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Learning Objectives

Recognize Urgent Lesions Understand Acute Traumatic Lesions Describe four types of herniation Triage Acute Vascular Lesions Recognize Diffuse cerebral swelling

Essentials of Neuroradiology
James G. Smirniotopoulos, M.D. Uniformed Services University Bethesda, MD And Armed Forces Institute of Pathology Washington, DC

2 y.o. with dilated pupil

Significant trauma Fracture & concussion (l.o.c.)

Lucid Interval
pt Wakes Up 40% pts.
Delayed neurologic Sx (hrs. Later) Herniation, coma and death
Midline Herniation: Subfalcial and Downward Transtentorial

Trauma -> fracture & concussion Tearing/stripping of both layers of dura away from inner table Laceration of outer periosteal layer of dura Laceration of meningeal vessels Inner (meningeal dura) intact Blood between naked bone and dura NORMAL arterial pressure continues to dissect

Epidural Hematoma


Brain Herniation Syndromes

Brain Herniation Syndromes






Kernohan’s Notch: Cerebral peduncle contralateral to the mass lesion



Four Types of Brain Herniation
Transcalvarial – cerebral cortex Subfalcial – Cingulate Gyrus Transtentorial
Downward – Uncus and Temporal Lobe Upward – Vermis
t f



Foramen Magnum – Tonsils and Medulla

Calvarial Herniation

Subfalcial and Transtentorial

Left to Right Shift … Subfalcial herniation … Downward Transtentorial


Complex Subdural Hematoma SDH: Subfalcial Herniation 1cm pineal shift. 3cm Right-to-Left shift and Subfalcial Herniation Dural Baffles: Falx and Tentorium f C Subfalcial Herniation Cingulate t UM t T T Subfalcial Herniation SDH » Brain Herniation 3 .

Oculomotor nerve (CN3) Posterior Cerebral a. Temporal Herniation Compresses CN3 Compresses PCA PCA Infarct Tentorial Herniation Courtesy Mauricio Castillo. M. UNC PCA Infarct from Herniation Diffuse cerebral swelling Anoxic Damage Loss of Autoregulation “Commotio Cerebri” Secondary herniation Duret Hemorrhage 4 .D.SDH » Brain Herniation Transtentorial Herniation The PCA is compressed between the uncus and midbrain Tentorial hiatus and Midbrain Superior Cerebellar a.

Duret Hemorrhages Downward displaced brainstem Kinks and compresses perforators Hemorrhagic Infarction No sulci.30 y.o. Upon arrival. Suggest Diffusion Weighted MR d. brainstem (midbrain) hyperattenuating lesion. no cisterns. 25 y/o man from a helicopter crash. what would you do next ? a. man after motor cycle crash with facial swelling and facial fractures. and c are ALL suggested 3 Reasons for Getting an MR CT fails to explain Pt’s Condition CT fails to explain Pt’s Condition CT fails to explain Pt’s Condition 5 . Make Diagnosis e. low-attenuation both temporal lobes. patient was intubated and sedated After reviewing this CT. Acute alteration in level of awareness. Suggest Magnetic Susceptibility Image (MSI or SWI) c. Suggest FLAIR MR b. a. b.

Terminology Intermediate Contusions Shearing Injury Diffuse White-matter Injury (DWI) WhiteDiffuse Axonal Injury (DAI) SHEARING INJURIES Deep lesions High Velocity (MVA) Trauma Acceleration/Deceleration Especially CORONAL angular momentum Side Impact (Running a Red Light) Do not require an impact or Fx.Findings Intraventricular hemorrhage Torn Choroid Plexus Shearing Injury Shearing Injury Shearing Injury Corpus Callosum MSI T2W SWI Deep Lesions . “SHEARING OF AXONS” AXONS” Breaks connections Actual force may be tension “SHEARING” of Small WM VESSELS SHEARING” Small (petechial) hemorrhages 6 .

etc. bundles of axons Axon Retraction Balls – Cytoplasm leaking from transected axons and disrupted axolemma. Radiol. 1998.O. brainstem. compact.DIFFUSE AXONAL INJURY Neurologic Sx Begin at Impact Some have Immediate L. Axon Retraction Balls Diffuse axonal injury (Magnetic Susceptibility) TSE T2 Turbo FLAIR FLASH T2* TE: 15 ms FLASH T2* TE: 35 ms Ref. Eur. axon retraction balls (ARB) Long-Term Survivors: Longmicroglial clusters foci of demyelination Deep Lesions – Coronal Forces Angular momentum in the Coronal Plane: Running a Red Light … T-Bone the cars Corpus Callosum WM – Axonal Transection Dense. Some have Persistent Vegetative State Pathology: foci of hemorrhage in corpus callosum.C. white matter. Parizel PM et al. 8: 960-965 7 .

MSI Thanks to Pam Schaefer Thanks to Pam Schaefer Trauma.Corpus Callosum and BG Unconscious Patient . Intraventricular Blood => MR Blindness 45 y.o.FLAIR Diffuse Axonal Injury .CT Thanks to Pam Schaefer Diffuse Axonal Injury . man with acute onset of homonymous hemianopsia CT SWI 8 .

Non-Contrast CT What we see .Findings Axial CT Abnormal Cortex and WM Where? Medial Occipital Lobe Minimal mass effect Imaging Infarction CT abnormal in hours MR abnormal in minutes Insular ribbon sign Increased water Hyperdense MCA Intraluminal Hyperintense MCA clot Vascular (intravascular) enhancement DWI Bright ADC Dark Intracellular Cytotoxic Edema Early MCA stroke Insular Ribbon Sign Carotid Thrombosis => MCA Clot MCA PCA Infarct ACA X PCA MCA Lights up like a lightbulb on MRI DWI 9 .

two hours after admission DWI Restricted Diffusion – or T2 ShineThru? ADC Map Cytotoxic Edema Normal Na+ pump K goes In Na goes Out Neuronal Swelling Normal Neuron K+ Energy Dependent Glucose O2 ATP Swollen Dead Neuron 10 .jpg Post. Infarct This 53 yo man presented to the Emergency Department reporting a several hour history of left-sided hemi-body weakness Repeat CT: Hyperdense MCA Matching DWI and ADC Images = Cytotoxic Edema = Acute Infarct Repeat CT scans. Cerebral A.medpix20366.

UVA 11 .Restricted Diffusion Chronic Infarct Atrophy Complications of rTPA Whole MCA Infarction Two days after IA Thrombolysis Acute Motor Hemiplegia INTRA-CEREBRAL HEMORRHAGE Dense and Homogeneous Round/oval shape Basal ganglia/deep white Proportional mass effect Extension into ventricle BP on presentation 185/105 Courtesy Doug Phillips.

UVA 12 .Hypertensive Hemorrhage BP on presentation 210/110 Courtesy Doug Phillips. UVA Hypertensive Hemorrhage “Found Down” 68 year old man with confusion and acute hemiplegia. UVA Glioblastoma multiforme. presenting w/ acute mental status changes. Hypertensive “hit list” Basal Ganglia Internal/External Capsule Thalamus Dentate Nucleus Pons Lobar Courtesy Doug Phillips. WHO 4 “Found Down” 34 yo marine stationed at Guantanamo Bay Cuba. UVA NOTE: Vasogenic Edema Courtesy Doug Phillips. Courtesy Doug Phillips. febrile.

Abnormal Gray Matter Vascular Ischemia Infarction Hyperemia (Migraine.D. UNC 13 . M. Infection – Multiple territories Non-Vascular » HSV Encephalitis ACA MCA MCA ACA ACA MCA AChoA PCA HSV encephalitis Courtesy Mauricio Castillo. Seizures) Abnormal Gray Matter Inflammatory Encephalitis Meningo-Encephalitis Vasculitis Vascular – Follows territory of MCA. etc.

HSV encephalitis HSV encephalitis HSV encephalitis Courtesy Mauricio Castillo. UNC Courtesy Mauricio Castillo. Lateral Lenticular Carbon Monoxide Methanol Intoxication 14 .D. M.D. M. UNC What do they have in Common? Multiple Toxic and/or Metabolic: Bilateral Symmetric •Acquired Anatomic •Congenital Basal ganglia Toxic/Metabolic Metabolic Intrinsic Diabetic Ketoacidosis Hypoglycemic Coma Extrinsic Toxic Exposures CO and Methanol Medial vs.

4-methylperazole) is a synthetic alcohol dehydrogenase inhibitor for IV administration Clear yellow liquid. or methanol poisoning or suspected EG ingestion PRECAUTIONS: Dilute in > 100 mL NS. mp 25º C (77º F) INDICATIONS: Antidote for ethylene glycol. Lateral Lenticular Carbon Monoxide Intoxication CO Intoxication CO binds to Hgb 240X stronger than O2 making carboxyhemoglobin Sx: HA. follow hepatic enzymes & WBC (eos) during Rx. Lethargy. and SOB TX is to displace CO with O2 T1/2 for CO is 320 min on room air 80 min on 100% O2 23 min at 3 atm 100% O2 MetOH Intoxication Tx for MetOH . interaction with ethanol (compete for ADH) DOSE: 15 mg/kg load.CO Poisoning Carbon Monoxide Methanol Intoxication Medial vs. dizziness.Fomepazole Fomepazole (Antizole. 10 mg/kg Q 12 h x 4 doses. confusion. nausea. weakness. mw 82.1. then 15 mg/kg Q 12 h till EG < 20 mg/dL 15 .

34 yo comatose woman. or twice normal.D. Findings Intraaxial Diffuse Bilateral abnormalities Low attenuation in Cortical Gray Matter Low attenuation in Basal Ganglia “Edema” Edema” What Kind? Interstitial Cytotoxic Hydrostatic Courtesy Aimee Hawley. or … Rapid Correction of serum Na+ Reduced Urine Output Exercise Heat Exposure Inappropriate ADH T1W T2W DWI Sodium Loss Inadequate Sodium Intake 16 . M. psychiatric pt. MGAFMC Diagnosis: Cytotoxic Edema Cytotoxic Edema Cerebral ischemia Metabolic Poisons CN Triethyl Tin Hexachlorphene Lab: Serum Na+ 121 Psychogenic polydipsia Overhydration Athletes drinking too much water Iatrogenic D5W w/o salts Hypoglycemia Treatment Hypertonic Saline 2% saline (not 4%) Gray matter > White matter Causes of Hyponatremia Increased total body water Excessive water intake Iatrogenic (IV therapy) Treatment: Correction by administration of IV Saline.

Osmotic Myelinolysis Anoxia During Surgery Diffuse and Bilateral Gray-matter hypointensities Anoxia During Surgery Headache 39 y.o. woman with abrupt onset of the “worst headache of my life” Diffuse and Bilateral Gray-matter hypointensities What we see .Findings Axial CT Abnormal Where? Subarachnoid space Worst HA: Non-Contrast CT How? Hyperdense 17 .

Brudzinski's Demographics: Common Cause of Stroke in Young (< 40) Most pts. CTD (connective tissue) Subarachnoid Hemorrhage LP more sensitive than CT Trauma is most common cause for RBC’S in CSF Not seen as easily or as often on CT SAH on CT Blood clot usually Aneurysm / AVM Uncommon from neoplasm Uncommon from spinal disease Subarachnoid Clots 18 . ADPCKD. 40-60yrs Risk Factors: Hypertension.Aneurysm and Rupture Clinical Hx: "Worst Headache of My Life” Nuchal Rigidity Photophobia Subarachnoid Hemorrhage Signs: Kernig’s.

Angiogram Common sites: ACA <-> ACOMM MCA branches Basilar Tip AP Oblique ICA Aneurysm Pulsation Artifact Phase-encoding direction ICA Aneurysm Summary Brain Herniation Epidural Subdural f C Trauma Ventricular blood Shearing Injury Gray matter Encephalitis Ischemia/Infarction t U M t Toxic/Metabolic Co vs.Aneurysm Round (‘berry’) shape Vessel bifurcation natural weakness exploited by high BP Angiography . Methanol T T 19 .

Thank You! Go Raimh Maith Agat Muito Obrigado Mahalo ! Dank u wel ! EUXAPIΣTΩ ! Merci Beaucoup Danke Schön ! Mil Gracias 20 .