1. BRAINSTORM Understanding Diagnostic Scans: MRI, CT, PET AND MORE Stanley Lu, MD Director, Neuroradiology Monmouth Medical Center March 5, 2012

2. Neuroradiology What is a Neuroradiologist? Design imaging protocols Interpret scans - make diagnosis Provide reports Consult with the Brain Tumor Team Suggest follow-up plan

3. Neuroradiology Imaging of the brain Tumors Stroke Infection Imaging of the spine

4. Neuroradiology Imaging modalities Computed tomography (CT) Magnetic resonance imaging (MRI) Advanced techniques Positron emission tomography (PET) Diagnosis - Different appearances for different tumors

5. Neuroradiology Post-operative assessment Tumor monitoring Challenges

6. CT Technique

11. MRI Technique

12. What is MRI? How does it work?

13. MRI Technique

14. Z-axis

15. MRI Technique Z-axis

16. MRI Technique

18. MRI Advantages Superior contrast resolution especially for soft tissue Multiplanar No ionizing radiation

19. MRI Disadvantages Higher cost Lower availability Longer study increased chance of patient motion Claustrophobia Metallic implants contraindicated pacemakers, aneurysm clips, etc.

20. Brain Tumors

21. Metastatic disease Meningioma Primary brain tumors Astrocytoma Oligodendroglioma Lymphoma

22. Brain Tumors Metastatic disease Meningioma Primary brain tumors Astrocytoma Oligodendroglioma Lymphoma

23. Metastatic Disease Pt with melanoma

24. Brain Tumors Metastatic disease Meningioma Primary brain tumors Astrocytoma Oligodendroglioma Lymphoma

25. Meningioma

26. Brain Tumors Metastatic disease Meningioma Primary brain tumors Astrocytoma Oligodendroglioma Lymphoma

27. Brain Tumors Astrocytoma WHO Grading Grade I: small subset Grade II: Low-grade astrocytoma Grade III: Anaplastic astrocytoma Grade IV: Glioblastoma multiforme (GBM)

28. Low-grade Astrocytoma

29. Anaplastic Astrocytoma

30. GBM

31. Gliomatosis Cerebri

32. Management of GBM Pre-operative Full brain MRI with STEALTH MR tractography Post-op day #1 Follow-up at 2-3 months, and further As needed, with new symptoms

33. Management of GBM Pre-operative Full brain MRI with STEALTH MR tractography Post-op day #1 Follow-up at 2-3 months, and further As needed, with new symptoms

34. Management of GBM Pre-operative Full brain MRI with STEALTH MR tractography Post-op day #1 Follow-up at 2-3 months, and further As needed, with new symptoms

35. MR Tractography

36. Disorganized water Water organized along neurons

37. MR Tractography

40. Management of GBM Pre-operative Post-op day #1 Follow-up at 2-3 months, and further As needed, with new symptoms

41. Management of GBM Pre-operative Post-op day #1 Follow-up at 2-3 months, and further As needed, with new symptoms 18 mo.

42. Pt #2: Two follow-up scans Dec 2007Jan 2008

43. Pt #3: Multiple follow-up scans 1 mo.Post-opPre-op

44. Pt #3: Multiple follow-up scans 1 mo.8 mo.4 mo.Post-opPre-op

45. Pt #4: Follow-up scan

46. ?

48. Challenge of Pseudo-progression We have great difficulty distinguishing real from pseudo Modalities that we utilize PET MR spectroscopy MR perfusion

49. Positron Emission Tomography (PET)

53. MR Spectroscopy

57. MR Perfusion

60. Summary What is a Neuroradiologist? Neuroradiology modalities CT MRI PET Astrocytomas Grades and appearances Radiologic follow-up Challenges and advanced techniques

61. Suggestions Know if a Neuroradiologist is involved with your care Know if your hospital has a Brain Tumor Board Know if the imaging facility can perform advanced techniques Get your scans at one place!

62. Thank You Any questions, medical or personal? Email me at slu@barnabashealth.org