Med Students Lecture Series NEURO University Hospitals Case Medical Center Department of Radiology

Normal Brain Anatomy

Normal Brain Anatomy http://www.radiologytutorials.com/main.cgi?tut=/main.cgi&frame=main&tt=1&t=168&s=2

Normal Brain Anatomy 1 – chiasma 2 – brainstem 3 – frontal sinus http://www.radiologytutorials.com/main.cgi?tut=/main.cgi&frame=main&tt=1&t=168&s=2 1 – chiasma 2 – brainstem 3 – frontal sinus 4 – orbit 5 – temporal lobe (middle cranial fossa) 6 – mastoid air cells 7 – cerebellar hemispheres

Normal Brain Anatomy http://www.radiologytutorials.com/main.cgi?tut=/main.cgi&frame=main&tt=1&t=168&s=2

Normal Brain Anatomy 7 – cerebellar hemispheres http://www.radiologytutorials.com/main.cgi?tut=/main.cgi&frame=main&tt=1&t=168&s=2 7 – cerebellar hemispheres 8 – interhemispheric fissure 9 – frontal horn (lateral ventricle) 10 – falx cerebri 11 – frontal lobe 12 – third ventricle 13 – quadrigeminal plate 19 - thalamus 20 – caudate nucleus 21 – basal ganglia

Normal Brain Anatomy http://www.radiologytutorials.com/main.cgi?tut=/main.cgi&frame=main&tt=1&t=168&s=2

Normal Brain Anatomy 8 – interhemispheric fissure http://www.radiologytutorials.com/main.cgi?tut=/main.cgi&frame=main&tt=1&t=168&s=2 8 – interhemispheric fissure 9 – lateral ventricle 11 – frontal lobe 14 – septum pellucidum 15 - sulci 16 – central sulcus 17 – chorioid plexus 18 – occipital lobe 22 – parietal lobe

Hemorrhage

Hemorrhage Extra-axial hemorrhage Intra-axial hemorrhage Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Intra-axial hemorrhage Intraparenchymal hemorrhage Intraventricular hemorrhage

Epidural Hematoma Hemorrhage in the potential space between the inner table of the skull and dura matter Causes Blunt trauma - injury to middle meningeal artery/vein 95% associated skull fracture Signs High-density, Extra-axial Biconvex lens-shaped mass Does NOT cross sutures CAN cross tentorium http://2.bp.blogspot.com/-WLNmeyLfTcc/UFoAXmwYw6I/AAAAAAAAAI0/dxRxzTTlFMc/s320/Epidural_Hematoma.jpg

Epidural Hematoma http://4.bp.blogspot.com/_FYzmMSSuvWc/TKg472aG4GI/AAAAAAAAGAI/l-HBWwDjVYg/s1600/Epidural+hematoma+on+CT+scans+copy.jpg

Subdural Hematoma Hemorrhage in the potential space between the dura mater and the arachnoid space Causes Damage to bridging veins that cross from the cortex to the venous sinuses of the brain Deceleration injuries (MVA) Falls (older patients) Signs High-iso-low density Depends on acuity Concave, crescent shaped CAN cross sutures Does NOT cross midline http://www.aao.org/news/eyenet/200702/images/AMR03_450.jpg

Subdural Hematoma http://www.virtualmedstudent.com/images/subdural_hematoma_all_types.jpg

Subarachnoid Hemorrhage Hemorrhage into the subarachnoid space Between the pia and arachnoid membranes Causes Arteriovenous malformation Aneurysm rupture Trauma Signs Hyperdense Within the sulci and basal cisterns Intraventricular blood http://radiopaedia.org/cases/diagram-intracranial-haemorrhage

Subarachnoid Hemorrhage http://3.bp.blogspot.com/-S2FFYPnqres/TtKb1Xq5hvI/AAAAAAAA4aQ/WECykpGDqAY/s1600/SAH+CT+brain.jpg

Intraparenchymal Hemorrhage Hemorrhage within the brain parenchyma Causes Hypertensive/Hemorrhagic Stroke Trauma Blood Vessel abnormalities Arteriovenous Malformation Aneurysm Rupture Intracranial Neoplasm Cerebral Amyloid Angiopathy Coagulopathy http://www.webmd.com/brain/brain-hemorrhage-bleeding-causes-symptoms-treatments

Intraparenchymal Hemorrhage Signs Well demarcated area of high attenuation Surrounded by hypoattenuation Edema Associated mass effect Compression of ventricles Effacement of sulci Midline shift Subtentorial herniation Can have intraventricular blood http://www.surgery.ucsf.edu/eastbaytrauma/Protocols/ER%20protocol%20pages/intracerebral%20fig4.gif

Intraparenchymal Hemorrhage Trauma - Closed head injury Coup (Point of impact) Shearing of small intracerebral vessels Countercoup (Opposite the point of impact) Acceleration/deceleration injuries Brain propels in the opposite direction http://www.braininjury.com/images/injured01.gif http://images.radiopaedia.org/images/2085692/26a340184c958b0bdc47058798af58.jpg

Intraparenchymal Hemorrhage Hypertensive Hemorrhagic Stroke 15% of strokes Location Basal ganglia, thalamus, pons, cerebellum http://images.radiopaedia.org/images/611986/a8430add000a9365d8fe6022d833ee.jpg http://images.radiopaedia.org/images/557327/44332fb460f093f44abb3fc2486c87.jpg

Intraventricular Hemorrhage Hemorrhage in the ventricular system Cause - Breakthrough bleeding Brain contusion or subarachnoid hemorrhage Signs Most common location Occipital horns (lateral ventricles) Can cause obstructing hydrocephalus

Intraventricular Hemorrhage http://www.ajnr.org/content/30/10/1877/F3.large.jpg

Brain Tumors

Most Common Brain Tumors Intra-axial mass Metastasis Primary intra-axial mass - ADULTS Glioblastoma multiforme Primary intra-axial mass – CHILDREN Medulloblastoma (PNET) Extra-axial mass Meningioma

Brain Metastasis Most common intra-axial mass Primary Malignancies Lung, Breast, Melanoma Signs Well-defined Near Gray-White Junction Multiple or Solitary Surrounding edema Enhances with contrast

Brain Metastasis SOLITARY MULTIPLE http://www.aboutcancer.com/brain_met_mri_2.htm http://braintumors.in/yahoo_site_admin/assets/images/brain_mets.38232748_std.3 SOLITARY MULTIPLE

Glioblastoma Multiforme Gliomas are the most common primary intra-axial malignancy in adults GBM – most common glioma Poor prognosis Male (age 65-75) > Female Signs Supra-tentorial Necrotic and Infiltrative Cross midline – “butterfly” glioma Enhances with contrast Significant vasogenic edema, mass effect

Glioblastoma Multiforme http://radpod.org/wp-content/uploads/2007/04/butterfly700.jpg http://img.medscape.com/pi/emed/ckb/radiology/336139-340870-8134.jpg

Medulloblastoma Most common primary intra-axial tumor in children Primitive neuroectodermal tumors (PNET) Male > Female Peak age 3-5 years Signs Infratentorial – Cerebellum Effacement of the 4th ventricle, basal cisterns Hydrocelphalus Hyperdense Necrosis +/- Calcifications Enhances with contrast http://radiopaedia.org/articles/medulloblastoma

Medulloblastoma http://reference.medscape.com/article/987886-overview http://wiki.cns.org/wiki/images/6/60/MedulloMRI.jpg

Meningioma Most common extra-axial mass Benign - Slow growing – good prognosis Middle-aged Female > Male Association - NF-2 Signs Hyperdense +/- calcifications +/- edema Enhance with contrast Dural Tail http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/brain_tumor/center/meningioma/img/meningioma3-ian-suk.jpg

Meningioma http://neurosurgery.ucla.edu/images/Meningioma/Meningioma_general.jpg http://images.radiopaedia.org/images/482108/1e4ab0b2dd02ddf1065da379208c03.jpg

Please read the supplemental article on cervical spine trauma Questions? Please read the supplemental article on cervical spine trauma Neuro quiz will be administered on Thursday at 11:30AM before conference Major Text Reference for Power Point: Learning Radiology: Recognizing the Basics By William Herring