard.edu/AANLIB

Digital Anatomist Project, including Washington Brain Atlas:

http://www9.biostr.Washington.edu/da.html

https://www.imaios.com/en/e-Anatomy/Head-and-Neck/Brain-MRI-in-
axial-slices

www.ch.ic.ac.uk/local/organic/nmr.html

http://www.mritutor.org/mritutor/index.html

 England MA and Wakely J. The Color Atlas of the Brain and Spinal Cord,
2nd Edition. Mosby, Elsevier 2005

 Scott W Atlas and Richard T Kaplan. Pocket Atlas of Cranial Magnetic Resonance
Imaging. Lippincott, Williams and Wilkins, 2001

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 Mary A Rutherford. MRI of the Neonatal Brain. WB Saunders, 2001

 James Barkovich and Charles Raybaud. Pediatric Neuroimaging, 5th

edition. Lippincott, Williams and Wilkins, 2011

 Marjo S van der Knaap and Jaap Valk. Magnetic Resonance of Myelin
and Myelination Disorders. Springer, 3rd edition 2005

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1. Identification of Neuroanatomical Landmarks

The interpretation of cranial CT and MR scans is a fundamental skill in paediatric
neurology. In order to appreciate abnormalities, it is important to appreciate the
imaging appearance of normal structures in the developing brain.

Activity 1:
***
 

Take a look at the excellent interactive website:

 
https://www.imaios.com/en/e-Anatomy/Head-and-Neck/Brain-
MRI-in-axial-slices
 
As you scroll through the images you will see the brain structures
labelled, familiarise yourself in particular with this axial view of the
brain, which is the view we most commonly use when looking at
brain MRI.

Identify the specified landmarks on the following MR/CT images.

a) Figure 1:
Midline Sagittal T1 weighted MR image

Corpus callosum Cisterna ambiens

Cingulate gyrus IVth ventricle
Pons Quadrigeminal plate
Medulla Pituitary gland
Aqueduct of Sylvius Optic chiasm
Cerebellar vermis
Cerebellar tonsil

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GC
C
CiA
Q
O A
Pgl P V CV

CT
M

Figure 1: Midline Sagittal T1 weighted MR image

You were asked to identify landmarks on the following MR/CT images –

here is where the arrows should have gone!

a) Figure 1:
Midline Sagittal T1 weighted MR image

Corpus callosum - CC Cisterna ambiens - CA

Cingulate gyrus - CG IVth ventricle - IV
Pons Quadrigeminal plate - QP
Medulla Pituitary gland - Pit
Aqueduct of Sylvius – A of S Optic chiasm - OC
Cerebellar vermis - CV
Cerebellar tonsil – CT

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CG

CC

OC

CA

QP

Pons A of S

Pit – “bright spot” IV

Medulla CV

Figure 1: Midline Sagittal T1 weighted MR image

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b) Figure 2:

Axial T2 weighted image (level of chiasm)

Optic chiasm
Midbrain
Aqueduct
Uncus
Temporal horns of the lateral ventricles
Cerebellar vermis
Superior sagittal sinus
Blood vessels in circle of Willis

Figure 2: Axial T2 weighted image (level of chiasmc)

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b) Figure 2:

Axial T2 weighted image (level of chiasm)

Optic chiasm - OC
Midbrain
Aqueduct
Uncus
Temporal horns of the lateral ventricles
Cerebellar vermis
Superior sagittal sinus - SSS
Blood vessels in circle of Willis – C of W vessels

C of W
vessels

OC

Uncu
Uncus
Temporal horns
Midbrain

Aqueduct

Vermis

SSS

Figure 2: Axial T2 weighted image (level of chiasm)

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c) Figure 3:

Identify structures on both the axial CT and then a T1 weighted MR

scanFrontal horn of the lateral ventricles

Head of the caudate nucleus

Lentiform nucleus
Thalamus
Posterior limb of the internal capsule
Posterior/occipital horn of the lateral ventricles
Sylvian fissure
Insula
Parietal lobe
Genu of corpus callosum
Splenium of corpus callosum

Figure 3a&b: Axial T1 weighted image and CT scan through Foramen of Munro

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c) Figure 3:

Axial CT and then a T1 weighted MR scan

Frontal horn of the lateral ventricles
Head of the caudate nucleus – H of CN
Lentiform nucleus - LN
Thalamus
Posterior limb of the internal capsule 0 PLIC
Posterior/occipital horn of the lateral ventricles
Sylvian fissure - SF
Insula
Parietal lobe
Genu of corpus callosum - G of CC
Splenium of corpus callosum – S of CC

Frontal horns

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GoCC

H of CN
Insula
LN
SF
Thalamus
PLIC
PL

SoCC

Post horns

Figure 3a: CT scan through Foramen of Munro

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Frontal horns
SoCC

Insula
H of CN
SF
LN
PLIC
Thalamus

PL

SoCC

Post horns
Figure 3b: Axial T1 weighted image through Foramen of Munro

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d) Figure 4:
Identify these structures on this T2-weighted axial MR image

Sagittal sinus
Corona radiata
Central sulcus

Figure 4: T2 weighted axial MR image

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d) Figure 4:
You then identified structures on this T2-weighted axial MR image

Sagittal sinus - SSS

Corona radiata
Central sulcus

Corona
radiata
Central sulcus

SSS

Figure 4: T2 weighted axial MR image

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Figure 5a & b:
Identify the following structures on these axial MR scans through Foramen of
Munro in a newborn infant
Frontal horn of the lateral ventricles
Head of the caudate nucleus
Lentiform nucleus
Thalamus
Posterior limb of the internal capsule
Posterior/occipital horn of the lateral ventricles
Sylvian fissure
Insula
Parietal lobe
Genu of corpus callosum
Splenium of corpus callosum

Figure 5a

Figure 5b

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Figure 5a & b:
This was of axial MR scans through Foramen of Munro in a newborn infant

Frontal horn of the lateral ventricles

Head of the caudate nucleus = HoCN
Lentiform nucleus - LN
Thalamus
Posterior limb of the internal capsule -- PLIC
Posterior/occipital horn of the lateral ventricles

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Sylvian fissure - SF
Insula
Parietal lobe
Genu of corpus callosum - GoCC
Splenium of corpus callosum - SoCC

Frontal horns

GoCC
HoCN

LN

PLIC

Thalamus SF

Insula

Parietal lobe Parietal lobe

Figure 5a
SoCC

Posterior horns

Frontal horns

GoCC

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PLIC

HoCN

SF
LN

Thalamus Insula

SoCC
Figure 5b
Posterior horns

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e) Figure 6:
Identify the following structures on this Coronal MR through temporal lobe

Thalamus
Basal ganglia
Temporal horn of lateral ventricles
Hippocampus
Frontal horns of lateral ventricles
Corpus callosum
Sylvian fissure

Figure 6: Coronal MR through temporal mode

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e) Figure 6:
Here you identified structures on a Coronal MR through temporal lobe

Thalamus
Basal ganglia (caudate nuclei and lentiform nucleus) = CN and LN
Hippocampus - HC
Frontal horns of lateral ventricles
Corpus callosum - CC
Sylvian fissure - SF

Frontal horns

CC

CN

LN
Thalamus SF

HC

Figure 6: Coronal MR through temporal mode

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If you found it difficult to identify these anatomical structures refer to the

websites/textbooks listed in the Resources section.

On T1 weighted MR images remember CSF has low signal intensity and looks
black. The appearance of the brain is similar to a black and white photograph of
histology specimen - grey matter looks grey and myelinated. White matter looks
white. Remember the bones are not visible on MR - the high SI comes from the
soft tissues and BM of the skull.

On a T2 weighted image CSF/water has a high signal intensity. The grey matter
is grey with myelinated white matter having a lower signal intensity - looking
blacker and unmyelinated. WM having a higher signal intensity - lighter than the
grey matter.

Figure 3 illustrates the differences between CT and MRimages. CT shows bony

structures but the differentiation between grey and white matter is much less
distinct than on MR and it is harder to identify specific sulci /gyri on the CT.

In the newborn infant the brain has a much higher water content, the cerebral
white matter is largely unmyelinated and the gyral pattern has still to fully
mature. Note the differences in white matter signal on the T1 and T2 weighted
images in the more mature brain in Figures 3a and 3b.

To fully appreciate neuroanatomical structures and indeed pathological lesions it

is important to look at structures in different planes. Take the opportunity to
examine the coronal and sagittal as well as axial images of your patient’s scans.

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2. Interpreting Neuroimaging Studies

As well as being familiar with the neuroanatomy, there are other considerations
when interpreting neuroimaging studies.

Activity 2:

***
List 3 other considerations when interpreting a particular brain scan.

1. From what incident was the examination made?

2.
the image obtained is correct?

3. What is the sequence?

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Commentary 2:
You may have considered any of the following factors, all of which are important
in establishing the significance of a neuroimages study.
Image quality
Is the image of adequate quality? Have the windows on the CT scan been set to
provide appropriate tissue discrimination or has the appropriate sequence been
selected on an MR image?
Coverage
Are all the regions of interest visible on the scan? For example, does a CT scan
show the brainstem within the foramen magnum and the sulci at the vertex, in a
child in whom raised ICP is a possible diagnosis?
Orientation
What plane is the image acquired in? CT is predominantly done in the axial or
transverse plane. The patient has to be repositioned to acquire a scan in a
different plane. MR can be acquired in the axial, sagittal and coronal planes while
the subject remains in the same position. Looking at neurological landmarks in
different orthogonal planes can be confusing, therefore take the opportunity to
examine MR images until you are confident picturing the brain in three
dimensions.
Sequence
By applying different gradient echoes with different relaxation and echo times it is
possible to enhance and suppress various structures on MR imaging. T1 and T2
weighted images are the standard imaging sequences, where CSF has a low signal
(appears black) and a high signal (appears white) respectively. However, other
techniques such as FLAIR (fluid attenuated inversion recovery, which highlights
white matter disease), T2* images (which can highlight blood) and Diffusion
Weighted imaging (which is dependent on the restriction of water movement,
highlighting fibre tracts and areas of pathology at an early stage) are often used.
Once again, to correctly identify pathology, you must have a clear idea of what
constitutes normal. If you are not familiar with the images produced using these
techniques ask your local radiologist to show you some examples.
Contrast
Radio opaque contrast can be injected into the venous circulation during imaging.
This allows better identification of vascular abnormalities and identifies whether
or not a particular lesion has an abundant blood supply – ie tumour or abscess.

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Artefact
Artefact can distort cranial images in two ways, either obscuring genuine
pathology or falsely creating the impression of a pathological lesion for example,
bony artifact on CT can obscure the posterior and temporal fossae.
Movement of the patient can lead to distortion of the image and is a particular
problem during MR acquisition. Therefore it is worth considering sedation or
even a GA when requesting an MR in infants and young children.
Individual scanners can produce specific artefacts, for example the frontal portion
of the brain may appear less well myelinated that the caudal portion. The
radiologists and radiographers using a particular scanner are usually aware of such
idiosyncrasies.
Metal artefact is a particular problem with MR imaging. The function of certain
devices such as dental braces, vagal nerve stimulators, cochlear implants and
cardiac pacemakers can be affected. Smaller objects, such as arterial clips may
move and larger metal implants such as spinal rods can create signal voids
obscuring the normal anatomy. There is also a risk that metal objects can heat up
in the radio frequency coil and cause local tissue damage.

Sensitivity and Specificity

Functional imaging techniques seek to identify areas of hypo and hyper
metabolism or perfusion and thereby identify possible foci of activity/ ischaemia
within the brain. Interpretation requires knowledge of the accuracy/limitations of
each technique.

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3. Choosing an Imaging Modality

Activity 3:
***
In the box below, list all the different neuroimaging techniques you have
encountered in your training.

CT scan
MRi with blood vessel sequence, T 1,T2,functional
Transfontanelar echography
PET CT
Scintigraphy
Cerebral doppler

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Commentary 3:
You may have included:
Cerebral ultrasonography and Doppler studies
CT scan
MR with angiography/venography, diffusion weighted, functional and perfusion
imaging

Or more specialist imaging techniques such as:

MR spectroscopy
PET
SPECT
Cerebral angiography

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Activity 4:
***
Go and visit your radiologist or specialist radiographer. Ask them to simply
explain how the following images are created. Then fill in the table below.

Imaging Technique Mode of Image Acquisition

USS
It uses a small probe called a transducer and gel
placed directly on the skin. High-frequency sound
waves travel from the probe through the gel into the
body. The probe collects the sounds that bounce
back. A computer uses those sound waves to create
an image.

Computerised
Tomography CT, refers to a computerized x-ray imaging
procedure in which a narrow beam of x-rays is
aimed at a patient and quickly rotated around the
body, producing signals that are processed by the
machine's computer to generate cross-sectional
images—or “slices”—of the body.

Magnetic Resonance
Imaging An MRI or magnetic resonance imaging is a
radiology techinque scan that uses magnetism, radio
waves, and a computer to produce images of body
structures. ... The magnet creates a strong magnetic
field that aligns the protons of hydrogen atoms,
which are then exposed to a beam of radio waves.

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Commentary 4:
Your table might look something like this:

Imaging Technique Mode of Image Acquisition

An ultrasonic beam is passed through a tissue. The

sound waves or echoes are reflected back from the
USS
tissue. The intensity of the reflections is dependent
on the density of the tissue, its ability to absorb
ultrasonic waves and its distance from the probe.

A multidirectional beam of X rays is directed through

a tissue. As it emerges the beam is blunted or
Computerised
‘attenuated’ according to the density of the
tomography
particular tissue. X ray detectors positioned around
the circumference of the scanner collect attenuation
readings. A computerised algorithm reconstructs a
cross- sectional image for a particular slice
thickness.

Protons placed in a magnetic field become capable

of receiving and then transmitting electromagnetic
Magnetic Resonance
energy. The strength of the transmitted energy is
Imaging
proportional to the number of protons (essentially H
molecules) in the tissue. The signal strength is
modified by each proton’s microenvironment, such
as its mobility and the local homogeneity of the
magnetic field. MR signal can be weighted to
accentuate some properties and not others. When
an additional magnetic field is superimposed and
the gradient is carefully varied at different points in
space, each point in space has a unique radio
frequency at which the signal is received and
transmitted. This makes it possible to construct an
image that represents the spatial encoding of
frequency ie the precise frequency of signal
transmission at each particular point or pixel.

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4. Additional Techniques to Supplement Conventional Neuroimaging

Basic imaging techniques can be modified to acquire additional information and
improve the clinical usefulness.

Activity 5:
***
Complete the table below.

Imaging Modality Additional Techniques Clinical Usefulness Clinical Scenario

Ultrasound Doppler flow studies Measure vascular Prognosis of HIE

resistance / blood flow
3D bony reconstruction To see exactly the depressed skull fracture
CT position of the bones

Perfusion Weighted To see blood vessel Blood vessel

MR Imaging anatomy malformation

Ischaemic penumbra

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Commentary 5:
Your table could look something like this.

Imaging Modality Additional Techniques Clinical Usefulness Clinical Scenario

Ultrasound Doppler flow studies Measure vascular Prognosis of HIE

resistance / blood flow

CT Contrast injection Highlights vascular Identify vascular

structures and highly malformations
3D bony reconstruction vascular tissues
Craniosynostosis repair
To define bony anatomy
for reconstructive surgery

MR Many different sequences Suppresses water and Demyelinating disease or

can enhance/suppress enhances white matter leukodystrophy
different tissues abnormalities
Early identification of
FLAIR Identification of fibre infarction – within hours
(fluid attenuated pathways and areas of of the event, before
inversion recovery) ischaemia changes seen on
conventional imaging
Diffusion Weighted Qualitative and
imaging, looks at quantitative assessment Identification of
restriction of water of cerebral perfusion ischaemic penumbra in
movement infarctions – areas that
Define vascular anatomy might recover following
Perfusion Weighted initial insult
Imaging
May show large vessel
occlusion in stroke

MRA and MRV

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5. Specialist Neuroimaging Techniques

These techniques should only be performed in specialist centres with appropriate
expertise in their application and interpretation. Functional imaging techniques
are used to supplement structural neuroimaging in the localisation or
classification of an abnormality. Each investigation has its own specificity and
sensitivity, and interpretation of the significance of a functional investigation rests
on this. In particular, the topographical extent of the lesion on functional imaging
may exceed the actual pathological lesion. It is important, however, to have some
appreciation of the nature of these techniques and of their potential applications.

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Activity 6:
*** Match the following imaging techniques with the statements below:

This technique uses the injection of

The biologically significant molecules positron (positively charged electrons)
that can be studied are N-Acetyl- emitting tracers which are joined to
Aspartate (NAA) present in neurones biologically active chemicals (ligands) to
but not glia, Creatine (Cr) and Choline study brain metabolism, blood flow or
(Cho) present in oligodendrocytes and receptor density.
astrocytes and lactate.

1H (proton) The nuclear magnetic

A molecular imaging resonance spectra of small
spectra are most technique using radio labelled
commonly freely mobile molecules
molecules to image molecular can be evaluated.
obtained. interactions of biological
processes in vivo.

SPECT PET MT Spectroscopy Cerebral

Angiography

18 –fluorodeoxyglucose
or FDG is the ligand This study is usually
most frequently used Contrast is injected to done under GA in
and is distributed in outline blood vessels children
proportion to regional
cerebral metabolism of
glucose.
99cT a single Measurement of pH and phospho-
This is an invasive technique, the femoral photon-emitting monoesters can provide
artery is cannulated and a catheter passed isotope is injected information about the energy
up into the carotid and vertebral arteries. into the patient and expenditure/consumption in a
follows regional region of interest.
blood flow.
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Commentary 6:

The investigations, techniques for acquisition and some indications are shown
below.

PET and SPECT Molecular imaging techniques using radio labelled

molecules to image molecular interactions of biological
processes in vivo.

SPECT 99cT a single photon-emitting isotope is injected into the

patient and follows regional blood flow. SPECT cameras
then measure the regional distribution of radioactivity
within the brain and can identify areas of increased
cerebral blood flow. Seizures are associated with
dramatic increases in cerebral blood flow; thus
comparing Interictal with Ictal SPECT can compliment
structural neuroimaging in the localisation of seizure
activity.

PET The injection of positron (positively charged electrons)

emitting tracers which are joined to biologically active
chemicals (ligands) can be used to study brain
metabolism, blood flow or receptor density. 18 –
fluorodeoxyglucose or FDG is the ligand most frequently
used and is distributed in proportion to regional cerebral
metabolism of glucose. Areas of sclerosis as in mesial
temporal lobe epilepsy show hypometabolism.

MRSpectroscopy The nuclear magnetic resonance spectra of small freely

mobile molecules can be evaluated. 1H (proton) spectra
are most commonly obtained. The biologically
significant molecules that can be studied are N-Acetyl-
Aspartate (NAA) present in neurones but not glia,
Creatine (Cr) and Choline (Cho) present in
oligodendrocytes and astrocytes and lactate. Changes in
the ratio of NAA/Cr +Cho can indicate neuronal loss +/-

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gliosis. Phosphorus MRS with measurement of pH and

phospho-monoesters can provide information about the
energy expenditure/consumption in a region of interest.
Characteristic MRS patterns are reported in certain types
of leukodystrophy and MRS may have a role in seizure
localisation

Cerebral angiography This is an invasive technique, usually done under GA in

children. The femoral artery is cannulated and a
catheter passed up into the carotid and vertebral
arteries. Contrast is then injected to outline the vessels.
It is particularly useful to outline vascular malformations
and is increasingly used in the investigation of childhood
stroke (see module x).

Activity 6a:
*
Understanding the principles underlying different imaging techniques

A comprehensive study of all the various neuroimaging techniques is clearly

beyond the scope of this introductory module. You will learn more about the
application of these techniques in paediatric neurology in later units. However, if
you would like to learn more about the techniques and methods involved in
different neuroimaging techniques, read the 1 st chapter of Pediatric Neuroimaging
by James Barkovich. You may also find the websites listed below helpful.

A. James Barkovich and Charles Raybaud

Pediatric Neuroimaging, 5th edition
Lippincott, Williams and Wilkins, 2011

1. www.shu.ac.uk/schools/sci/chem/tutorials/molspec/nmr1.htm

2. www.ch.ic.ac.uk/local/organic/nmr.html

3. http://www.mritutor.org/mritutor/index.html

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6. Choosing an Investigation
Given the number of available neuroimaging techniques, it is important to
appreciate which techniques might be appropriate in a given clinical situation.

Activity 7:
***
Think about the neuroimaging investigations you have requested over the last
week. What factors did you take into account when you decided that the
particular investigation you requested was the most appropriate one for a
particular child? For example, a preterm infant who has collapsed may be too
unwell to move from the neonatal intensive care unit and a cranial ultrasound
scan can be done at the bedside.
List 2 considerations that may determine your choice of investigation.

I suspected that a child may have a malformation caused by abnormal

neuronal migration, so we decided to request a 3 Tesla MRI because it is
1.
better at detecting and characterizing structural brain abnormalities.

I had a patient with a sudden intense headache so I decided to request an

MRI with angiography with contrast because I wanted to see if there is any
2.
abnormality concerning the blood vessels, malformation, tumor etc.

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Commentary 7:
Considerations:

1. You need to consider what particular abnormality you are looking to confirm or
exclude. Are you worried about an acute bleed – a space occupying lesion – or
confirmation that a child with a ventriculo-peritoneal shunt in situ is not
developing ventricular dilatation? Which imaging technique will identify the
structures and pathology you are concerned about?

2. You need to identify the CNS region that you want to illustrate on neuroimaging.
Are you interested in the spinal cord - posterior fossa - extra-axial space? Will the
imaging technique you have selected demonstrate this region adequately?

3. You need to determine the urgency with which you need to perform
neuroimaging? A child with a head injury following an RTA – a child with focal
seizures - an infant with a history of global developmental delay? In certain
situations it may be worth compromising on imaging quality in order to exclude
pathology that might require urgent neurosurgical intervention – for example, it is
important to identify a compressing extradural haematoma as soon as possible.

At this point, having determined the optimum neuroimaging technique for your
patient, other factors may need to be considered. The relationship between
these factors is illustrated in the diagram below.

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Availability

Equipment Waiting Time

? on site facility ?6 months for routine
appointment

Staff
? radiologist
? anaesthetist

Cost
Safety
Movement Artifact
Sedation/GA

Technique Patient
Radiation ? fit for transfer
Anaphylaxis ? safe to sedate

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Therefore, selecting the appropriate imaging modality is not always

straightforward and the relevant factors must be considered in each particular
situation:
1. Child factors
2. Hospital / local factors
3. Imaging strengths and limitations
For example, it may be that a CT scan is the initial investigation to quickly exclude
neurosurgical complications in a given situation, but that an MR is required 3 days
later to confirm or establish the diagnosis.

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6.1 Advantages and Disadvantages of Specific Neuroimaging Techniques

Activity 8:
***
Having considered the factors involved in selecting the appropriate imaging
modality, complete this table outlining the advantages and disadvantages of the
different imaging techniques.

Advantages Disadvantages

fast
Cranial safe Limited view
Ultrasound You can do it without moving the quality may vary
the patient.
Doppler

quite accessible Radiation

Cheaper than an MRI Poor images sometimes
CT Scan Great to see the bones Not great for soft tissue
it offers ok images that can artefacts
guide you

Great for soft tissues Expensive

No radiation harder to access
It can not be used if there are
MRI metallic materials in the body

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Commentary 8:
Your table may look something like this.

Advantages Disadvantages

Cranial Portable Poor grey/white differentiation

Ultrasound Safe
Measurements Limited view dependent on
fontanelle
Quantitative
Poor view posterior fossa
Doppler flow studies Operator dependent

Reasonable anatomical Limited grey/white

CT scan differentiation differentiation

Blood/Ca easily identified Posterior fossa/ brainstem/

Relatively quick temporal lobes obscured by bony
artefact
Movement only limits 1 slice
Generally available Radiation

Bony imaging Contrast allergy

3D reconstruction
May need sedation/GA

Excellent anatomical detail Availability

Altering orientation/ Small movement affects whole

sequences improves tissue sequence, not 1 slice
enhancement and
MRI identification Need GA/sedation as long
acquisition time and noisy
No bony interference
Metal artifact
No radiation Contraindicated with pacemakers

Aging haemorrhage with Need compatible monitoring and

altered ferromagnetic anaesthetic equipment
properties of organizing
blood/haematoma Can miss acute bleed and
calcification

Cannot identify bony

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Abnormalities

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7. Interpreting Neuroimaging Studies

As clinicians, we often rely on reports from our colleagues in radiology when
interpreting neuroimaging studies in children.

Activity 9:
***
List three factors that might affect the accuracy of neuroradiology reports:

Radiologist's knowledge, especially regarding pediatric patients and the

appearance of the brain as it matures.
1.

2. Enough quantity of information that the radiologist has received from the
clinician to guide the investigation and attention that he gives to certain
details.

Ability to perform certain protocols ideal for investigating certain

pathologies.
3.

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Commentary 9:
Important factors are:

1. The experience of the radiologist. In particular, an appreciation of the

normal appearances of a developing brain and the likely pathologies in
different age groups. For example, CT scans in newborn infants show areas
of low attenuation in the white matter. This represents the normal
appearance of unmyelinated white matter in a brain with a high water
content and not infarction.
2. The amount of clinical information that the radiologist has been given. If
the radiologist is not informed of the clinical findings in a child and the likely
diagnosis, an inadequate study may be performed. For example, if the
clinical concern is a possible Chiari malformation causing hydrocephalus,
but only ‘increasing head circumference’ is written on the request card, it is
possible that the foramen magnum and its contents might not be
visualised.
3. The study protocol. The correct protocol must be undertaken to ensure
that a particular pathology can be excluded or confirmed. For example, a
child with pneumococcal meningitis who has a persistently raised
temperature despite antibiotics must have a contrast study to exclude a
subdural empyema which can be missed on standard CT.
4. Knowledge of typical artefacts. Movement artefact is a particular problem
in paediatrics, particularly on MR. However each modality has its own
particular artefact, for example bone causing linear artefact in posterior
fossa on CT, metal causing signal voids on MR. In addition, specific scanners
can produce specific artefacts, which can mimic significant pathology.

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8. Selecting an Appropriate Imaging Modality in a Particular Clinical Situation

Activity 10:
***
Consider the following clinical scenarios and complete the table on the following
page.

Firstly, determine the pertinent clinical question/s in each case. This should be
based around the key management decisions that need to be made. Then select
an appropriate investigation from the list of neuroimaging techniques you
produced in Activity 3.

Case A has been completed as an illustration.

Case A 5-week-old baby born at 27 weeks gestation and known to have

bilateral IVH, has an increasing head circumference.

Case B Term infant with poor apgars starts fitting on day 3.

Case C 3-month-old infant comes in pale with poor respiratory effort and
reduced conscious level.

Case D 4-year-old with a VP shunt in situ, admitted with headache and

vomiting.

Case E Sequence of investigations in a 7-year-old boy with sudden onset of

left sided weakness.

Case F 10-year-old with difficulty walking and urinary retention of sudden

onset.

Case G 8-year-old with 2-month history of frontal headache worse in the

mornings.

Case H Sequence of investigations in a 9-year-old boy with complex partial

seizures.

Case I 15-month-old baby with global developmental delay of unknown

cause.

Case J 7-month-old baby with infantile spasms.

Case K 10-year-old who fell out of a tree and has a GCS of 6.

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Case Pertinent Question Imaging Reason

Modality

? infant developing CUSS Lateral ventricles well visualized

A ventricular dilatation Portable, safe, baseline
Measurement of ventricular index

MRI To confirm the diagnostic

B HIEP?

Head trauma - haemorrhage CT with It is fast, largely available

C /tumor/infection? contrast To see if a haemorrhage exist or another
space occupying lesion

CT To see the ventricles and the shunt position

D Intracranial hypertension Shunt series
due to shunt obstruction X-rays

CT with To see the bleeding/ stroke/ demyelinating

E Ruptured AVM or contrast lesions
anevrism/stroke/MS/ADEM? MRA

MR with Differential diagnosis

F Spinal cord contrast
compression/lesion (tumor,
abcees, demyelinating
lesions etc)

space occupying lesion? CT with Differential diagnosis

G contrast

underlying lesion MR- Anatomy- malformations?

H Surgery? 3T/functiona If no lesion- functional
l?
PET
Ictal SPECT
Malformation/leukodystroph MR Anatomy - identify lesion/malformations/
I y/HIEP demyelinating lesions

Malformation/leukodystroph MR Anatomy - identify lesion/malformations/

J y/HIEP demyelinating lesions

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CT To see blood, ventricules, herniation, midline

K Bleeding? shift, sulcal compression

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Commentary 10:
Also additional comments on the following pages.

Case Pertinent Question Imaging Reason

modality
?infant developing CUSS Lateral ventricles well visualized
A ventricular dilatation Portable, safe, baseline
Measurement of ventricular index
? hypoxic ischaemic MR at 10-14 days Confirm diagnosis
B encephalopathy Look for prognostic features
? prognosis
? sepsis or acquired CT +contrast Confirm/exclude SDH, space occupying lesion,
C brain injury, especially raised ICP and parenchymal lesion, safety of LP
SDH
? shunt malfunction CT CT for ventricular size and plain X-rays for
D blockage/infection / Shunt series disconnection along shunt track
disconnection
Probable stroke CT +contrast CT identifies bleed
E ?MR +MRA, MR/MRA/angiography ?vascular
?cause ?risk of
?angiography malformation/vasculitis/disection
recurrence
?cord compression MR + gadolinium differential diagnosis, tumour, myelitis,
F abscess

?space occupying lesion CT +contrast CT will exclude most lesions. May need MR to
G May need MR define lesion, plan treatment
later
?symptomatic of MR Detailed anatomy ie.identify heterotopias,
H underlying lesion which ?PET sclerosis
could be amenable to ?Ictal SPECT Functional imaging if no lesion on MR, but EEG
surgery focus
?functional MR ?significance of certain lesions
?CNS malformation, MR Good structural detail
I leukodystrophy, TS ?MRS Certain leukodystrophies characteristic pattern
on MRS

Similar to I MR MR better structural detail, but if long wait CT

J ?CT can exclude TS, congenital infection etc

intracerebral/extracereb CT Shows fresh blood well, evidence of raised

K ral bleed?
? Raised ICP
? meningoencephalitis
L ? space occupying lesion
pressure; ventricular size, herniation, midline
shift, sulcal compression
MR if available MR better for early evidence of encephalitis,
CT should be done if MR not readily available

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Additional comments:
A. In this case a baseline measurement of ventricular index is useful as it can
be monitored in the future. The most common cause of hydrocephalus in
preterm infants would be post haemorrhagic ventricular dilatation and
intraventricular haemorrhage is easily detectable with ultrasound. A
CT/MR may be necessary at some point if there is doubt as to the
underlying diagnosis and/or to define the precise neuroanatomy if the
infant requires neurosurgical treatment.

B. The appearance of the neonatal brain on MR is quite different to the brain

of older children. It has a higher water content and the white matter is not
fully myelinated.
MR at about 2 weeks has a characteristic appearance in HIE, with altered
signal intensity in basal ganglia, absence of myelination in the posterior
limb of the internal capsule, cortical highlighting, and if severe, altered
signal in sub cortical WM. The degree of abnormality on MR at this stage
correlates with the developmental outcome in the affected infants and can
be a useful prognostic test. The textbook “MR in Neonatal Brain”, by Mary
Rutherford, illustrates the appearance of both ‘normal’ preterm infants and
those with neurological disease.

C. There are many reasons why an infant may collapse but it is important to
diagnose and treat sepsis and identify acquired brain injury. Infants with
SDH following NAI often present with non-specific symptoms and this
diagnosis must be considered and excluded/confirmed as soon as possible.
A CT scan with contrast will demonstrate evidence of SD collection and
other space occupying lesions. In addition assessment of the sulci, basal
cisterns, ventricles and grey/white differentiation can identify raised ICP,
herniation and cerebral oedema. A normal CT does not guarantee that an
LP can be safely performed in a neurologically unstable infant. If in doubt –
treat and wait.
Fresh blood can be easily missed on MR as it can appear isointense on both
T1 and T2 weighted images. Thus MR imaging is rarely the choice in an
acute presentation, where bleeding needs to be excluded. MR is useful in
the follow up of children with SDH or intracranial bleeding as the
ferromagnetic properties of the various breakdown products of
haemoglobin give characteristic appearances at different stages of
haematoma organization, dependent on the structure in which bleeding
has occurred. In addition MR is more sensitive at identifying parenchymal
injury.

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The other factor affecting emergency use of MR is the fact that child must
lie still for 3-5 minutes per sequence. Administering sedative drugs in a
neurologically compromised child is clearly dangerous and should be
avoided. Thus a GA is almost always required and administering a GA in a
magnetic scanner is a skill that only senior anaesthetists have.

D. VP Shunt dysfunction can occur as a result of a number of different

processes; blockage at either the distal or proximal end, movement,
disconnection and infection. The combination of a plain series of X-rays
along the shunt pathway – skull, neck, chest and abdomen, together with a
CT scan to assess ventricular size is required to exclude a problem.
Interpretation of a single CT in the absence of previous scans can be
difficult, particularly in children with significant background abnormalities.

E. Initially this child has needs a CT scan with contrast to confirm/ exclude a
stroke – haemorrhagic, thrombotic or infarction. Depending on the CT
findings, he will need MR + angiography and probably cerebral angiography.
Diffusion weighted MR can pick up areas of ischaemia earlier than
conventional T2 weighted MR and is useful in the early identification of
ischaemia. MR angiography is good for identifying large vessel disease but
is not sensitive enough to detect small vessel abnormalities – such as
vasculitis and mycotic aneurysms, or to define the anatomy of AV
malformations. It is especially difficult to interpret in the very young child.
Cerebral angiography is therefore still used in the investigation of CV
disease. Spiral CT angiograms can produce good anatomical detail, but
involve a high dose of radiation.

F. This child must have an MR spine with Gadolinium as soon as possible (even
if requires GA and transfer) to exclude cord compression, as early
decompression is vital. A CT myelogram is a much more invasive technique
and would also require a GA.

G. This a common outpatient problem, but if either the history or examination

suggests raised ICP a CT scan with contrast is indicated to exclude a space
occupying lesion. If the CT shows a lesion, an MR will almost certainly be
required to make a diagnosis/plan treatment.

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H. In a child with focal seizures it is important to determine whether or not

these are symptomatic ie related to an underlying brain abnormality. MR is
the investigation of choice. CT does not demonstrate grey/white
differentiation with enough accuracy. Identifying an underlying structural
abnormality may have implications for both prognosis and further
treatment.
If a child fails to respond to medical treatment and MR is normal, may need
to confirm focal seizure disorder with EEG monitoring and identify location
of focus with ictal SPECT (looking at pattern of cerebral blood flow, during a
seizure) and interictal PET (looking at cerebral metabolism,? identify focus
of activity). Functional MR can be used for example to specifically locate
the motor strip etc if electrical focus or structural abnormality appears to
be proximal to the central gyrus

I. An MR is indicated to exclude causes of delay such as CNS malformation,

leukodystrophy, or TS. MR imaging is more likely to identify such
abnormalities in comparison to CT. MRS is useful for diagnosing certain
leukodystrophies which have a characteristic pattern of metabolites on
spectroscopy as in Vanishing WM disease.

J. An MR is ideal for the same reason as in Case I. However, rather than wait
6 months for an appointment, a CT should be done to look for the
calcification of TS, in utero infection etc. NB: MR does not demonstrate
calcification; there is no signal from bone.

K. Is the investigation of choice CT to identify any bleeding or evidence of

raised ICP?

L. Again, MR is more sensitive at detecting early evidence of encephalitis and

parenchymal injury. CT should be done if MR is likely to be delayed, to
exclude raised ICP, cerebral oedema or a space-occupying lesion such as an
abscess. Contrast would be essential in this case.

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7. Summary
In this section you have:
 Identified major anatomical landmarks on cranial MR and CT images.
 Thought about the range of available neuroimaging investigations and their
relative strengths and weaknesses.
 Considered factors that might affect the choice and interpretation of
neuroimaging studies in a given clinical situation.

8. Key Learning Points

 Before requesting a neuroimaging study consider precisely what diagnosis

you are hoping to confirm/exclude – ‘What is the question?’
 Determine which neuroimaging technique will best answer your ‘question’ –
if in doubt ask for advice.
 Communicate well with the radiologists/ radiographers performing and
reporting the scan ie, fill in the request card appropriately.
 You may have to compromise on imaging quality to exclude/confirm
important diagnoses with an impact on treatment/outcome.

9. References
James Barkovich and Charles Raybaud
Pediatric Neuroimaging, 5th edition
Lippincott, Williams and Wilkins, 2011

www.shu.ac.uk/schools/sci/chem/tutorials/molspec/nmr1.htm

www.ch.ic.ac.uk/local/organic/nmr.html

http://www.mritutor.org/mritutor/index.html

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