1. Neuroradiology

2. CT Basics Neuroradiology The BASICS of CT –CT History –Protocol –Terminology –Contrast –Radiation Safety –Cases

3. CT Basics Neuroradiology The BASICS of CT –CT History –Protocol –Terminology –Contrast –Radiation Safety –Cases

4. CT Basics No disclosures

5. Neuroradiologist A consultant in imaging and disease of the brain, spinal cord, head, neck, face and peripheral nerves

6. Neuroradiology Plain Film CT US MRI Interventional –Angiography –Myelography –Biopsy Nuclear Medicine

7. Neuroradiology A request for an exam is a consultation –History –Pertinent physical exam findings Lab results –Creatinine –PT/INR –What is the question?

8. CT Basics Computed tomography (CT) Computed axial tomography or computer – assisted tomography (CAT)

9. CT Basics

10. Neuroradiology The BASICS of CT –CT History –Protocol –Terminology –Contrast –Radiation Safety –Cases

11. CT History 1972 – First clinical CT scanner –Used for head examinations –Water bath required –80 x 80 matrix –4 minutes per revolution –1 image per revolution –8 levels of grey –Overnight image reconstruction

12. CT History 2004 – 64 slice scanner –1024 x 1024 matrix –0.33s per revolution –64 images per revolution –0.4mm slice thickness –20 images reconstructed/second

13. CT Basics Neuroradiology The BASICS of CT –CT History –Protocol –Terminology –Contrast –Radiation Safety –Cases

14. CT Protocolling What happens when an exam is requested? –A requisiton is completed. –The requested exam is protocolled according to history, physical exam and previous exams. –The patient information is confirmed. –The exam is then performed. –Images are ready to be interpreted in … Uncomplicated exam – 5-10 minutes after completion Complicated exams with reconstructions take at least 1 hour but usually 1-2 hours.

15. CT Protocolling CT head protocols –With or Without contrast –CT Brain –CT Brain with posterior fossa images –CT Angiogram/Venogram –CT Perfusion –CT of Sinuses –CT of Orbit –CT of Temporal bones –CT of Mastoid bones –CT of Skull –CT of Face

16. CT Protocolling Variables –Plain or contrast enhanced –Slice positioning –Slice thickness –Slice orientation –Slice spacing and overlap –Timing of imaging and contrast administration –Reconstruction algorhithm –Radiation dosimetry

17. CT Protocolling Patient Information –Is the patient pregnant? Radiation safety –Can the patient cooperate for the exam?

18. CT Basics Neuroradiology The BASICS of CT –CT History –Protocol –Terminology –Contrast –Radiation Safety –Cases (Stroke)

19. CT Terminology Exams using Ionizing radiation –Plain film –CT 1/10 of all exams 2/3 OF RADIATION EXPOSURE –Fluoroscopy Angiography, barium studies –Nuclear medicine V/Q scan, bone scan

20. CT Terminology Attenuation –Hyperattenuating (hyperdense) –Hypoattenuating (hypodense) –Isoattenuating (isodense) Attenuation is measured in Hounsfield units –Scale -1000 to 1000 -1000 is air 0 is water 1000 is cortical bone

21. CT Terminology What we can see –The brain is grey White matter is usually dark grey (40) Grey matter is usually light grey (45) CSF is black (0) Things that are brite on CT –Bone or calcification (>300) –Contrast –Hemorrhage (Acute ~ 70) –Hypercellular masses –Metallic foreign bodies

22. CT Terminology Voxel –Volume element A voxel is the 2 dimensional representation of a 3 dimensional pixel (picture element). –Partial volume averaging

23. CT Terminology

24. Window Width –Number of Hounsfield units from black to white Level or Center –Hounsfield unit approximating mid-gray

25. CT Terminology

26. CT Artifacts

27. CT Terminology Digital reading stations are the standard of care in interpretation of CT and MRI. Why? –Volume of images –Ability to manipulate and reconstruct images –Cost

28. CT Terminology DICOM –Digital Imaging and Communications in Medicine –DICOM provides standardized formats for images, a common information model, application service definitions, and protocols for communication.

29. CT Basics Neuroradiology The BASICS of CT –CT History –Protocol –Terminology –Contrast –Radiation Safety –Cases

30. Contrast Barium Iodinated –vascular –Biliary, Urinary –CSF Gadolinium

31. Contrast

32. Types of iodinated contrast –Ionic –Nonionic - standard of care No change in death rate from reaction but number of reactions is decreased by factor of 4. If an enhanced study is needed, patient needs to be NPO at least 4 hours and have no contraindication to contrast, ie allergy or renal insufficiency.

33. Contrast What are the risks of iodinated contrast? –Contrast reaction 1 in 10,000 have true anaphylactic reaction 1 in 100,000 to 1 in 1,000,000 will die –Medical Issues Acute renal failure Lactic acidosis in diabetics »If on Glucophage, patient must stop Glucophage for 48 hours after exam to prevent serious lactic acidosis Cardiac –Extravasation

34. Contrast Who is at risk for an anaphylactic reaction? –Patients with a prior history of contrast reaction –Patients with a history asthma react at a rate of 1 in 2,000 –Patients with multiple environmental allergies, ie foods, hay fever, medications Amin MM, et al. Ionic and nonionic contrast media: Current status and controversies. Appl Radiol 1993; 22: 41-54.

35. Contrast Pretreatment for anaphylaxis –50 mg Oral Prednisone 13, 7 and 1 hour prior to exam –50 mg oral Benedryl 1 hour prior to exam –In emergency, 200 mg iv hydrocortisone 2-4 hours prior to exam

36. Contrast What are the risk factors for contrast induced acute renal failure? –Pre-existing renal insufficiency –Contrast volume –Dehydration –Advanced age –Drugs –Multiple myeloma –Cardiac failure

37. Contrast Considerations in patients with renal insufficiency –Is the exam necessary? –Is there an alternative exam that can answer the question? –Decrease contrast dose

38. Contrast Pretreatment for renal insufficiency –Hydration –Mucomyst 600 mg po BID the day before and day of study Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. Tepel M, et al. N Engl J Med 2000 Jul 20;343(3):180-4

39. Contrast Contrast induced renal failure –Elevated creatinine 24-48 hours after contrast which resolves over 7-21 days. –Can require dialysis Mehran, R. et al. Radiocontrast induced renal failure:Allocations and outcomes. Reviews in Cardiovascular Medicine Vol. 2 Supp. 1 2001

40. CT Basics Neuroradiology The BASICS of CT –CT History –Protocol –Terminology –Contrast –Radiation Safety –Cases

41. Radiation Safety Diagnostic CT Scans: Assessment of Patient, Physician, and Radiologist Awareness of Radiation Dose and Possible Risks –Lee, C. et al. Radiology 2004;231:393

42. Radiation Safety Deterministic Effects –Have a threshold below which no effect will be seen. Stochastic Effects –Have no threshold and the effects are based on the dose x quality factor.

43. Radiation Safety Terminology –Gy = Gray is the absorbed dose (SI unit) The equivalent of 1 joule/kg of tissue Rad = radiation absorbed dose –Sv = Sievert is the dose equivalent (SI unit) Absorbed dose multiplied by a quality factor Rem = radiation equivalent man

44. Radiation Safety Relative values of CT exam exposure –Background radiation is 3 mSv/year Water, food, air, solar In Denver (altitude 5280 ft.) 10 mSv/year –CXR = 0.1 mSv –CT head = 2 mSv –CT Chest = 8 mSv –CT Abdomen and Pelvis = 20 mSv -The equivalent of 200 CXR

45. Radiation Safety Effects of X rays. –Absorption of photons by biological material leads to breakage of chemical bonds. –The principal biological effect results from damage to DNA caused by either the direct or indirect action of radiation.

46. Radiation Safety Tissue/Organ radiosensitivity –Fetal cells –Lymphoid and hematopoietic tissues; intestinal epithelium –Epidermal, esophageal, oropharyngeal epithelia –Interstitial connective tissue, fine vasculature –Renal, hepatic, and pancreatic tissue –Muscle and neuronal tissue

47. Radiation Safety Estimated Risks of Radiation-Induced Fatal Cancer from Pediatric CT –David J. Brenner, et al. AJR 2001; 176:289-296 Additional 170 cancer deaths for each year of head CT in the US. –140,000 total cancer deaths, therefore ~ 0.12% increase –1 in 1500 will die from radiologically induced cancer

48. Radiation Safety 3094 men received radiation for hemangioma –Those receiving >100 mGy –Decreased high school attendance –Lower cognitive test scores Per Hall, et al. Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study BMJ, Jan 2004; 328: 19 - 0.

49. Radiation Safety Hiroshima and Nagasaki –There has been no detectable increase in genetic defects related to radiation in a large sample (80,000) of survivor offspring, including: congenital abnormalities, mortality (including childhood cancers), chromosome aberrations, or mutations in biochemically identifiable genes. William J Schull, Effects of Atomic Radiation: A Half-Century of Studies from Hiroshima and Nagasaki, 1995.

50. Radiation Safety Hiroshima and Nagasaki –However, exposed individuals who survived the acute effects were later found to suffer increased incidence of cancer of essentially all organs. William J Schull, Effects of Atomic Radiation: A Half-Century of Studies from Hiroshima and Nagasaki, 1995.

51. Radiation Safety Hiroshima and Nagasaki –Most victims with high doses died –Victims with low doses despite their large numbers are still statistically insignificant.

52. Radiation Safety Comparison of Image Quality Between Conventional and Low- Dose Nonenhanced Head CT Mark E. Mullins a, et al. AJNR April 2004. Reduction of mAs from 170 to 90

53. Radiation Safety What does all this mean? –1 CXR approximates the same risk as: 1 year watching TV (CRT) 1 coast to coast airplane flight 3 puffs on a cigarette 2 days living in Denver –1 Head CT is approximately 20 CXR Health Physics Society on the web--http://hps.org

54. Radiation Safety The pregnant patient –Can another exam answer the question? –What is the gestational age? –Counsel the patient 3% of all deliveries have some type of spontaneous abnormality The mother’s health is the primary concern.

55. Radiation Safety "No single diagnostic procedure results in a radiation dose that threatens the well-being of the developing embryo and fetus." -- American College of Radiology "Women should be counseled that x-ray exposure from a single diagnostic procedure does not result in harmful fetal effects. Specifically, exposure to less than 5 rad has not been associated with an increase in fetal anomalies or pregnancy loss." -- American College of Obstetricians and Gynecologists

56. Conclusion Neuroradiologists are consultants Garbage in ------- Garbage out CT Terminology –Attenuation (density) in Hounsfield units –Digital interpretation is standard of care CT has risks –Contrast –Radiation exposure

57. CT Basics Neuroradiology The BASICS of CT –CT History –Protocol –Terminology –Contrast –Radiation Safety –Cases

58. Normal CT

59. 1 day 1 year 2 years

60. Normal CT Older person

61. Normal Enhanced CT

62. Case 1 55 yo female with sudden onset of worst headache of life

63. Case 1

65. What do I do now?

66. CTA

67. Normal Angiography

68. Diagnostic Angiography

69. Case 1 Subarachnoid Hemorrhage –Most common cause is trauma –Aneurysm –Vascular malformation –Tumor –Meningitis –Generally a younger age group

70. Case 2 82 yo male with mental status change after a fall

71. Case 2

72. Subdural hematoma Venous bleeding from bridging veins General presentation –Older age group –Mental status change after fall –50% have no trauma history

73. Subdural Hematoma

74. Case 3 44 yo female with right sided weakness and inability to speak

75. Case 3

76. Acute ischemic left MCA stroke

77. MCA Stroke “Dense MCA”

78. Case 4 50 yo male post head trauma. Pt was initially conscious but now 3 hours post trauma has had a sudden decrease in his neurological function.

79. Case 4

80. Epidural hematoma –Typical history is a patient with head trauma who has a period of lucidity after trauma but then deteriorates rapidly. –Hemorrhage is a result of a tear through a meningeal artery.

81. Case 5 71 yo male who initially complained of incoordination of his left hand and subsequently collapsed

82. Case 5

83. Intraparenchymal hemorrhage –Hypertensive –Amyloid angiopathy –Tumor –Trauma

84. Case 6 62 yo female acute onset headache – Hemiplegic on the right and unable to speak

85. Case 6 Add htn image here

86. Case 6 Hypertensive hemorrhage –Clinically looks like a large MCA stroke –Generally younger than amyloid angiopathy patients

87. Chronic Ischemic change = Encephalomalacia

88. Thrombolysis: Intravenous –3 hours Intra-arterial –6 hours ICA territory –24 hours basilar territory CT head plain shows no established stroke nor hemorrhage CT perfusion shows a salvagable penumbra

89. Case 7 53 y.o. male Sudden onset of ataxia loss of consciousness proceeding rapidly to coma

91. Case 7 Probable basilar occlusion with cerebellar and brainstem infarction

92. Case 8 52 yo male with right sided weakness

93. Case 8

95. Acute lacunar infarction –Cannot reliably differentiate this finding on CT from remote lacune without clinical correlation. –MRI with diffusion is the GOLD STANDARD –A word on TIA

96. Chronic Small Vessel Disease

97. Case 9 59 yo female with multiple falls over last weekend

98. Case 9

99. Stroke involving caudate head, anterior limb internal capsule and anterior putamen. What is the artery? Recurrent artery of Heubner

100. Case 10 42 yo male found in coma

101. Case 10

102. Global ischemia

103. Angiographic Brain Death

104. Case 11 24 yo male with siezures

105. Case 11

106. Heterotopia

107. Case 12 34 y.o. female Severe H/A,nausea Taking oral contraceptives

108. Case 12

110. Transverse sinus thrombosis