NEUROSURGERY

Day 3: Neuroradiology • In neurosurgery, CT of the head is used for preoperative and

EMMANUEL E. ALBANO JR MD. postoperative evaluation for hemorrhage, infarction, hydrocephalus,
mass effect, and fracture and for postsurgical assessment.
OBJECTIVES • CT is the study of choice in evaluating for acute hemorrhage because it
• TO DISCUSS THE BASIC OF CT SCAN READING has higher sensitivity and specificity for this indication than MRI does.
• TO DISCUSS THE BASIC MRI READING
ORIENTATION
• TO INTRODUCE ANGIOGRAPHY
• TO DISCUSS THE UTILITY OF XRAY IN NEUROSURGERY

Fundamental principle behind Radiography

“X-rays are absorbed to different degrees by different tissues”
• Dense tissues such as bone absorb the most x-rays, and hence allow
the fewest passing through the body part being studied to reach the
film or detector opposite.
• Tissues with low density (e.g., air and fat) absorb almost none of the x-
rays, allowing most to pass through to the film or detector opposite.

ATTENUATION COEFFICIENT
• Ability to block x-rays as they pass through a substance is known as
attenuation.
• For a given body tissue, the amount of attenuation is relatively constant
and is known as that tissue’s attenuation coefficient.

HOUNSFIELD UNIT

Figure 69-2. Head CT-Normal Anatomy: A, Posterior fossa; B, low cerebellum

Table 13.1 Hounsfield units for a sample CT scanner

Definitions Hounsfield units Comment
No attenuation (air) -1000 Definition
Water 0 Definition
Dense bone +1000 Definition
Cranial CT
Brain (grey matter) 30 to 40
Brain (white matter) 20 to 35 Figure 69-3. Head CT-Normal Anatomy: A, High pons; B, cerebral peduncles
Cerebral edema 10 to 14
CSF +5
Bone +600
Blood clota 75 to 80 Acute SDH or EDH, fresh
SAH
Fat -35 to -40
Calcium 100 to 300
Enhanced vessels 90-100
Spine CT
Disc material 55-70 Disc density ≈ 2 x thecal
Thecal sac 20-30 sac Figure 69-4. Head CT-Normal Anatomy: A, High midbrain level; B, basal ganglia region

COMPUTED TOMOGRAPHY SCAN (CT SCAN)

• most often the first study of choice in evaluation of a patient with
suspected acute intracranial disease because of its ready availability,
ease of use, short acquisition time, and high sensitivity for detection of
acute hemorrhage and fractures.
• It can provide a wealth of information about the brain, including
ventricular size, presence of brain edema, mass effect, presence and
location of hemorrhage or masses, midline shift, evolving ischemic
injuries, fractures, benign and malignant osseous disease, and
evaluation of the paranasal sinuses. Figure 69-5. Head CT-Normal Anatomy: A, lateral ventricles; B, upper cortex

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BLOOD INTRAPARENCHYMAL HEMORRHAGE
• Acute hemorrhage will appear hyperdense (bright white) on cranial CT
images.
o attributed to the fact that the globin molecule is relatively dense,
and hence effectively absorbs x-ray beams.
o Acute blood is typically in the range of 50 to 100 HU.
• On the CT scan, blood will become
o isodense with the brain at 1 to 2 weeks
o hypodense with the brain at approximately 2 to 3 weeks
Notes: As the blood becomes older and the globin molecule breaks down, it will lose this
hyperdense appearance, beginning at the periphery and working in centrally
INTRAVENTRICULAR HEMORRHAGE
EPIDURAL HEMATOMA
• most frequently
appears as a lens-
shaped (biconvex)
collection of blood
• Does not cross a
suture line, as the
dura is tacked down
• arise primarily
(85%) from arterial
laceration due to a
direct blow
• the middle meningeal artery the most common source.

SUBARACHNOID HEMORRHAGE

SUBDURAL HEMATOMA
• Crescent-shaped collection of
blood, usually over the cerebral
convexity
• cross suture lines, CISTERNS
• can be either an acute lesion or • Circummesencephalic (Ambient)—Hypodense CSF ring around the
a chronic one midbrain; most sensitive marker for increased intracranial pressure; will
become effaced first
with increased
pressure and
herniation
syndromes.
• Suprasellar—Star-
shaped hypodense
space above the sella
and pituitary; location
of the circle of Willis,
hence an excellent
location for
identifying
aneurysmal
subarachnoid
hemorrhage.
• Quadrigeminal—W-shaped cistern at the top of the midbrain; can be a
location for identifying traumatic subarachnoid hemorrhage, as well as

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an early marker of increased intracranial pressure and rostrocaudal
herniation
• Sylvian—Bilateral CSF space located between the temporal and frontal
lobes of the brain; another good location to identify subarachnoid
hemorrhage, whether caused by trauma or aneurysm leak (particularly
distal middle cerebral artery aneurysms).
Notes: The ventricles of the brain are a communicating network of cavities filled with
cerebrospinal fluid (CSF) and located within the brain parenchyma.
The ventricular system is composed of 2 lateral ventricles, the third ventricle, the
cerebral aqueduct, and the fourth ventricle
These structures are responsible for the production, transport and removal of
cerebrospinal fluid, which bathes the central nervous system.

• Evan’s ratio
A. Suprasellar cistern B. Sylvian o Ratio of frontal horn to maximal biparietal diameter (BPD)
Cistern measured on the same CT
o >0.3 suggest hydrocephalus

A. Quadrigeminal cistern B. compressed

FRACTURES
• LINEAR SKULL FRACTURES
TUMORS • DEPRESSED SKULL FRACTURES
• DIASTATIC SKULL FRACTURES
• BASILAR SKULL FRACTURES

LINEAR SKULL FRACTURE

DEPRESSED SKULL FRACTURES

INFARCT

VENTRICLES

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BASILAR SKULL FRACTURES

Notes: Diffusion weighted imaging: early detection of ischemia (stroke) and

Telltale sign differentiating active MS plaques from old ones. DWI is sensitive to random Brownian
motion of water molecules
• Battle Sign?
• Raccoon’s Eye?
• Rhinorhea? ANGIOGRAPHY
Angiography/Arteriography
• Otorrhea?
• a medical imaging technique used to visualize the inside, or lumen, of
MAGNETIC RESONANCE IMAGING blood vessels and organs of the body, with particular interest in
the arteries, veins, and the heart chambers
• a non-invasive imaging technology that produces three dimensional
detailed anatomical images. • traditionally done by
injecting a radio-
• particularly well suited to image the non-bony parts or soft tissues of
opaque contrast
the body
agent into the blood
• the brain, spinal cord and nerves, as well as muscles, ligaments, and
vessel and imaging
tendons are seen much more clearly with MRI than with regular x-rays
using x-ray-based
and CT
techniques such
as fluoroscopy
MAGNETIC RESONANCE IMAGING (Pulse images)
• CT ANGIOGRAPHY
• T1 weighted imaging (T1WI)
• MR ANGIOGRAPHY
• T1 weighted imaging with gadolinium contrast
• CEREBRAL CATHETER
• T2 weighted imaging (T2WI)
ANGIOGRAPHY
• Fluid Attenuated Inversion Recovery (FLAIR)
Diffusion Weighted Imaging with ADC

Notes: T1 weighted: somewhat resemble CT scan: CSF is black, subcutaneous fat is white
T2 weighted: CSF is white; most pathology shows up as high signal, inc surrounding
edema RELEVANCE

Notes: FLAIR – resembles T2except that the CSF is nulled out (appears dark); grey/white
intensity pattern is reversed from T1WI and is more prominent
most abnormalities including MS plaques, white matter lesions, tumors,
edema, encephalomalacia, gliosis and acute infarcts appear bright

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SPINE RADIOLOGY

Notes: (MRI)T2 WEIGHTED IMAGING-sagittal view

(CT SCAN) bone window sagittal view
Xray lateral view

X-ray
• Most appropriate screening technique if fracture or other bone
pathology is suspected

MRI
• provides for the best evaluation of soft tissue pathology and, in
essence, provides the only direct evaluation of the spinal cord
• can be also used to accurately identify fractures or the presence of
other pathologies when initial radiographs do not allow for adequate
interpretation
• indicated when a neurologic deficit is present or when there is clinical
suspicion of a vascular abnormality following trauma.
Notes: All 7 cervical vertebrae visualized
C7-T1 junction noted

CT scan
Contraindication to MRI:
• shows detailed images of any part of the body, including the bones,
• Hemodynamic monitoring and temporary pacing devices
muscles, fat, and organs
o E.g. Swan-Ganz catheter
• Hemodynamic support devices
• Cardiac pacemaker
• Implanted cardioverter-defibrillator (ICD)
• Retained transvenous pacemaker and defibrillator leads
• Electronic implant or device, eg, insulin pump or other infusion pump
• Permanent contraceptive devices, diaphragm, or pessary
• Cochlear, otologic, or other ear implant
• Neurostimulation system
• Shunt (spinal or intraventricular)

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