Kuliah Unpad Dr. Farhan

NEURORADIOLOGYdr. Farhan Anwary, Sp.Rad

Bagian/SMF RadiologiFK Unpad / RS dr. Hasan SadikinBandung

NEURORADIOLOGY (NEUROIMAGING)

Plain FilmCT Scan(Computed tomography)MRI(Magnetic Resonance Imaging)Angiography / DSA (Digital Subtraction Angiography)Sonography / USG / Color DopplerNuclear Medicine

PLAIN FILM/CONVENTIONAL RADIOLOGY

SKULL : - Lateral view- Sella- Straight posteroanterior view- Caldwell view- Towne view- Basal (submentovertex) view- Waters view

Normal, Radiographic, Anatomy

LATERAL VIEW

Sutures Calvarium Sella Dorsum sellae Sinus sphenoidalis

STRAIGHT POSTEROANTERIOR VIEW

Coronal - lamdoid suture Orbital roof, petrus ridge, internal auditory canal, cribriform plate - crista galli, maxillary sinus, nasal cavity, upper lateral rim orbita

CALDWELL VIEW

Lesser - greater wings Foramen rotundum ( V2 ) Orbital rim Zygoma - zygomaticofrontal suture Floor of anterior cranial fossa Frontal sinus

TOWNE VIEW

Occipital, parietal, frontal Sagital suture Posterior clinoid processes - dorsum sellae Internal auditory canal

WATERS VIEW

Maxillary - frontal sinuses Orbital margin - zygomaticofrontal sutureZygomatic process Body, ramus, condyle, coronoid process

BASAL (SUBMENTOVERTEX) VIEW

Odontoid Middle fossa Foramen ovale ( V 3 ) Foramen spinosum ( mma ) Sphenoid sinus

I . SINGLE LUSCENT DEFECT IN THE SKULL

DDX : Normal variant Pacchionian granulation Parietal foramina

DDX : Abnormal solitary luscent skull defect ( Help Me ) Hemangioma Epidermoid, dermoid Leptomeningeal cyst Paget's : osteoporosis circumscripta Post surgical Metastatic (solitary) Eosinophilic granuloma Encephalocele

II. MULTIPLE LUCENT DEFECTS IN THE SKULL

DDX : - Metastases - Myeloma - Hystiocytocis - Hyperparathyroidism - Cushing's - Osteomyelitis - Radiation

III. INCREASED SKULL DENSITY

A. Diffuse increased skull density

DDX : - Osteopetrosis - Hematologic; anemias, myelofibrosis- Fibrous dysplasia- Paget's disease- Acromegaly - Metastasis - Dilantin - Hypervitaminosis D

B. Focal increased skull density

DDX : - Osteoma- Hyperostosis frontalis- Meningioma- Fibrous dysplasia- Paget's disease- Metastasis- Calcified cephalhematoma

IV. INTRACRANIAL CALCIFICATION

A. Physiologic can occur in

1. Pineal2. Habenula3. Basal ganglia4. Choroid5. Dura

B. Phatologic calcifications

1. Tumorsa. O1igodendriglioma (90%)b. Craniopharyngioma (70%)c. Ependymoma (60%)d. Choroid plexus papilloma (25%)e. Low-grade astrocytoma (20%)f. Meningioma (10%)g. Other (Dermoid, pineal tumor, lipoma)

B. Phatologic calcifications

2. Infection : CMV, toxoplasmosis, cysticercosis3. Vascular :a. Atherosclerotic disease b. Aneurysm c. Arteriovenous malformation4. Pathologic basal ganglia calcification

B. Phatologic calcifications

5. Neurocutaneous syndromesa. Neurofibromatosisb. Sturge-Weber syndromec. Tuberous sclerosis

6. Post trauma

C. Basal Ganglia Calcifications

DDX :Endocrine : hypothyroidism, pseudohypoparathyroidismInfectious : CMV, toxoplasmosis, cysticercosisToxic/Anoxic : CO, lead, radiationCongenital : Tuberosclerosis, Fahr's disease

V. Large Sella

DDX :Tumor : Adenoma, craniopharyngioma, optic nerve gliomaAneurysmIncrease intracranial pressureEmpty sella

CEREBROVASCULAR DISEASE

I. Cerebral Infarction a. Etiology1. Atherosclerosis (large vessels)2. Atherosclerosis (small vessels)3. Hypoxia / anoxia4. Dissection

CEREBROVASCULAR DISEASEI. Cerebral Infarction a. Etiology

5. Fibromuscular dysplasia6. Vasculitis7. Basal arteriovascular occlusiv disease8. Venous thrombosis9. Miscellaneous; vasospasm, trauma

b. Imaging in ischemia / infarction :

- Vascular distribution- Evidence of cytotoxic edema- Involvement of cortex- Hemorrhagic transformation

c. IMAGING : CT, MR, MRA, Angiography

II. Spontaneous Intracranial Hematoma;Intraparenchymal hematoma

DDX : Causes of intraparenchymal hematoma 1. Aneurysm rupture 2. Arteriovenous malformation rupture 3. Hypertension 4. Tumor

DDX : Causes of intraparenchymal hematoma 5. Blood dyscrasia 6. Anticoagulant 7. Drug abuse 8. Infarct 9. Amyloid angiopathy 10. Idiopathic

III. Spontaneous Intracranial Hemorrhage;

Subarachnoid and extra-axial1. Subarachnoid hemorrhage (SAH)2. Extra-axial hemorrhage (SDH, EDH)

IV. Intracranial Aneurysm

V. Cerebrovascular Malformations

1. Capillary telangiectasis2. Cavernous angioma (hemangioma)3. Venous angioma4. Arteriovenous malformation (AVM)5. Occult cerebrovascular malformation (cryptic AVM)6. Vein of galen aneurysm

CRANIAL TRAUMA

1. ImagingSkull film, CT, MRI

2. Type of Injuries a. Directb. Indirectc. Skull fractures

3. Types of the Hemorrhagesa. Appearance of hemorrhage by CTb. Appearance MRc. Extra axial hemorrhageCRANIAL TRAUMA

Extra Axial Hemorrhage

1. Epidural hematomas2. Sub dural hematomas3. Sub arachnoid hemorrhage (S.A.H)4. Intra ventricular hemorrhage5. Intra parenchymal hemorrhage

DDX : Parenchymal Hematoma

Aneurysm rupture AVM rupture Hypertension Hemorrhagic infarct Hemorrhagic tumor Bleeding diathesis Amyloid angiopathy

INTRACRANIAL MASSES

1. Radiografic Characteristic of Lesiona. Intrinsic CT densityb. Contrast enhancement BBB (ring, gyriform, homogenous)c. Multiple lesionsd. MR appearance

DDX : Intracranial Mass (TEACH )

Tumor Edema Abcess, AVM, aneurysm Cyst Hematoma

A. Primary Tumor

1. Gliomaa. Astrocytomab. Ependymomac. Oligodendrogliomad. Ganglioglioma 2. Meningioma 3. Lymphoma

B. Metastatic Tumor

DIFFERENTIAL DIAGNOSIS BY LOCATIONDDX : Enhancement pattern of focal cerebral parenchymal lesionsA. Cerebral parenchymal lesion Ring : - Glioma- Meta- Abcess- Resolving hematoma- Resolving infarction Homogenous :- Lymphoma- Aneurysm

DDX : Intraventicular Mass Lesion

Meningioma, Astrocytoma, Choroid plexus papilloma, Colloid cyst, Meta, Ependymoma, Subependymoma, AVM, Oligo, Lymphoma

DDX : Pineal Region Mass

Germ cell tumor, Pineal cell tumorGerminoma, Pineoblastoma, Teratoma, Glial cell tumor, Dermoid, Epidermoid, Choriocarcinoma, Meta

DDX : Juxta Sellar and Supra Sellar

AdenomaCraniopharyngiomaAneurysmMeningiomaUncommon : Meta, Arachnoid cyst, Glioma

DDX : CPA Mass

Acoustic neurinoma Trigeminal neurinoma Meningioma Arachnoid cyst Epidermoid Aneurysm Meta

INTRACRANIAL INFECTIONS DISEASE

I. Focal LesionsA. Pyogenic brain abcessB. Atypical brain abcessC. AIDS : Toxo, Lympho, TB, Abcess

II. EncephalitisCongenital : TORCH Toxo, CMV, Rubella, Herpes

III. Meningitis

WHITE MATTER DISEASE

A. Demyelinating Diseases

DDX : - Primary : MS- Viral- Toxic and Metabolic- Post therapy- Vascular / SAE

B. Dysmyelinating Diseases - Leucodystrophies

IMAGING OF THE SPINEI. Approach1. Primarily a bony lesion2. Primarily a joint-space lesion3. Primarily a lesion involving the soft tissues with the neural canal or exit foramina4. Congenital abnormality may involve dysplastic changes of both osseous and neural components

II. Primarily an Osseous Lesion

1. Primary bone tumor2. Secondary bone tumor3. Inflammatory bone disease4. Hematologic or vascular5. Trauma6. Metabolic7. Congenital anomaly

III. Primarily a Joint-space Lesion

1. Degenerative disc disease2. Trauma (iatrogenic)3. Disc-space infection

IV. Primarily a Lesion Involving Soft Tissues of Canal or Foramina

1. Intramedullary2. Intradural and extramedullary3. Extradural

V. Congenital Anomalies1. Scoliosis2. Vertebral anomalies3. Dysraphism4. Syrinx5. Tumors6. Neurofibromatosis7. Spinal stenosis

dr. Farhan Anwary, Sp.RadTERIMA KASIH