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Neuroradiology

NEUROANATOMY

LOBAR ANATOMY

1. FRONTAL LOBE

2. PARIETAL LOBE

3. TEMPORAL LOBE

4. OCCIPITAL LOBE

LOBAR ANATOMY • 1. FRONTAL LOBE • 2. PARIETAL LOBE • 3. TEMPORAL LOBE • 4.

FRONTAL LOBE

-emotional control center -personality -motor function -problem solving -spontaneity -memory -language -initiation -judgement -impulse control -social
-emotional
control center
-personality
-motor function
-problem solving
-spontaneity
-memory
-language
-initiation
-judgement
-impulse control
-social
-sexual behavior

PARIETAL LOBE

PARIETAL LOBE • involves sensation and perception and the other is concerned with integrating sensory input,

involves sensation and perception and the other is concerned

with integrating sensory input, primarily with the visual system.

PARIETAL LOBE • involves sensation and perception and the other is concerned with integrating sensory input,

TEMPORAL LOBE

TEMPORAL LOBE • The temporal lobe is involved in auditory perception and is home to the

The temporal lobe is involved in auditory perception and is home to the primary auditory cortex.

It is also important for the processing of semantics in both speech and vision.

contains the hippocampus and plays a key role in the formation of long-term memory.

Paired thalami Basal ganglia caudate nucleus putamen

globus pallidus

Ventricular system 2 lateral ventricles

third ventricle fourth ventricle.

Corpus callosum Brainstem

main motor and sensory innervation to the face and neck via the cranial nerves.

regulation of cardiac and respiratory function.

regulates the central nervous system, and is pivotal in maintaining

consciousness and regulating the sleep cycle.

medulla oblongata (myelencephalon), pons (part of metencephalon), and midbrain (mesencephalon)

Cerebellum

involved in the coordination of voluntary motor movement, balance and

equilibrium and muscle tone.

VENTRICLES

VENTRICLES -Cavities within the brain -Filled with cerebrospinal fluid (CSF) -CSF is formed primarily by specialized
VENTRICLES -Cavities within the brain -Filled with cerebrospinal fluid (CSF) -CSF is formed primarily by specialized
VENTRICLES -Cavities within the brain -Filled with cerebrospinal fluid (CSF) -CSF is formed primarily by specialized

-Cavities within the brain -Filled with cerebrospinal fluid (CSF) -CSF is formed primarily by specialized tissues in the ventricles called the choroid plexus

CEREBROSPINAL FLUID FLOW

4
4

Aqueduct of Sylvius

1
1

Lateral ventricle

7
7

Subarachnoid space

2
2
6
6

Foramen of Luschka

Foramen of Monro

3
3
6
6

Fourth ventricle

Third ventricle

5
5

Foramen of Magendie

CEREBROSPINAL FLUID FLOW

CEREBROSPINAL FLUID FLOW lateral ventricles--> foramen of Monro third ventricle --> aqueduct of Sylvius --> fourth

lateral ventricles--> foramen of Monro third ventricle --> aqueduct of Sylvius --> fourth ventricle --> foramina of Magendie and Luschka --> subarachnoid space over brain and spinal cord --> reabsorption into venous sinus blood via arachnoid granulations.

MENINGES

the system of membranes which envelops the central nervous system.

Consist of three layers:

dura mater

arachnoid mater

pia mater

The primary function of the meninges and of the cerebrospinal fluid is to protect the central nervous system.

The dura is a thick, durable membrane, closest to the skull.

It contains larger blood vessels which split into the capilliaries in the pia mater.

The arachnoid is the middle layer of the meninges.

They transfer cerebrospinal fluid from the ventricles back into the bloodstream.

The pia or pia mater is a very delicate membrane.

It is the meningeal envelope which firmly adheres to the surface of the brain and spinal cord.

The subarachnoid space is the space which normally exists between the arachnoid and the pia mater, which is filled with cerebrospinal fluid.

• The dura is a thick, durable membrane, closest to the skull. • It contains larger

VASCULAR ANATOMY

CIRCLE OF WILLIS

VASCULAR ANATOMY • CIRCLE OF WILLIS ACA aca MCA pca Basilar A. PCA
ACA aca MCA pca Basilar A. PCA
ACA
aca
MCA
pca
Basilar A.
PCA

Anterior Cerebral Artery

3 Subgroups:

1. Medial lenticulostriate

Rostral portion of the basal ganglia 2. Pericallosal Branches

3. Hemispheric branches - medial aspect of the frontal and parietal lobes

Middle Cerebral Artery

1. Lateral lenticulostriate most of the basal ganglia region 2. Hemispheric region

lateral cerebral surface

Posterior Cerebral Artery

Midbrain Thalamic perforating vessels Choroidal arteries Medial temporal Occipital

MR. X

MR. X

PENTAGON OR JEWISH STAR

PENTAGON OR JEWISH STAR

MR. HAPPY

MR. HAPPY

MR. SAD

MR. SAD

WORMS

WORMS

COFFEE BEAN

COFFEE BEAN
Falx Cerebri Gray matter White matter

Falx Cerebri

Gray matter

Falx Cerebri Gray matter White matter

White matter

Falx cerebri Body of lateral ventricle Corona radiata Choriod plexus Falx cerebri Occipital lobe
Falx cerebri Body of lateral ventricle Corona radiata Choriod plexus Falx cerebri Occipital lobe

Falx cerebri

Body of lateral ventricle

Corona radiata

Falx cerebri Body of lateral ventricle Corona radiata Choriod plexus Falx cerebri Occipital lobe
Falx cerebri Body of lateral ventricle Corona radiata Choriod plexus Falx cerebri Occipital lobe

Choriod plexus

Falx cerebri

Occipital lobe

Falx cerebri
Falx cerebri

Frontal horn of the lateral ventricle

Septum pellucidum

Falx cerebri Frontal horn of the lateral ventricle Septum pellucidum Sylvian fissure Choroid plexus

Sylvian fissure

Choroid plexus

Frontal horn of lateral ventricle Falx cerebri Head of caudate nucleus Corpus callosum Sylvian fissure Anterior
Frontal horn of lateral ventricle
Falx cerebri
Head of caudate
nucleus
Corpus callosum
Sylvian fissure
Anterior limb
of internal
Third ventricle
capsule
Posterior limb of
internal capsule
Quadrigeminal cistern
thalamus

Frontal sinus Frontal bone

Frontal sinus Frontal bone Frontal lobe Suprasellar cistern Sylvian fissure Temporal horn of lateral ventricle Temporal
Frontal sinus Frontal bone Frontal lobe Suprasellar cistern Sylvian fissure Temporal horn of lateral ventricle Temporal

Frontal lobe

Suprasellar cistern

Sylvian fissure

Temporal

horn of

lateral

ventricle

Frontal sinus Frontal bone Frontal lobe Suprasellar cistern Sylvian fissure Temporal horn of lateral ventricle Temporal

Temporal lobe

Frontal sinus Frontal bone Frontal lobe Suprasellar cistern Sylvian fissure Temporal horn of lateral ventricle Temporal

Temporal

bone

pons

cerebellum

Fourth ventricle

Basilar artery

Occipital bone

Frontal sinus
Frontal sinus

cerebellum

Frontal bone

Frontal lobe

Temporal lobe

Pituitary

gland

Basilar

artery

Frontal sinus cerebellum Frontal bone Frontal lobe Temporal lobe Pituitary gland Basilar artery Dorsum sellae and
Frontal sinus cerebellum Frontal bone Frontal lobe Temporal lobe Pituitary gland Basilar artery Dorsum sellae and
Frontal sinus cerebellum Frontal bone Frontal lobe Temporal lobe Pituitary gland Basilar artery Dorsum sellae and

Dorsum sellae and clivus

Frontal sinus cerebellum Frontal bone Frontal lobe Temporal lobe Pituitary gland Basilar artery Dorsum sellae and

Mastoid air cells

Temporal bone

Occipital bone

LOOKING AT THE BRAIN…
LOOKING AT THE BRAIN…

LOOKING AT THE BRAIN…

MIDLINE

MIDLINE
MIDLINE
MIDLINE
MIDLINE
MIDLINE
MIDLINE
MIDLINE
MIDLINE

SYMMETRY

SYMMETRY
SYMMETRY
SYMMETRY
SYMMETRY
SYMMETRY
SYMMETRY
SYMMETRY
SYMMETRY

BASAL CISTERNS

BASAL CISTERNS
BASAL CISTERNS

QUADRIGEMINAL CISTERN

QUADRIGEMINAL CISTERN

SUPRASELLAR CISTERN

SUPRASELLAR CISTERN

EMERGENCY CT CHECKLIST

1. Is the middle of the brain in the middle of the head? 2. Do the two sides of the brain look alike? 3. Can you see the smile and the pentagon or Jewish Star? 4. Is the fourth ventricle in the midline and more or less symmetrical? 5. Are the lateral ventricles huge, with effaced sulci?

GENERAL RULE

CT IS PERFORMED FOR ACUTE NEUROLOGIC ILLNESS AND MR

FOR THE MORE CHRONIC AND

SUBACUTE CASES

VASCULAR LESION

VASCULAR LESION AVM or aneurysm Catheter Angiogram, MR or CT Angiogram

AVM or aneurysm

Catheter Angiogram, MR or CT

Angiogram

TUMOR

TUMOR CONTRAST

CONTRAST

TIA OR STROKE

TIA OR STROKE CAROTID DOPPLER US, OR MRA OR CTA

CAROTID DOPPLER US, OR MRA OR

CTA

IMAGING STRATEGY FOR

COMMON CLINICAL SYNDROMES

Acute Trauma

• Acute Trauma non-contrast enhanced CT scan

non-contrast enhanced CT scan

Stroke

• Stroke non-contrast CT scan

non-contrast CT scan

Seizure

Infection and Cancer

• Infection and Cancer contrast-enhanced MR

contrast-enhanced MR

Headache

  • non-contrast CT

Chronic Headache

  • MR scanning

Coma

Dementia

  • non-contrast CT

  • non-contrast MR

ANALYSIS OF THE ABNORMALITY

Mass- displacement of normal structures away

from the abnormality

Atrophy- widening of the sulci or enlargement of

the ventricle adjacent to the lesion

MASS LESIONS

INTRA-AXIAL OR EXTRA-

AXIAL???

SOLITARY OR MULTIPLE?

GRAY MATTER OR WHITE MATTER?

Gray Matter- infarct, trauma or encephalitis

White Matter- vasogenic edema caused by an intracerebral mass

LESION DISTRIBUTION CONTRAST ENHANCEMENT

SIGNAL INTENSITY OR ATTENUATION PATTERN

HEAD TRAUMA

Imaging strategy:

CT Scan

»Skull films »SCALP INJURY »SKULL FRACTURES

• Imaging strategy: CT Scan » Skull films » SCALP INJURY » SKULL FRACTURES

CLASSIFICATION OF HEAD TRAUMA

A. Primary Head Injury B. Secondary Head Injury

PRIMARY HEAD INJURY

1. Epidural

2. Subdural 3. Subarachnoid 4. Intraventricular Hemorrhage 5. Diffuse Axonal Injury 6. Cortical contusions 7. Intracerebral Hematoma 8. Subcortical Gray Matter Injury

SECONDARY HEAD INJURY

1. Cerebral swelling

2. Brain Herniation 3. Hydrocephalus 4. Ischemia

5. CSF Leak 6. Leptomeningeal Cyst 7. Encephalomalacia

PRIMARY HEAD INJURY: Extra-axial

Epidural Hematomas

-skull fracture -middle meningeal artey -temporal or temporoparietal

PRIMARY HEAD INJURY: Extra-axial • Epidural Hematomas - skull fracture -middle meningeal artey -temporal or temporoparietal

Subdural Hematomas

-venous -cortical veins -superficial cerebral veins

• Subdural Hematomas - venous -cortical veins -superficial cerebral veins

Subarachnoid Hemorrhage

• Subarachnoid Hemorrhage -common, but rarely large enough to cause significant mass effect. -subarachnoid vessels -linear

-common, but rarely large enough to cause significant mass effect. -subarachnoid vessels -linear areas of high attenuation within the cisterns and sulci

Intraventricular Hemorrhage

• Intraventricular Hemorrhage -tearing of subependymal veins -extension of parenchymal hematoma into the ventricular system -retrograde

-tearing of subependymal veins -extension of parenchymal hematoma into the ventricular system -retrograde flow of subarachnoid hemorrhage

PRIMARY HEAD INJURY: Intra-axial

Diffuse Axonal Injury

PRIMARY HEAD INJURY: Intra-axial • Diffuse Axonal Injury -MRI -CT, small petechial Hemorrhages at Gray-white junction

-MRI -CT, small petechial Hemorrhages at Gray-white junction

Cortical Contusion

• Cortical Contusion - superficial gray matter -better prognosis -temporal lobes, above The petrous bone, or

-superficial gray matter -better prognosis

-temporal lobes, above The petrous bone, or Posterior to the greater Sphenoid wing and the Frontal lobes above

The cribriform plate,

Planum sohenoidale, and Lesser sphenoid wing

Intracerebral Hematoma

-intraparenchymal small blood vessels

-frontotemporal white matter, basal ganglia -assoc. with skull fractures, contusions and DAI

• Intracerebral Hematoma - intraparenchymal small blood vessels -frontotemporal white matter, basal ganglia -assoc. with skull

SECONDARY HEAD INJURY

SECONDARY HEAD INJURY -loss of cerebral autoregulation -hyperemia -cerebral edema -generalized mass Effect, effacement of Sulci,

-loss of cerebral autoregulation

-hyperemia

-cerebral edema

-generalized mass Effect, effacement of Sulci, suprasellar and QuadrigeminAL Cisterns, compression

Of ventricular system

-tissue hypoxia

Diffuse Cerebral Swelling

BRAIN HERNIATION

BRAIN HERNIATION

BRAIN HERNIATION Subfalcine Herniation

• BRAIN HERNIATION • Subfalcine Herniation

Uncal Herniation

• Uncal Herniation
• Encephalomalacia

Encephalomalacia

FACIAL TRAUMA

Imaging strategy: Plain films

Caldwell view

Waters view

Cross-table lateral view

Submental vertex view

CT scan- provides excellent bone details

Soft tissue swelling Nasal fractures Maxillary and Paranasal Sinus fractures

Maxillary alveolus

Anterolateral wall of the maxillary antrum

Orbital Trauma Fractures of the Zygoma Mandibular fractures

FRACTURES OF THE MIDFACE

Le Fort I or floating palateLe Fort II or pyramidal fractureLe fort III or craniofacial dysjunction

FRACTURES OF THE MIDFACE

FRACTURES OF THE MIDFACE • Le Fort I or “ floating palate ” • Le Fort

Le Fort I or floating palate

Le Fort II or pyramidal fracture

Le fort III or craniofacial dysjunction

Bridge of the nose, nasal

septum, frontal process of the maxilla, medial wall of the orbit, inferior orbital rim, superior, lateral and posterior walls of the maxillary antrum and mid point of the pterygoid plates

Le Fort I or floating palateLe Fort II or pyramidal fractureLe fort III or craniofacial dysjunction

Nasofrontal suture, and extends posteriorly to the nasal septum, medial and lateral orbital walls, zygomatic arch,
Nasofrontal suture, and
extends posteriorly to the
nasal septum, medial and
lateral orbital walls,
zygomatic arch, and base
of the pterygoid plates

Le Fort I or floating palateLe Fort II or pyramidal fractureLe fort III or craniofacial dysjunction

Thank You!!!