Curs 2 Neuroimagistica
Curs 2 Neuroimagistica
Curs 2 Neuroimagistica
CURS
Brain Imaging
Was the frontal cortex damaged by the stroke? Does the frontal cortex show normal metabolism?
Neuroimaging Modalities
Radiography (X-Ray) Fluoroscopy (guided procedures) Angiography Diagnostic Interventional Myelography Ultrasound (US) Gray-Scale Color Doppler Duplex Magnetic Resonance (MR) MR Angiography/Venography (MRA/MRV) Diffusion and Diffusion Tensor MR Perfusion MR MR Spectroscopy
Functional MR (fMRI)
Nuclear Medicine SPECT PET
CT Angiography (CTA)
Perfusion CT CT Myelography
Radiography (X-Ray)
Static: X-Ray
X-ray tube projects through head Detector plate measures transmission of X-rays
Useful for Angiography, looking for broken bones Poor for questions about grey vs white matter
Radiography (X-Ray)
Primarily used for spine: Trauma Degenerative Dz Post-op
Angiography Myelography
Identifies arterial disease, aneurysms and AV malformations Radiopaque substance released into blood and followed through system Digital subtraction: computer development to improve contrast in pictures
Ultrasound
US transducer
carotid
Static: CT
Computerized Tomography (CT) or Computerized Axial Tomography (CAT) Looks at radiographic pictures taken in series across brain May be enhanced by use of compounds injected Excellent for distinguishing relationships and shifts and lesions
Plaque in ICA
Gray-scale image of carotid artery
Static: CT
Imaging technique that relies on X-rays Widely available Most (if not all) hospitals have CT Many clinics also have CT scanners CT shows body structures (bone and soft tissue) does not show function (metabolism)
Computed Tomography
A CT image is a pixel-by-pixel map of X-ray beam attenuation (essentially density) in Hounsfield Units (HU) HUwater = 0 Bright = hyperattenuating or hyperdense
Computed Tomography
Typical HU Values:
Air 1000 Fat 100 to 40 Water 0 Watery fluid (e.g. CSF) 020 White matter 2035 Gray matter 3040 Blood clot 5575 Calcification >150 Bone 1000 Metallic foreign body >1000
Brain
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
Computed Tomography
CT Angiography
1. Rapid IV contrast bolus
2. Dynamic scanning during arterial phase Neck: arch to skull base Head: circle of Willis
3. Advanced 2D and 3D Reconstructions: 2D multi-planar (sagittal, coronal) Volumerendered 3D recons
CT Angiography - Neck
Carotid
bifurcations
Vertebral arteries
Aortic arch
CT Angiography - Head
Circle of Willis
Vascular Malformations
Aneurysms
CT Angiography
3D Volume Rendering
CT Angiography
3D Volume Rendering
CT Perfusion
CBF MTT
CBV
Venous phase:
Bolus arrival
Vein
Artery
CTP
CBF
8.2
13.3
CBV 2.7
1.4
CT Myelography
CT Myelography
Static: CT
Is based on absorption of x-rays as they pass through the different parts of a patients body Depending on the amount absorbed in a particular tissue such as muscle or lung, a different amount of x-rays pass through and exit the body The amount of x-rays absorbed contributes to the radiation dose to the patient During conventional x-ray imaging, the exiting x-rays interact with a detection device (x-ray film or other image receptor) and provide a 2 dimensional image of the tissues within the patients body an x-ray produced photograph called a radiograph. CT uses the same principle but uses a rotating x-ray
Static: CT
Advantages of CT Very quick Good spatial resolution compared to metabolic imaging Newer CTs can scan perfusion Is widely available (cheap compared to MRI)
Disadvantages of CT Uses X-rays (radiation!) Cannot detect acute ischemic stroke Poor spatial resolution compared to MRI
Static: CT
CT is mainly used for bone scans (broken bones!), chest x-rays, and stroke imaging CT is very quick (1-5 minutes) and is optimal for detection of cerebral hemorrhage Usually does not detect acute ischemic stroke Patients who receive tPA always get a CT before administration to rule out hemorrhage
Static: CT
Abnormal
CT scan
Enhancement
Normal
Dense bone Air Fat Water Brain CT scan Bright Dark Dark Dark Gray
Infarct
Dark
Subacute
Bleed
Tumor
Bright
Dark
No
Yes
MS plaque
Dark
Acute
Computed Tomography
Parenchyma
Attenuation: High or Low?
High:
1. Blood, calcium 2. Less fluid, more tissue
Low:
1. Fat, air 2. More fluid, less tissue
Air Fat Water Watery fluid White matter Gray matter Blood clot Calcification Bone Metallic foreign body
Static: CT
Hemorrhage Infarct Tumor
Static: MRI
MRI
Magnetic Resonance
Transmitter Receiver
RF
RF = Radio Frequency
B0
COMPUTER
The first use of MRI on a human happened on July 3, 1977 at 4:45am. Dr Damadian and his post-graduate assistants, Doctors Lawrence Minkoff and Michael Goldsmith, made a MRI image of Larry Minkoffs chest. This scan was done using the very first MRI machine, known as Indomitable. The first scans of patients with cancer occurred in 1978. Indomitable can now be found in the Smithsonian Institute as a piece of pioneering medical history.
Dr Damadian and his assistants, Dr Minkoff and Goldsmith standing next to the Indomitable
The first ever Magnetic Resonance Image. This is an image of Dr Minkoffs Chest taken on July 3, 1977 at 4:45am
MRI revolves around the fact that the human body is primarily composed of fat and water. Both of which contain hydrogen atoms. The human body is roughly 63% hydrogen. MRI also uses the fact that the nuclei of some atoms behave like a magnet. Whilst there is no magnetic field external to our body the hydrogen atoms are not lined up in any particular order. When these atoms are subjected to a strong magnetic field, such as one created by an MRI machine, the nuclei align the axis of spin either with or against the direction of the magnetic field. In picture A the atoms have no external magnetic field acting upon it, therefore the alignment of the atoms is not uniform. In picture B however there is an external magnetic force acting upon the atoms causing them to line up uniformly either along or against the magnetic axis of B0
Principles of MRI
When the magnetic field applied is turned off, the atoms will return to their un-uniform state again. In doing this they release a certain radio frequency photon emission. These emissions are whats collected and can be turned into an image by a computer.
Shimmingrf coil
rf gradient coil
main magnet
main magnet
Transmit
Receive
Control Computer
Imaging Equipment
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Radiology Systems
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Mechanical Failures
Carriage supports Table Foot rest Falling parts Impacts Collisions (failure of anti-collision sensors
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MR Environment Problems
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Projectile Effect
O2 cylinder
MR system
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Torque Problems
Magnetic implants
Aneurysm clips
Tiny magnetic particles or fragments Greater risk with highfield-strength systems (1.0 T)
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Burns
Coiled or looped devices Pulse-oximeter sensors ECG electrodes Implantable infusion pumps Nitroglycerin patches Metal-containing tissue expanders Pacing electrodes Contact with bore walls or RF coils
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Device Malfunctions
Static Field Effects on ECG
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Device Malfunctions
Pacemakers and other implanted devices Electric motors Electronic circuits Magnetically attached device ECG waveforms Analog gauges/meters
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Magnetic Resonance
Excited protons relax back to equilibrium
T2 T1
Magnetic Resonance
T1
T2
Magnetic Resonance
Tissue contrast in MR may be based on:
Proton density Water/fat/protein content Metabolic compounds (MR Spectroscopy)
e.g. Choline, creatine, N-acetylaspartate, lactate
Diffusion of water
Perfusion (capillary blood flow) Bulk flow (large vessels, CSF)
Magnetic Resonance
T1-Hyperintense (bright)
Fat and the 4 Ms
T1-Hypointense (dark)
Water, paucity of mobile protons (air, cortical bone) High flow (e.g. arterial flow voids)
Magnetic Resonance
T2-Hyperintense (bright)
Water
T2 bright = more water and/or less tissue (T2 = H20)
e.g. fluid collections, edema, demyelination, gliosis, some tumors, et al (non-specific!!)
T2-Hypointense (dark)
Some blood products (subacute hematoma)
Magnetic Resonance
T1
T2
Magnetic Resonance
Magnetic Resonance
Magnetic Resonance
Magnetic Resonance
Fat Suppression
Magnetic Resonance
Fluid Suppression
T2-weighted
Magnetic Resonance
Fluid Suppression
T2-weighted
Magnetic Resonance
Magnetic Resonance
Accentuating blood/calcium
T2
T2*
Magnetic Resonance
Cranial nerves
FIESTA
High spatial resolution, high tissue-CSF contrast (T2 weighting)
Diffusion MR Imaging
NORMAL
CYTOTOXIC EDEMA
Diffusion MR Signal
Magnetic Resonance
Imaging Diffusion
Highly sensitive to acute ischemia
MRA
Perfusion MR
IV Contrast in Neuroimaging
1. CT: Iodine-based (I is highly attenuating of X-ray beam) MRI: Gadolinium-based (Gd is a paramagnetic metal that hastens T1 relaxation of nearby water protons) 2. Normal blood-brain barrier keeps contrast out of brain! Enhancement implies BBB either leaky or non-existent
IV Contrast in Neuroimaging
Enhancement:
1. 2. Vessels Meninges
pachy = dura
lepto = pia-arachnoid 3. Circumventricular organs (structures outside BBB)
Pineal gland
Pituitary gland Choroid plexus 4. Disrupted/leaky BBB
Some tumors
Inflammation Infarction
with contrast
Congenital malformations Trauma R/O stroke R/O hemorrhage Hydrocephalus Dementia Epilepsy
Always best to provide detailed indication! Radiologist will protocol exam accordingly
MR vs. CT
CT
Advantages: Simpler, cheaper, more accessible Tolerated by claustrophobics No absolute contraindications Fewer pitfalls in interpretation Better than MR for bone detail Disadvantages: Advantages: Much broader palette of tissue contrasts (including functional and molecular) yields greater anatomic detail and more comprehensive analysis of pathology No ionizing radiation Direct multi-planar imaging IV contrast better tolerated
MR
Ionizing radiation
IV contrast complications Need recons for multi-planar Limited range of tissue contrasts
Disadvantages:
Higher cost, limited access Difficult for unstable patients Several absolute contraindications (cardiac pacer, some aneurysm clips, etc.)
MRI
T1 (anatomical): fast to acquire, excellent structural detail (e.g. white and gray matter). T2 (pathological): slower to acquire, therefore usually lower resolution than T1. Excellent for finding lesions.
T1
T2
Static: MRI
Abnormal
T1MRI
dark
T2MRI
bright
Normal
T1-MRI
dense bone
air
T2MRI
dark
dark
bright
dark
Infarct
Bleed
Tumor MS plaque
bright1
dark
bright1
fat
bright
bright
bright
water
dark bright
dark
bright
gm=gray, wm=white
medium
Static: MRI
Infarct
T1
T2
Static: MRI
Bleed
T1
T2
Static: MRI
Tumor
T1
T2
Static: MRI
Multiple-Sclerosis
T1
T2
Physics of PET
Cherry, S. R. & Phelps, M. E. (1996) Imaging brain function with positron emission tomography. In A. W. Toga & J. C. Maxxiotta (Eds.), Brain Mapping: The Methods (pp. 191-221). Toronto, ON: Academic Press.
O15 Water
Dynamic: PET
Positron Emission Tomography (PET) Measures uptake of radioactively-tagged tracer. Often tracer is glucose to determine which tissues have highest energy use during activity to CT scans: PET is similar
CT scans measure X-ray transmission: which parts of the body block X-rays PET scans measure X-ray emissions: where is the tracer uptake?
Tumor detection (increased metabolism) Decreased metabolism in the brain Can help distinguish between Alzheimer's disease, blood flow shortages, depression, or some other reason for dementia PET can localize the origin of seizure activity, guiding neurosurgery
PET
T2 MRI
PET can tell if muscle tremor is Parkinson's disease or another of the "Movement" disorders. PET can look at brain tumor and reveal if it's benign or malignant. It is also widely used when recurrence is suspected to show whether structural change is tumor re-growth or merely scar tissue. PET can "map" the areas of the brain responsible for movement, speech, and other critical functions. This is a remarkable guide for surgeons who are performing delicate operations on different areas of the brain.
Poor spatial resolution (compared to MRI) Can be used for functional imaging but because of spatial resolution very few researchers still use PET Much more expensive than CT Takes a long time. Therefore:
Not optimal for persons with acute condition needing immediate medical management Not for persons who have difficulty laying still for extended period of time
Dynamic: fMRI
Take rapid MRI scans that are sensitive to bloodoxygen level (T2* weighted images). Used to determine which parts of the brain are activated by different types of physical sensation or activity. By collecting repeated MRI scans while a subject is processing a specific task, it is possible to identify what regions of the subjects brain receive increased blood flow
Dynamic: fMRI
We can use fMRI to examine recovery from brain injury and guide neurosurgery. We can also use fMRI to discover how the healthy brain functions. Analysis of a series of fMRI scans Shown on top of T1 scan
Wada Test
Intracarotid injection decreases function in one hemisphere for 2-10 min. Can test function of remaining hemisphere separate from one receiving drug. Used early in epilepsy cases
Electroencephalography (EEG)
Measuring electrical potentials from electrodes placed on the scalp Can make comparisons of activity in various parts of the brain Comparison of different wave patterns to represent different physiological functioning Compares function over time
When neurons fire, they create electical dipoles. Neurons aligned perpendicular to cortical surface.
Magnetoencephalography (MEG)
MRI vs MEG
EEG
Alpha 7-13 Hz: mostly posterior. It is brought out by closing the eyes and by relaxation, and abolished by thinking. It is the major rhythm seen in normal relaxed adults Beta >13 Hz: most evident frontally. It is accentuated by sedatives. It is the dominant rhythm in people who are alert or anxious or who have their eyes open Theta 3.5-7.5 Hz and is classed as "slow" activity. It is abnormal in awake adults but is perfectly normal in children upto 13 years and in sleep Delta <3 Hz. It tends to be the highest in amplitude. It is quite normal and is the dominant rhythm in infants up to one year and in stages 3 and 4 of sleep
Electromyography (EMG)
Measure electrical activity at the level of the muscle Can determine if muscle is receiving electrical stimulation Helpful in spinal injury cases and myoneural problems
Additional Procedures
Dichotic listening
Assesses cerebral dominance Individuals usually understand speech better with right ear as fibers cross to left hemisphere which is dominant for speech Two words presented simultaneously - one to each ear Person reports which word was processed Spinal Tap to determine the presence of infections in
Lumbar Puncture