Pocket tutor: Neuroimaging Rory Piper
INDEX
ABCDEFGHIJLMNOPRSTVWX
Note: Page numbers in bold or italic refer to tables or figures respectively.
A
ABCDE approach, for trauma patient 77, 84
Acoustic neuroma see Vestibular schwannoma
Ageing, features of see Elderly patients
Air, presence of see Pneumocephalus
Anterior circulation, brain 17, 17
Anterior fossa, skull 3, 3
Anteroposterior view 21, 22
Antiplatelet therapy, after ischaemic stoke 103
Aqueduct of Silvius 18, 19
Artefact 72
beam hardening 73, 74
foreign bodies 72, 73–74
motion 67, 74
starburst 73, 74
types of 72–73
Arterial dissection 115
CT angiography for 115, 116
MRI for 115–117, 116
Arterial stenting 115
Arteriovenous malformation 112–114
bag of worms 112, 114
CT scan for 112, 113, 114
digital subtraction angiography 112, 114
MRI for 112, 113
multiple flow voids 112, 113
Atlanto-occipital joint 4
Atlas 4
Axial section 22, 23
Axis 5
B
Basal cisterns 59
Basal ganglia 9
Battle's sign 80
Bitemporal hemianopia 11
Blossoming of contusion 90
Bone window 40, 40
Brain
arterial supply to 16, 17, 17
herniation 68, 68–69, 69
metastases 137, 148–150, 149
venous system of 18, 18
ventricular system of 18, 19
Brainstem
functions of 12
structure of 12, 13
Brain tumour 137–140
assessment in 140–141
brain metastases 137, 148–150
CT for 141
gliomas 142–146
image-guided neurosurgery 154–156
management of 142
medulloblastoma 152
meningioma 146–148
MRI for 141
pituitary adenoma 150–151
primary 137
secondary 137
vestibular schwannoma 152–154
Broca's area 8, 9
Burst fractures 165–166, 167
C
Carotid artery dissection 115–117, 116
Cauda equina 15
Cauda equina syndrome 157–159, 173
MRI scan 158
Central nervous system 1 see also Brain; Spinal cord
Central sulcus 8
Cerebellum 12, 13
Cerebral abscess 127–132, 129, 141
CT for 128, 130
diffusion-weighted MRI scan 131, 131
MRI for 129, 130–131
rim-enhancing effect 129, 130
vasogenic oedema 129, 131
Cerebral aqueduct see Aqueduct of Silvius
Cerebral contusions 89–91, 91
burst lobe 90
contrecoup 90, 92
coup 90
CT for 90, 91, 92
haemorrhagic contusions 90, 91
MRI for 90
Cerebral laceration 89
Cerebral oedema 62–63
types and features of 64, 65
Cerebritis 127, 130 see also Cerebral abscess
Cerebrospinal fluid 18
CT for 57
MRI for 58, 58, 59
Cerebrospinal fluid cleft sign 146, 147
Cerebrovascular disease 95
arteriovenous malformation 112–114
carotid and vertebral artery dissection 115–117
dural venous sinus thrombosis 117–119
stroke 95–112, 96
Cerebrum 8
cerebral cortex 8–9
hemispheres 8
lobes 8, 8, 9
pituitary gland 11, 11
subcortical structures 9–11, 10
vascular territories of 17
Cervical spine
CT scans of 45–46, 47, 159
plain radiographs of 159
protection 160, 163
Cervical spine fractures 160–164
CT scan 163
facet fractures 161, 164
flexion teardrop fracture 161, 163
hangman's fracture 160, 161
Jefferson's fracture 160
MRI for 163
odontoid fracture 160, 162
plain radiography 161–163
Circle of Willis 16, 17, 55
Cisterns 7
Contrast-induced nephropathy 32
Computerised tomography (CT) 24–25
appearance in 35–36
brain 48–50, 49
cerebrospinal fluid 57
cervical spine 45–46, 47
contrast agent in, use of 25
CT angiography 27, 54
CT perfusion 27
CT venography 27
Hounsfield scale used in 36, 36
image acquisition in 25, 26
meninges 46–47, 47, 48
and MRI, comparison of 25
orientation in 34–35, 35
safety concerns 30–31, 31
skull 40, 40–41, 41
spine 45–46
vascular system 52–53, 54
window, creation of 36, 37
Contrast agents 29, 32, 53
Contrecoup contusions 90, 92 see also Cerebral contusions
Contusions see Cerebral contusions
Coronal section 22, 23
Coronal suture, skull 2, 3
Corpus callosum 9
Cortical atrophy 70, 71
Corticospinal tract 15
Coup contusions 90 see also Cerebral contusions
Craniotomy 85
CT see Computerised tomography (CT)
Cytotoxic oedema 64, 65
D
Denis’ three-column theory of stability 165, 165
Dexamethasone 138, 174
Diffuse axonal injury 91, 93
CT for 93
MRI for 93
Diffusion tensor imaging 29
Diffusion-weighted imaging 29
Digital subtraction angiography 24, 55–56, 56, 57
Disc herniation 168–169
Dorsal (posterior) column 15
Dural venous sinuses 7
Dural venous sinus thrombosis 117–119, 118
CT for 117
CT venography for 118, 118
MRI for 119
MR venography for 118, 119
E
Elderly patients 70
cortical atrophy in 70, 71
small vessel disease in 71
ventriculomegaly in 70
Empty delta sign 117
Encephalitis 127
Endovascular coiling 110, 111
Ethmoid air cells 40, 41
Extradural empyema 132
Extradural haematoma 62, 83–85, 84
CT scan 76, 84, 84
subdural and, differences between 89
F
Facet fractures 161, 164
Falx cerebri 7, 46, 47
Fibre tracking see Tractography
Flexion teardrop fracture 161, 163
Foramen magnum 3, 3
Foramen of Munro 18, 19
Frontal lobe 8, 9
Frontal sinus 41, 41
Functional MRI 29–30, 155
G
Gadolinium 29
Glasgow Coma Scale (GCS) score 75, 77, 78
Glioblastoma 144, 145 see also Gli
Gliomas 137–138, 139, 140, 142–146
high-grade 143, 144–146, 145
low-grade 142–143, 143, 144
WHO classification of 142, 143
H
Haematoma 61, 62 see also Intracranial haemorrhage
Haemorrhage 61 see also Intracranial haemorrhage
Hangman's fracture 160, 161
Head injuries 75 see also Traumatic brain injury
Herniation 68, 68–69
subfalcine 68, 68–69
tonsillar 69, 69
transtentorial 68, 69
Horner's syndrome 115
Hounsfield units (HU) 36
Hydrocephalus 63, 66
communicating 63, 65–66
non-communicating 66, 67
normal pressure 65–66
Hypothalamus 10, 11
I
Image-guided neurosurgery 154–156
frameless image guidance 154
functional MRI 155
stereotactic surgery 154
tractography 155, 155
Incidental findings, on imaging 71
Infections, of central nervous system 127 see also specific infection
Inflammatory disorders 121
multiple sclerosis 121–124
sarcoidosis 124–126
Internal capsule 11
Internal carotid artery 56
Intervertebral disc 4
herniation 168–169
Intracerebral haemorrhage see Parenchymal brain haemorrhage
Intracranial haemorrhage 61
CT 61
extra-axial 61
intra-axial 61
MRI 62, 63
types of 62
Intracranial pressure, increased 66, 140–141
and brain herniation 68, 68–69, 69
features of 66–67, 67
Intraparenchymal haemorrhage see Parenchymal brain haemorrhage
Intraventricular haemorrhage 62 see also Intracranial haemorrhage
Ischaemia 62
Ischaemic stroke 97–103
CT perfusion scan 98, 99
CT scan 98, 99, 100
hyperdense artery sign 98, 99
hypodense area 97
malignant middle cerebral artery infarction 99–100, 100–101
MRI for 100–101, 102
US imaging 103
J
Jefferson's fracture 160
L
Lacunar stroke 96
Lambdoid suture, skull 2, 3
Lateral sulcus 8–9
Lateral view 21, 22
Leptomeningitis 127
Log-rolling technique 159
Lumbar puncture 108
Lumbar sacral spine, MRI scans 52
Lumbar vertebra, MRI scan 53
M
Magnetic resonance imaging (MRI) 27–30
advantages and limitations of 25
appearance in 37
assessment prior to 31
brain 50, 50–51, 51
cerebrospinal fluid 58, 58, 59
contrast agents in, use of 29
diffusion tensor imaging 29
diffusion-weighted imaging 29
functional MRI 29–30
image acquisition in 27–29, 28
meninges 48
MR angiography and venography 29, 53, 55, 55
MRI perfusion 30
MRI spectroscopy 30
orientation in 37
safety concerns 31–32
sequences 37–38, 38, 39
spinal cord 51–52, 52, 53
T1-weighted and T2-weighted MRI signals 39
vascular system 53, 55, 55
ventricular system 58
Malignant middle cerebral artery infarction 99–100, 100–101, 103
Mastoid air cells 41, 41, 81
Medulloblastoma 152
Meninges 6, 7
arachnoid mater 7
dura mater 6–7
pia mater 7
Meningiomas 146–148
CT scan 147, 147
imaging findings 146–147
MRI scan 147, 147, 148
Meningitis 48, 127
Metastatic spinal cord compression 172–174, 173
Middle fossa, skull 3, 3
Missile effect 32
MRI see Magnetic resonance imaging (MRI)
MS see Multiple sclerosis (MS)
Multiple sclerosis (MS) 121–124
clinically isolated syndrome 123
Dawson's fingers’ 123, 124
McDonald diagnostic criteria for, revised 121
MRI for 122–123, 123–124, 124
radiologically isolated syndrome 123
N
Neuroanatomy 1
brainstem 12
cerebellum 12
cerebrum 8–11
meninges 6–7, 7
scalp 1
skull 1–3, 2, 3
spinal cord 14–15
spine 4, 4–5, 5, 6
Neurocranium 1, 2 see also Skull
Neurofibromatosis type 2 152
Neurosarcoidosis 124–126
MRI in 125, 125
Nidus 112
Nimodipine 112
O
Obstructive hydrocephalus 152
Occipital lobe 8, 9
Odontoid fracture 160, 162
Optic chiasm 11, 11
Orientation terminology 20, 20–21
anterior 21
contralateral 21
inferior 21
ipsilateral 21
lateral 21
medial 21
posterior 21
superior 21
Osmotic therapy 85
P
Pachymeningitis 127
Parenchymal brain haemorrhage 62, 103–105 see also Intracranial haemorrhage
CT for 104, 105
deep bleeds 104
MRI for 105
primary 104
secondary 104
Parietal lobe 8, 9
Partial anterior circulation stroke 95–96, 96
Patient safety 30
contrast agents 32
MRI 31–32
radiography and CT 30–31, 31
Pepper pot skull 39
Pituitary adenoma 150–151
classification of 150
MRI for 150, 151
Pituitary fossa, skull 3, 3
Pituitary gland 3, 11, 11
Plain radiography 23–24, 33–34
attenuation 33–34, 34
cervical spine 42, 42–44, 43
orientation in 33
safety concerns 30–31, 31
skull 39–40
thoracic and lumbar spine 44–45, 45, 46
Pneumocephalus 69, 70, 80, 82, 83
Posterior cerebral artery 57
Posterior circulation 17
stroke 96
Posterior communicating artery aneurysm 108
Posterior fossa, skull 3, 3
R
Radiography, plain see Plain radiography
S
Sagittal section 22, 23
Sagittal suture, skull 2, 3
SAH see Subarachnoid haemorrhage (SAH)
Sarcoidosis 124–126, 125
Scalp 1
SCALP (mnemonic) 1
Sieverts (Sv) 31, 31
Sinuses of skull 40–41, 41
Skull 1, 2
base 3, 3
CT for examination 40, 40–41, 41
neurocranium 1, 2
pterion 2
radiographs 39–40
splanchnocranium 1, 2
sutures of 2, 3
vault 2, 2–3
venous drainage of 18
Skull fractures 80–83, 81, 82
bone window, hypodense lines on 81
comminuted fractures 81, 82
CT scan 81, 81, 82
depressed fractures 81, 82
pneumocephalus 80, 82, 83
Small vessel disease 71
Sphenoid sinus 40, 41
Spinal cord 14–15
MRI for 51, 52, 53
Spinal degeneration 167–169, 168
Spinal diffusion-weighted imaging 134
Spinal epidural abscess 133–135
MRI for 134, 134
Spinal fractures 160
cervical 160–164
thoracolumbar 164–167
Spinal nerves 15
Spinal tracts 14, 15
Spinal trauma, approach in 159–160
Spinal tumours 169–170
classification of 170
ependymoma 171–172, 172
intradural 169–170
meningioma 170–171, 171
metastatic spinal cord compression 172–174, 173
primary 170
secondary 170
Spine
CT scans 45–46, 47
plain radiography 42–45, 42–46
Spinocerebellar tract 15
Spinothalamic tract 15
Splanchnocranium 1, 2 see also Skull
Spondylolisthesis 169
Spondylolysis 169
Spondylosis 169
Stereotactic surgery 154
Stroke 95
haemorrhagic 103–112
ischaemic 97–103
Oxford (Bamford) classification of 96
parenchymal brain haemorrhage 103–105
partial anterior circulation 95–96, 96
subarachnoid haemorrhage 103, 105–112
transient ischaemic attack 97–103
Subarachnoid haemorrhage (SAH) 62, 103, 105–112, 106 see also Intracranial haemorrhage
CT angiography for 109, 110
CT for 106, 107–109
digital subtraction angiography for 109, 111
modified Fisher grading scale for 109, 109
MRA for 109–110
non-traumatic 107, 108
World Federation of Neurosurgical Societies grading scale 107
Subarachnoid space 7
Subcutaneous emphysema 69
Subdural empyema 132, 133
Subdural haematoma 62, 85–89, 86–88, 89
acute 85, 86, 86
chronic 85, 86, 87
extradural and, differences between 89
isodense 86, 88
subacute 86, 88
Subfalcine herniation 68, 68–69
Superior sagittal sinus 18, 18
T
Tattoo inks 31
Temporal lobe 8, 9
Tentorium cerebelli 7, 46, 48
Terminology, related to radiology 20
orientation 20, 20–21
sections 21–22, 23
views 21, 22
Thalamus 10, 11
Third cranial nerve palsy 108
Thoracolumbar fractures 164–167
burst fractures 165–166, 167
imaging findings 166
wedge fractures 165, 166
Thrombolytic therapy 97
Tonsillar herniation 69, 69
and Chiari malformation 69
Total anterior circulation stroke 96
Tractography 29, 155, 155
Transependymal oedema 63, 64, 65
Transient ischaemic attack 97
Trans-sphenoidal hypophysectomy 151
Transtentorial (uncal) herniation 68, 69
Traumatic brain injury 75, 76
assessment in 77
cerebral contusion 89–91, 91, 92
CT head scan in 77, 78
differential diagnoses 79
diffuse axonal injury 91, 93
extradural haematoma 83–85, 84
GCS score 75, 77, 78
prevention of 75
primary 75
secondary 75
severe 75–77, 76
skull fractures 80–83, 81, 82
subdural haematoma 85–89, 86–88, 89
V
Vascular system 52
CT 52–53, 54
digital subtraction angiography 55–56, 56, 57
MRI 53, 55, 55
Vasogenic oedema 64, 65
Ventricular system 18, 19, 57, 58
Ventriculitis 127
Ventriculomegaly 63, 66, 70
Vertebrae 4, 4, 5
cervical 4–5, 5, 6
coccygeal 4, 5
lumbar 4, 5
sacral 4, 5
structure of 4
thoracic 4, 5
Vertebral artery 57
Vertebral dissection 115–117
Vestibular schwannoma 152–154
cystic component 153, 153
MRI scan 153, 153–154
solid component 153, 154
Virchow–Robin spaces 71
W
Wedge fractures 165, 166
Wernicke's area 8
X
X-rays see Plain radiography
×
Chapter Notes

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Neuroimaging
Neuroimaging
Rory Piper MBChB BMedSci(Hons) MRCS(Ed) NIHR Academic Clinical Fellow University of Oxford Specialty Trainee in Neurosurgery John Radcliffe Hospital Oxford, UK
© 2018 JP Medical Ltd.
Published by JP Medical Ltd, 83 Victoria Street, London, SW1H 0HW, UK
Tel: +44 (0)20 3170 8910
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The rights of Rory Piper to be identified as the author of this work have been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission in writing of the publishers. Permissions may be sought directly from JP Medical Ltd at the address printed above.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author assumes any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
9781909836570
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Publisher:
Richard Furn
Development Editor:
Thomas Banister-Fletcher
Editorial Assistant:
Adam Rajah
Design:
Designers Collective Ltd
Foreword
Brain imaging is a core hospital service: a quarter of all admissions are ‘neurological’ and most of these patients will have their brains imaged. Every minute lost prior to treatment is thought to represent one million extra brain cells dying, therefore many diagnoses need to be made swiftly in order for the patient to receive the best treatment as soon as possible. This makes the ability to interpret neuroradiological imaging crucial and Pocket Tutor Neuroimaging is an excellent portable and accessible guide to the essential knowledge of neuroradiology.
The book opens by describing the main neurological imaging techniques, particularly MRI and CT. The indications, interpretation and protocols for each technique are detailed, with common conditions presented alongside their differential diagnosis and a large number of high-quality images.
The teaching of neuroradiology is frequently haphazard and often missed by students completely. However, it is crucial to have an understanding of neuroradiology; what other specialty will allow you to see what an unconscious patient's brain looks like? So be smart, buy this book and have a real edge on your peers. Even better, use this book to make a real difference to your patients with your speedy and accurate diagnoses.
Robin Sellar
Professor of Neuroradiology
The University of Edinburgh
Edinburgh, UK
Preface
Neuroimaging is encountered across all medical specialties, not only neurology and neurosurgery – from trauma calls in the emergency department to falls in the medicine of the elderly ward, and of course in medical school or postgraduate exams.
Pocket Tutor Neuroimaging is intended for medical students in their clinical years and doctors in the early years of their training. Its aim is to demystify neuroimaging and provide a broad understanding of how to interpret normal and abnormal appearances.
The book opens with a summary of the essential anatomy and describes the different imaging techniques. Next is an introduction to the principles of interpretation of images of the normal and abnormal nervous system. The remaining chapters demonstrate the uses of neuroimaging in disease and they focus on the serious but common pathologies that a junior doctor may encounter. Each one includes at least one case scenario to relate the content back to clinical practice.
I wish you the best of luck in your studies and clinical careers, and I hope that this book will help you along the way.
Rory J Piper
March 2018
Dedications and acknowledgements
I would like to thank Richard Furn, Thomas Banister-Fletcher and Adam Rajah at JP Medical for all of their hard work and for making this book possible.
Thank you to my wife, Allisyn, for her endless patience and support.
Thank you to the reviewers of the book:
Chapter 1 - Dr Samantha Mills
Chapter 2 - Dr Conal Corbally
Chapter 3 - Dr Paul Burns and Dr Phillip Rich
Chapter 4 - Mr Aimun Jamjoom and Dr Shahriar Islam
Chapter 5 - Dr Grant Mair
Chapter 6 - Dr Mark Rodrigues
Chapter 7 - Dr Gerard Thompson
Chapter 8 - Mr Stephen Price and Dr Harpreet Hayre
Chapter 9 - Mr Rodney Laing and Dr Peter Keston
Lastly, thank you to Professor Sellar for the kind foreword and for the support in the writing process.
RP
Figures 2.10, 2.11, 2.12, 2.14, 2.24, 3.11, 4.9, 5.1, 5.2, 9.2, 9.3 and 9.4 are reproduced from Heir M, Vaidhyanath R. Pocket Tutor Emergency Imaging. London: JP Medical, 2013.
Figures 1.3, 1.59, 1.7, 3.3, 5.10, 5.12, 5.14, 5.15 and 6.3 are reproduced from Collins DR, Goodfellow JA, Silva AHD, et al. Eureka Neurology & Neurosurgery. London: JP Medical, 2016.