Diagnostic Radiology of Central Nervous System

Raphael B. Jiang, Section of Diagnostic Radiology Sun Yat-Sen University First Affiliated Hospital

Outline

Normal Imaging Anatomy of Brain Basic Features of Brain Lesions Brain Tumor Cerebrovascular Disease Traumatic Brain Injury

Normal Imaging Anatomy of Brain Meninges

Dura mater Falx cerebri Tentorium cerebelli Venous sinuses Arachnoid mater subdural space a potential space btw dura and arachnoid subarachnoid space interval btw arachnoid and pia Pia mater

Normal Imaging Anatomy of Brain Meninges

Tentorium cerebelli Falx cerebri

Normal Imaging Anatomy of Brain Meninges

S. sagittal sinus Arachnoid granulation Dura mater Arachnoid

Falx cerebri

Subarachnoid space Pia mater

Normal Imaging Anatomy of Brain Meninges

Falx and Tentorium Iso-/-mildly hyperdense compared with cortex on CT Hyperdense when calcified Markedly enhanced after iodine contrast

Hypointense in T1WI and T2WI

Homogeneity in signal intensity Markedly enhanced after Gadolinium

Normal Imaging Anatomy of Brain Cerebral Hemisphere

The layer of gray matter covers entire surface of cerebral hem. Its deep layer is white matter and nucleus Gray matter is slightly hyperattenuating than white matter White matter slightly hyperintense than gray matter on T1WI

Gray matter hyperintense than white matter on T2WI

Normal Imaging Anatomy of Brain Cerebral Hemisphere

T1WI

T2WI

Normal Imaging Anatomy of Brain

FL

CS LF PL

SSS

SECTION AT CENTRUM SEMIOVALE Frontal lobe Centrum semiovale Parietal lobe Longitudinal fissure Superior sagittal sinus

Normal Imaging Anatomy of Brain Basal Ganglia

Clusters of neurons, located deep in the brain Caudate nucleus, putamen, globus pallidus, substantia nigra CT and MR finding Basal ganglia and Thalamus gray matter density/intensity Internal and External capsule white matter density/intensity

Normal Imaging Anatomy of Brain

Normal Imaging Anatomy of Brain

IC

CNH PU EC

TH FC

SECTION AT BASAL GANGLION Caudate Nucleus Head Putamen Thalamus Internal Capsule External Capsule Falx Cerebri

Normal Imaging Anatomy of Brain

IC

CNH
PU EC

TH FC

SECTION AT BASAL GANGLION Caudate Nucleus Head Putamen Thalamus Internal Capsule External Capsule Falx Cerebri

Normal Imaging Anatomy of Brain Brain Stem

Mid-brain, pons and medulla oblongata CT appearance Brain stem nuclei not identifiable Surrounded by fluid-density cistern MR finding Brain stem nuclei Mildly hypointense on T1WI, hyperintense on T2WI White matter fibera slightly high intensity signal Mildly hyperintense on T1WI, hypointense on T2WI

Normal Imaging Anatomy of Brain

GR

SF

OC MB

HI AS SCV

OL

SECTION AT OPTICAL CHIASM

Gyrus Rectus Sylvian Fissure Hippocampus Mid-

brain Aqueduct of Sylvius Optical Chiasm Occipital L S. Cerebellar Vermis

Normal Imaging Anatomy of Brain Cerebellum

CT appearance Gray and white matter can be distinguished Cerebellar tonsils and vermis slightly denser than other parts MR finding Signals of cortex, medulla and nuclei similar to those of brain

Normal Imaging Anatomy of Brain

TL TN FV

PO CH OL

SECTION AT FOURTH VENTRICLE Occipital Lobe Cerebellar Hemisphere Pons Temporal Lobe Trigeminal Nerve Fourth Ventricle

Normal Imaging Anatomy of Brain

SECTION AT MID-SAGITTAL PLANE

CC

Mb Po MO

Th AS Ce FV

Corpus callosum Thalamus Aqueduct of Sylvius Fourth Ven. Mid-brain Pons Cerebellum Medulla oblongata

SECTION AT LATERAL & THIRD VEN.

LV IN TL

CC

TV

Lateral Ven. Third Ven. Corpus Callosum Insula Temporal Lobe

Normal Imaging Anatomy of Brain Cerebral Vasculature

Internal Carotid Artery anterior cerebral artery and middle cerebral artery

Basilar Artery
posterior cerebral artery Communicating Artery anterior and posterior communicating arteries Cerebral Vein superior sagittal, transverse, straight, sigmoid sinuses inferior sagittal sinus, Vein of Galen

Normal Imaging Anatomy of Brain

Normal Imaging Anatomy of Brain

ACA
MCA ICA PCA BA

Internal Carotid Artery Anterior CA Middle CA Posterior CA Basilar A. Anterior&Posterior Com. A

Normal Imaging Anatomy of Brain

Normal Imaging Anatomy of Brain

Superior Sagittal Sinus Straight Sinus Confluence of sinuses

Inferior Sagittal Sinus

Sigmoid Sinus

Transverse Sinuse

Normal Imaging Anatomy of Brain

Basic Features of Brain Lesions Hydrocephalus

The term hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning head

As the name implies, it is a condition in which the primary characteristic is excessive accumulation of fluid in the brain
The excessive accumulation of CSF results in an abnormal widening of spaces in the brain called ventricles This widening creates potentially harmful pressure on the tissues of the brain

Normal CSF flow passage Lateral V (Foramina of Monro) Third V (Aqueduct of Sylvius) Fourth V (Median aperture & Luschka Foramina) Subarachnoid Space (Arachnoid Granulations) Superior SS

Basic Features of Brain Lesions Hydrocephalus

Classification Non-communicating Communicating

Basic Features of Brain Lesions Hydrocephalus

Non-communicating Hydrocephalus Obstructive hydrocephalus CSF-flow obstruction ultimately preventing CSF from flowing into subarachnoid space Secondary to congenital, infectious or tumor diseases Dilation of Ventricles above obstruction Ventricles normal below obstruction

Basic Features of Brain Lesions Hydrocephalus

Communicating Hydrocephalus Impaired CSF re-absorption in the absence of any CSF-flow obstruction btw ventricles Secondary to subarachnoid inflammation, craniocerebral injury, intracranial hemorrhage and brain tumors Ventricles and cisterns ubiquitously enlarged

Communicating Hydrocephalus

Basic Features of Brain Lesions Brain Atrophy

Reduction in brain tissue volume Secondary to expansion of the cranial CSF volume Caused by Normal Aging and diseases Diffused brain atrophy and localized brain atrophy

Basic Features of Brain Lesions Necrosis and cystic degeneration

Lack of blood supply or interruption of blood flow Tissue necrosis and liquefaction-cystic degeneration Commonly found in tumor

Basic Features of Brain Lesions Calcification

Physiological Calcification Pineal calcification Age-related basal ganglia calcification Pathological calcification Calcification of craniopharyngioma Calcification of gliomas Calcification of meningioma

CHONDROMA

MENINGIOMA

Basic Features of Brain Lesions Mass effect

Structure departed from normal position due to intracranial lesion Commonly found in tumors, hematoma, infarction, abscess, etc

Basic Features of Brain Lesions Mass effect

Signs of supratentorial space-occupying Displaced or compressed ventricle Narrowing or occlusion of ipsilateral cerebral sulcus and cistern Shift of midline structures Signs of infratentorial space-occupying Deformation and shift of fourth ventricle and brainstem Ventricular dilatation caused by CSF pathway obstruction

Brain Tumor Intra-axial tumor

Primary Glioma 40~50 70Astrocytoma Angioma Medulloblastoma Lymphoma Secondary Metastatic

Brain Tumor Intra-axial tumor

Astrocytoma The most common type of gliomas At any age, most commonly between the ages of 20- 40 Supratentorial predominantly for adult, infratentorial for children Present with seizures or focal neurological deficits, headache and increased intracranial pressure Graded from I to IV based on histological differentiation

Brain Tumor Intra-axial tumor

Astrocytoma Grade 1
Lower density on CT Long T1 and long T2 intensity Slight mass effect Mild surrounding edema Well-demarcated boundary No post-contrast enhancement

Malignant astrocytoma
Heterogeneous density Mixed signal intensity Marked mass effect Severe surrounding edema Ill-demarcated boundary Post-contrast enhancement

Astrocytoma Grade 1

Astrocytoma Grade 2

Astrocytoma Grade 2

Glioblastoma multiforme(Malignant)

Brain Tumor Intra-axial tumor

Brain Metastases Via blood stream route Most commonly from lung cancer Imaging features Multiple nodules Necrosis-frequently seen Solitary nodule-rarely Lower density, hypointense on T1WI, hyperintense on T2WI Massive peri-nodular edema Substantial post-contrast enhancement

60Y/F

Lung Adenocarcinoma

Neoplasm, metastasis, renal cell primary

Brain Tumor Extra-axial tumor

(1)Meningioma The most common tumor outside the brain Originate from arachnoid villi cells The clinical symptomsare closely related to the exact site of the tumor Solid tumors most commonly. Adjacent skull is showed reactive hyperplasia or bone destruction CT appearance Iso-density or slight low-density. Somtimes with calcification MR finding Isointense/slight hypointense on T1WI , slight hyperintense onT2WI High vascularized in or arround tumors Enhancement significant

Brain Tumor Extra-axial tumor

Meningioma The most common extracerebral tumor Originate from arachnoid villi cells Clinical symptoms closely related to site of tumor Most are solid texture Adjacent skull shown reactive hyperplasia or bone destruction

Brain Tumor Extra-axial tumor

Acoustic neurinoma High incidence, lower than that of meningioma Located in the internal auditory canal Combined with hemorrhage and cystic degeneration No calcification, Iso-/ slight hyperdense on CT Iso-/hypointense on T1WI and hyperintense on T2WI Enlarged internal auditory canal Post-contrast enhancement on both CT and MRI

Neoplasm, schwannoma, cerebellopontine angle

Cerebrovascular Disease

Hypertensive intracerebral hemorrhage (HIH) Intracranial aneurysm Brain infarction

Cerebrovascular Disease HIH

Hypertensive intracerebral hemorrhage Location: most frequently striatum and internal capsule Etiology: chronic hypertension

Cerebrovascular Disease HIH

CT appearan A ellipse -shaped high-density mass Surrounding edema Hemorrhage breaking into ventricle Mass effect Cerebral hernia

Cerebrovascular Disease HIH

MR finding Signal intensity of intracerebral hemorrhage changes with the evolution of hemoglobin Super-acute stage (within 6h) Isointense or lower signal on T1WI, Hyperintense on T2WI Acute stage (7h~3d) Isointense or lower signal on T1WI, Hypointense on T2WI Subacute stage (4d~4w) Hyperintense on T1WI, Central isointensity or hypointensity surrounded by hyperintensity on T2WI

14 D later

2 days after first CT

Acute stage intracerebral hemorrhage

16 D later

Cerebrovascular disease
2 Intracranial aneurysm Congenital aneurysm Associated with arterial fibro- muscular dysplasia or absence Often occur in branches of the Circle of Willis , in particular at the arterial bifurcation Acquired aneurysm Traumatic Infection Atherosclerosis Easily mistaken for tumor to surgical resection

Cerebrovascular Disease Intracranial Aneurysm

Intracranial aneurysm Aneurysm rupture Severe headache is the most common symptom Depends on size, morphology and high blood pressure CTsubarachnoid hemorrhage, with intramural calcification Aneurysm Flow void sign on T1WI and T2WI MRA helps to find medium-size aneurysms Small aneurysms are confirmed by DSA

Internal carotid artery aneurysm

Internal carotidsiphon aneurysm

Cerebrovascular Disease Brain Infarction

Brain Infarction Caused by arterial occlusion Signs and symptoms vary with vessel involved and collateral circulation available. Most commonly, sudden hemiplegia, aphasia

Neuronal eosinophilic degen.and nuclear pyknosis 4 h after attack

Nuclear necrosis starts within 15~24h Phagocytic cells emerge within 2~3d Reactive astrocytosis and capillary hyperplasia 1w after onset

Cerebrovascular Disease Brain Infarction

CT appearance
The gray and white matter junctions vanish within 3h. No positive-findings within 24h

Direct-Signs:low-density Indirect signs: gyri swelling, sulci disappearing, ventricular compression Hemorrhage occurs due to reperfusion injury in infarction

Cerebrovascular Disease Brain Infarction

MR finding Long T1 and long T2 signal intensity Diffusion Weighted Imaging (DWI) can identify cerebral infarction within 1 hour after onset Acute stage: Enhancement of vessel Subacute stage: Typical enhancement of gyri Perfusion MRI can display the ischemic core and penumbra MRA can demonstrate the corresponding arterial disorders

Traumatic Brain Injury

Epidural hematoma Subdural hematoma Acute contusion and laceration

Traumatic Brain Injury Epidural Hematoma Epidural Hematoma Caused by rupture of blood vessels and dural artery Accumulation of blood in space btw inner plate and dura mater Temporo-parietal lobe the most commonly involved Not cross suture lines, mostly unilateral Dura mater adheres skull so firmly that hematoma is confined and shuttle-shaped Acompanied with fracture, but no intraparenchymal injury

Traumatic Brain Injury Epidural Hematoma

CT appearance
Confined shuttle-shaped or biconvex-shaped high density beneath the inner plate Adjacent skull fracture, cerebral edema, midline deviation

Traumatic Brain Injury Epidural Hematoma MR finding Morphological alteration similar to CT Signal intensity depends on changes of hemoglobin over time Acute stage(~3D): Isointense on T1WI, Hypointense on T2WI Subacute stage(4D~3W): Hyperintense on T1WI and T2WI Chronic stage(3W~): Hyperintense on T1WI and T2WI

Acute epidural hematoma, fusiform high density beneath Frontoparietal bone plate (white arrow) , liquid-plane (black arrow) Fracture in bone window ( white arrow)

MRI Acute stage epidural hematoma

Traumatic Brain Injury Subdural Hematoma

Subdural Hematoma Caused by rupture of cortical A and V or bridging veins Accumulation of blood in space btw dura and arachnoid Typically, hematoma crescent-shaped Staging of subdural hematoma similar to that of epidural Hem.
Acute stage Subacute stage Chronic stage Low-density

High-density High-/Isodensity

Traumatic Brain Injury Subdural Hematoma

CT appearance Acute stage Crescent-shaped high density beneath inner skull plate Accompanied with cerebral contusion, subarachnoid hemorrhage, significant mass effect Subacute stage Crescent-shaped high density or isodensity Inward shift of the gray and white matter junctions on the affected side, sulci disappear, ventricle deformation Chronic stage Crescent-shaped low density

Acute stage subdural hematoma banded high density beneath the skull plate in left frontoparietal (black arrow)

Traumatic Brain Injury Subdural Hematoma

MR finding Staged signal intensity stage

Acute stage Subacute stage
T1WI T2WI

Isointense /Hyperintense Hyperintense

Hypointense Hyperintense

Chronic stage

Hyperintense

Hyperintense surrounded by hypointense ring

MRI Subacute stage subdural hematoma, cortical vein is stripped from the skull

Traumatic Brain Injury Subdural Hematoma CT vs MRI

Acute stage CT High desity CT Iso-density CT Low density Like CSF MRI Isointense MRI Hyperintense MRI Hyperintense CT Advantage MRI Advantage MRI Advantage

Subacute stage

Chronic stage

Subacute stage subdural hematoma CT :compression displacement of the right occipito-temporal sulcus

MRI : hyperintense
FLAIR :subarachnoid hemorrhage MRI is superior to CT in display iso-density hematoma

1 M later

Subdural hematoma (isodense to brain)1

17 D later

Traumatic Brain Injury Contusion and Laceration

3 Acute contusion and laceration of brain

Damage occurs at (and sometimes opposite) the point of

impactthe contact part of the gyri with the skull

Traumatic Brain Injury Contusion and Laceration

Acute contusion and laceration of brain Pathology: regional cerebral edema, necrosis, liquefying, bleeding foci Clinical symptoms: headache, nausea, vomiting, disturbance of consciousness

Traumatic Brain Injury Contusion and Laceration

CT appearance Low density edema with multiple scattered microhemorrhages mass effect, subarachnoid hemorrhage, subdural hematoma Mild cerebral contusion can be absorbed

Acute cerebral contusion, there are low-density edema with flake high-density shadow(Asterisk), accompanied with subarachnoid
hemorrhage in the suprasellar pool, sylvian cistern and around the right falx cerebri(black arrow). The gas in the suprasellar pool indicates basal skull fractures(black arrowhead).

Traumatic Brain Injury Contusion and Laceration

MR finding
Acute and subacute cerebral contusion and laceration

multiple areas of mixed signal

Chronic cerebral contusion and laceration

edema and mass effect reduced, malacia, brain atrophy

IR/T2WI Oxyhaemoglobin in Hematoma Isointense Edema with mass effect

Acute cerebral contusion Intracerebral hemorrhage and subarachnoid hemorrhage MRI is superior to CT in showing subarachnoid hemorrhage

questions
Headache 4 months
No traumatic history

Acute onset of headache Hypertension for 10 years

15 D later

Acute onset of left hand numbness CT 1

MRI 2

Subacute hemorrhage