【Brain Imaging, Crash Course】

Brain Imaging, Crash Course

introduction

case

This is 73-year-old previously healthy woman With weeks of memory difficulties, 10 days of increasing lethargy, 3 days of urinary incontinence, and now mild left sided weakness and rigidity Head CT was already conveniently done for you by the emergency department team.

approach to reading imaging

landmark-head CT

• Head CT without contrast is the most common imaging modality that we get.
• Contrast can be added to look for breakdown of blood brain barrier, for example with neoplastic or infectious lesions, but that’s better seen on MRI.
• CT can be used to obtain vascular imaging, by rapidly tracking a bolus of contrast into the brain. This is called a CT angiogram.
• And finally, CT-based perfusion can be used to estimate brain blood flow.
  the only sequence we will focus on is the plain old non-contrast head CT.
  

this slice is taken though the upper frontal and parietal lobes, How do I know that? A better method is to locate the central sulcus, It makes a curve that looks like the Greek letter “omega”. Anything anterior to that sulcus is the frontal lobe, and posterior is the parietal lobe. the “omega” looking bump in the pre-central gyrus is also called the “hand knob.” This is where the motor control of the hand resides.

we should probably quickly introduce the T1 sequence of the MRI. T1 is the called the “anatomical” sequence, because it shows white matter as white, and grey matter as grey as they would look on gross pathology.

Scanning lower down, now we are at the level of the basal ganglia. Lateral ventricle is in the middle. Head of caudate in next to the frontal horn of the lateral ventricle. Thalami are separated by the 3rd ventricle. Head of caudate and thalamus are separated from the lentiform nucleus, by the internal capsule. More laterally, you will find the insular cortex covered by the anterior temporal lobe.

structure on T1 image.

Moving right along. This is a slice through the sylvian fissure. Incidentally, the orbits and eyeballs are back. What lives in the Sylvian fissure? Yes, the middle cerebral artery. Here it is, isodense to the brain parenchyma.

Here is the sylvian fissure on T1. As you can see on the localizing image in the upper left corner, T1 and CT slices are not necessarily at the same angle. So, on this T1 you can actually make out the mickey mouse-looking midbrain.

here is the CT axial cut at the level of the midbrain. The midbrain is central here with the CSF-filled basal cistern right behind it. The medial temporal lobe or uncus is lateral to the midbrain. Uncus, as in uncal herniation. Next, temporal horn of the lateral ventricle.

Moving lower down, now we are at the mid-pontine level. Here is the pons with its brachis pontis – “arms of the pons” or cerebellar peduncles. It’s as if the pons is reaching out to the cerebellum for a hug. While the pons and the cerebellum are hugging, the structure in the middle of the hug that feeling the love is the 4th ventricle. The place where brachis pontis meets the cerebellum is called the cerebello-pontine angle.

Here is what the pons looks like on T1.


Now this slice is even more caudal (or lower). Here is the medulla with the 4th ventricle adjacent to the cerebellum.

Look at how much better the resolution of MR is, especially in the posterior fossa.

finally，the foramen magnum with the cervical spinal cord bathed in CSF.


Now back to the case, Can you identify the major landmarks on our patient’s head CT?

Symmetry

Here is a non-contrast head CT(left), axial slice through the basal ganglia. Let’s locate the midline by drawing a line from the falx cerebri to the confluence of venous sinuses, right through the septum pellucidum in the middle of the lateral ventricle. There is no asymmetry here.
Now, what about this slice through the pons?(right), also symmetric.

what about in this picture(left), Once you spot asymmetry, look for a lesion causing it. It has to be on the patient’s right side, since the shift is towards the left. And here it is a concave subacute subdural hematoma.
What about in this image?(right) there is significant mass effect and midline shift. But this time, the lesion is a massive acute right middle cerebral artery stroke.

Let’s analyze a posterior fossa slice. Let me highlight the pons, the 4th ventricle, and the cerebellum. Yes, there is definitely midline shift. Now, what’s causing the mass effect? There is a mass at the cerebellopontine angle. This happens to be a vestibular schwannoma.

And finally, not all asymmetry is just about midline shift. There are two subcortical hypodensities that are present on the patient’s the right side, but not on the left. This happens to be a patient with toxoplasmosis.

now let’s back to our case, we can see it has a left shift. so the lesion is on the right.

Density

Hyperdensities

Hyperdensities on the CT are easy to spot, and by design, which makes them an excellent diagnostic tool. Bright signal on CT is caused by mineralized structures, such as calcium-rich bone and chronic calcified lesions. But also head CT is wonderful at detecting acute blood, with a sensitivity of above 90%.
Here is a non-contrast head CT axial cut through the sylvian fissure.

• Calcified pineal,
• calcified choroid plexus,
• calcified bones
  are some examples of normal hyperdensities.
  

Hypodensity

Fluid is less dense and appears dark on CT, so hypodensities usually reflect chronic lesions, cysts, or cerebral edema.
First up, chronic damage(left). This hypodensity is very well defined, wedge-shaped, same density as the CSF, and conforms to a vascular territory. The brain on the right side looks shrunken, and the frontal horn of the right lateral ventricle is expanded as a result. The proper name for this loss of brain tissue is encephalomalacia. The proper name for this loss of brain tissue is encephalomalacia. So, you probably guessed by now that this is an example of a chronic right MCA stroke.
Where is the encephalomalacia on this image?(right) It’s bifrontal. More so on the left but the right is abnormal too. This does not conform to a vascular distribution. Bilateral frontal lobes are a common site of trauma,
How is this hypodensity different? It looks well-defined, but also smooth unlike the previous examples. The location of this lesion is extra-axial with similar density to CSF because it is a CSF-filled structure. This is an example of a fronto-temporal arachnoid cyst, which is fairly benign but may become large enough to exert mass effect and cause seizures.