Diagnostic Radiology: Neuroradiology Including Head and Neck Imaging Veena Chowdhury, NK Mishra, Manorama Berry, Sima Mukhopadhyay, Sudha Suri, N Khandelwal
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1DIAGNOSTIC RADIOLOGY Neuroradiology Including Head and Neck Imaging
2AIIMS-MAMC-PGI IMAGING COURSE SERIES
3DIAGNOSTIC RADIOLOGY Neuroradiology Including Head and Neck Imaging
Second Edition
Editors Manorama Berry MD FAMS FICR FIMSA Emeritus Professor National Academy of Medical Sciences and Formerly Professor and Head Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi Veena Chowdhury MD Director Professor and Head Department of Radiodiagnosis Maulana Azad Medical College New Delhi Sudha Suri MD FICR DABR FAMS Dean PGI, Professor and Head Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research Chandigarh Sima Mukhopadhyay MD FAMS FICR FIMSA Professor and Head Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi Joint Editors NK Mishra MD Professor and Head Department of Neuroradiology CN Centre All India Institute of Medical Sciences New Delhi N Khandelwal MD DNB FICR Additional Professor Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research Chandigarh
4Published by
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DIAGNOSTIC RADIOLOGY: Neuroradiology Including Head and Neck Imaging
© 2006, Editors
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
First Edition: 1999
Second Edition: 2006
9788180616365
Typeset at JPBMP typesetting unit
Printed at Lordsons Publisher
5Contributors 7Foreword
“Even if you're on the right track,
you'll get run over if you just sit there.”
—Will Rogers (1879–1935)
There have been major advances in neurosciences in India since independence. The earlier years were dominated by advances in the clinical neurosciences, with lesser but parallel development of allied neurosciences. The growing preponderance of technological means for progress in medical science is undeniable. There is an interrelationship between the advancement of knowledge and the amount and complexity of research technology required. Since the 1970s, neuroradiology has benefited from significant technological advances and has become less and less invasive. Neuroradiology departments of excellence have developed in several institutions across the country. Remarkable advances in this field continue to expand the vista of diagnosis and management of neurological disorders. The advent of the CT scan was considered the major breakthrough of the century until it was overtaken by the MRI. Advances in computer technology and imaging techniques have revolutionised not only the diagnosis but the management of disorders affecting the nervous system. High resolution CT, spiral CT and MRI have made the majority of conventional neuroradiological procedures of the past redundant.
The new generation of imaging procedures, such as MR angiography, MR spectroscopy and PET are superior to other currently available technologies. These have been used to investigate a wide spectrum of neurological and neurosurgical disorders, including those of the peripheral nervous system. MR spectrosopy and PET are increasingly being used in the field of functional imaging of the nervous system.
Following the development of digital subtraction angiography (DSA) and superselective catheterisation, a new field of interventional neuroradiology had opened up. These techniques have been used not only to accurately diagnose various vascular lesions of the brain and spinal cord but are also being used extensively in their management. A number of conditions for which major neurosurgical procedures had to be undertaken are now in the domain of the interventional neuroradiologists, with negligible morbidity and mortality.
The imaging courses organized by the departments of Radiodiagnosis and Imaging at the Postgraduate Institute of Medical Education and Research, Chandigarh, All India Institute of Medical Sciences, New Delhi, and Maulana Azad Medical College, New Delhi, continue to the 8runaway successes. That these well attended courses are still going on speaks volumes for their popularity and academic contents.
The second course on Neuroradiology including Head and Neck Imaging has certain welcome additions covering the fields of epilepsy and trauma. Rapid ongoing advances in the fields of computerized tomography, magnetic resonance imaging and PET scanning, combined with technological strides in interventional neuroradiology, have worked towards better and, perhaps, optimal healthcare for the society. However, it remains to be seen whether these newer techniques of diagnosis and therapy would be made equally available to the vast multitude of poor and needy patients of our country as they are to the rich and insured population. It is for the concerned physicians, manufacturers, and the government and private sectors to achieve cost-effectiveness in this field for us all to practice a more humanistic medicine. We must also strive to evolve Evidence Based Medical guidelines for interventional procedures towards good clinical practice in the new millennium.
The series of volumes accompanying these courses are a valuable addition to the libraries of all medical practitioners in the country.
VK Kak
ms, frcs, frcse, fams, fihe
Emeritus Professor of Neurosurgery
Postgraduate Institute of Medical Education and Research
Chandigarh
9Preface to the Second Edition
In the last 7 years, since the 1st edition was published, the discipline of Neuroradiology including Head and Neck Imaging has made rapid strides. Availability of higher magnetic field strength magnets and superior coil technology have led to the development of highly sophisticated MR sequences which has boosted the potential of magnetic resonance imaging. From being a technique used primarily to demonstrate the structural and morphological details of the brain, MR is now being used to provide neuronal, metabolic (MR spectroscopy) and functional brain activity (Diffusion MR, BOLD contrast).
The introduction of multislice CT with its capability for excellent delineation of the vascular anatomy has made tremendous impact on the diagnosis and management of stroke and vascular conditions such as aneurysms and AVMs. DSA instead of being used purely as a diagnostic technique is now being used more frequently for therapeutic procedures which are sometimes preferred alternative to surgery. All these advances have prompted us to revise the 1st edition. In the current edition we have incorporated chapters on Epilepsy, Head, Spinal and Facial trauma in addition to updating the chapters on techniques used for neuroimaging. Chapters on Neuro-interventions have been expanded and supplemented with new and many more illustrations. We hope the book will be useful to the students as well as clinicians/surgeons working in the field of Neuro sciences.
We take this opportunity to thank the faculty of three contributing institutes, i.e. Postgraduate Institute of Medical Education and Research, Chandigarh, All India Institute of Medical Sciences, New Delhi and Maulana Azad Medical College, New Delhi who have put together their collective experience to contribute various chapters. We also wish to acknowledge the tremendous hardwork and contribution of our residents who have actively helped in compiling the entire work. We are also grateful to M/s Jaypee Brothers Medical Publishers Pvt. Ltd., their Chairman and Managing Director Shri JP Vij, Senior Production Manager Mr PS Ghuman and the other staff for working hard to make this volume see the light of the day in time before the commencement of the course.
Manorama Berry
Sudha Suri
Veena Chowdhury
Sima Mukhopadhyay
NK Mishra
N Khandelwal
10
11Preface to the First Edition
It gives us immense pleasure and a sense of great satisfaction to present the 6th AIIMS-MAMC-PGI Imaging course in the form of a book on Neuroradiology Including Head and Neck Imaging.
During the last two decades, the practice of Neuroradiology has completely changed. Improvements in diagnostic and interventional radiological techniques have resulted in dramatic advances in our ability to diagnose and manage neurological diseases. In the 1970s, computed tomography revolutionised imaging of the nervous system by providing superb cross-sectional anatomical images. In 1980s, this revolution has been carried further by magnetic resonance imaging which, in addition to providing multiplanar images with excellent soft tissue contrast also enables us to obtain flow measurements and biochemical characterisation of tissues. This makes MR specially useful to diagnose diseases, where biochemical changes precede anatomical changes such as demyelinating disorders. Advances in angiographic equipment, catheters and guidewires have led to the birth of discipline of Neurointervention enabling the radiologists to treat aneurysms and AVMs by percutaneous techniques with results comparable to those of surgery.
This book provides a comprehensive review of both conventional and latest imaging techniques as they are applied to the diagnosis of various diseases of the central nervous system including all relevant interventional procedures. The text has been divided into six major sections. Starting with Fundamentals of Neuroimaging, the contents scan through the plain film evaluation, normal anatomy of brain as seen on CT and MRI, CNS infections, tumours, stroke, head and neck imaging and lastly a complete section has been devoted to the various interventional procedures both in the head and spine. The techniques have been described in great detail so as to provide a comprehensive guide which we hope will prove useful to all interventional radiologists.
This book is intended for the radiology residents as well as practicing radiologists. We hope that this text will serve as a primary reference for all those interested in neurosciences including head and neck imaging.
We feel greatly indebted to the faculty of the three premier institutions of the country who have contributed chapters for this book. Without their knowledge, expertise and experience it would not have been possible for us to assemble this textbook. We must acknowledge the tremendous contribution of our residents and other faculty members who have contributed cases and have actively helped their hard work in compiling the entire work. We also wish to thank our publishers M/s Jaypee Brothers Medical Publishers (P) Ltd., their Managing Director Shri J. P. Vij, Production Manager Mr. P.S. Ghuman and other staff for timely publication of this volume.
Manorama Berry
Sudha Suri
Veena Chowdhury
NK Mishra
N Khandelwal