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Neuro Radiology

Neurology

QuestionAnswer
MRI: T1/T2 T1: fat bright (water dark); T2: water bright (fat dark)
Spinal cord abnormalities: imaging usually MRI (if CI: myelogram)
Nuclear imaging: indications Blood Flow; Brain Activity (Alz dz, Parkinson, Epilepsy); suspected brain death; mets
quadrigeminal cistern appearance on imaging: should smile
suprasellar cistern appearance (if healthy): resembles a star
Trauma/Bleeds: imaging of choice noncontrast CT
Head trauma: 5 questions Is middle of brain in middle of head? Symmetry? Suprasellar cistern = star? 4th ventricle midline & symmetric? Lateral ventricle effaced?
Lucid interval seen in what trauma? epidural hematoma
epidural hematoma: appearance on CT lenticular (biconvex)
subdural hematoma: blood source usually venous (bridging veins in space)
subdural hematoma: etiology Acceleration/ Deceleration injury; Veins transversing subdural space
subdural hematoma: appearance on CT Cross suture lines and extends over larger area; Crescent shaped
SAH: etiology Trauma, Drugs, or Ruptured Aneurysm. Sx: thunderclap/ worst HA of my life
SAH: appearance on CT Linear, within cisterns and sulci; bleed follows outlines of the gyri
Le Fort I: Floating palate, fx maxillary sinus
Le Fort II: Pyramidal fx, medial orbital and lateral maxilla
Le Fort III: Craniofacial disjunction, horizontal orbits
Orbital blowout fx comminuted floor fx: herniated orbital contents; inf rectus mx entrap or vert diplopia d/t edema; blood in max sinus when orbital trauma
Nasal bone fx prob not need CT, but need look in nose
Spine x-ray: 5 lines Prevertebral ST: should be thin. Anterior & posterior vert lines: should be aligned vertically. Spinolaminar line: join spinous process & lamina: should be aligned vertically. Ensure none of spinous processes are fractured. Check facet joints
Spondylolisthesis: look also for: facet fx
Normal disk on MRI: low T1 signal, High T2 (nuc pulposus is mostly water); normal disks do not extend past margin of vert
Degenerative disk on MRI: dehydrates: decreased T2; loses height
Spinal cord lesion types: Demyelination; Cysts; Infarction; Tumor
Demyelination on MRI patchy T2 signal; may be d/t: MS; Post infectious Myelitis; Compressive Myelopathy; Post Radiation
Spinal cord infarction on MRI Gray Matter Affected Preferentially: H-pattern high T2 signal
Spinal cord tumors may be: Ependymomas; Astrocytomas; Hemangioblastomas; Mets
CVA 3d leading COD; 75% infarction, 25% hemorrhage; cell death; Na pump fail; Na influx; cytotoxic edema; gray matter usu gets more blood, suffers more w/infarct;
Edema on MRI T1: dark; T2: bright
Purpose of CT in CVA Not dx; only to r/o other conditions that would CI some tx (tumor, bleed)
2/3 of all cerebral infarcts are: MCA stroke
CVA on CT Hyperdense Artery Sign; Loss of grey; CT normal up to 12 hours post; insula ribbon sign: blurring of gray-white junction
Brain neoplasm: imaging of choice MRI
Brain neoplasm: presentation Increased ICP (HA, Seizure, Neuro Deficit); Hydrocephalus (HA, N/V, Papilledema)
Brain neoplasm: Extra-axial: Meninges, Ventricles, Skull
Brain neoplasm: Intra-axial: Brain parenchyma
Astrocytoma Glial tumors: 40-50% of CNS Neoplasms
Astrocytoma: Grade IV GBM (45-55 yo); necrosis/ hemorrhage, edema, ring enhancement
Meningioma 50-60 yo; may increase in PG; various grades (90% benign)
Brain neoplasm: mets 1/3 of all intracranial neoplasms; lung, breast, melanoma, colon, lymphoma, prostate
Brain neoplasm: imaging Gray-White matter junction; Marked Edema; Can be multiple, bilateral
Brain neoplasm: most common site for kids (unlike adults) posterior fossa (medulloblastoma)
Head & Neck ca SCCA; older, smoker OR younger, HPV-associated
Acute sinusitis imaging not needed (but show air-fluid levels or complete opacification; H flu, SP, or M Cat (kids)
Chronic sinusitis: imaging: not needed; shows mucosal thickening, wall indistinctness
Croup laryngotracheitis/ bronchitis; barking seal cough, fever, hoarse; steeple sign on imaging
Epiglottitis Acute fever, dysphagia, stridor, sniffing position, resp fail; formerly H flu, now SP; Imaging: Thumb print sign
AIDS-related CNS infxn: imaging of choice MRI; 2/3 develop CNS infxn
MS imaging MR sensitive, but not diagnostic; Periventricular T2 bright signal: inflammation
NPH Chronic hydrocephalus; Sx: incontinence, gait abnormalities, dementia; CT: Ventriculomegaly out of proportion to sulcal prominence
Imaging findings assoc w/ 4 stages of brain abscess evolution early cerebritis (swollen/edema; high T2); late cerebritis (inc central necrosis; vasogenic edema at edges); early capsule; late capsule (well define ring)
Meningioma: imaging Often Along Brain Surface; Hyperdense, Homogeneous Enhancement
Lacunar infarct: if R upper extremity deficit = Lesion is at subthalamic nucleus on left
Cerebral aneurysm imaging of choice Angiography is definitive. CT / MRI may not be thorough enough for smaller
ICH / SAH imaging of choice Noncontrast CT > MRI. Avoid LP.
MRI for CVA: Diffusion weighted is more sensitive thatn nondiffusion weighted for cerebral ischemia
3 mHz spike-and-wave on EEG Absence (petit-mal) seizures
Atheroembolic stroke dx studies Normal head CT. Carotid Doppler: high grade stenosis (eg, left ICA). Also do MRA, CTA, catheter angiography
Cardioembolic stroke imaging results: Carotid US normal (no brain large vessel problem)
Cardioembolic stroke: dx studies pulse; EKG; 24-48 hr EKG; TTE (microcavitation); TEE
Asymptomatic carotid stenosis: dx studies Carotid bruit; Doppler US; MRA, CTA
best modality to distinguish ischemic from hemorrhagic stroke: CT
TIA definitive study: arteriography; MRA more common (less invasive)
TIA dx studies CT or MRI to r/o cerebral hemo; cardiac w/u; cbc, esr, coags, antiphospholipids; Poss echo, ecg, carotid doppler
SAH dx studies CT (90%); CSF: hi opening P & bloody fluid; cerebral angiography, EEG
EEG: focal rhythmic discharge at onset, poss no ictal activity seen: simple partial seizure
EEG: interictal spikes assoc w/slow waves in temporal/frontotemp complex partial seizure
MS: MRI findings multiple characteristic white matter lesions or plaques: periventricular or subcortical U-fibers, corpus callosum lesions
MS: types of dx criteria Schumacher; Poser: Macdonald
Ring enhancing lesion is usually: abscess or tumor
Symptoms from plateau waves Transitory episodes of altered consciousness & visual disturbances
Brain tumor: eval & dx H&P; CT +/- MRI; EEG; LP; PET
Trauma/Bleeds: imaging of choice noncontrast CT
epidural hematoma: appearance on CT lenticular (biconvex)
subdural hematoma: appearance on CT Cross suture lines and extends over larger area; Crescent shaped
SAH: appearance on CT Linear, within cisterns and sulci; bleed follows outlines of the gyri
Normal vertebral disk on MRI: low T1 signal, High T2 (nuc pulposus is mostly water); normal disks do not extend past margin of vert
Degenerative disk on MRI: dehydrates: decreased T2; loses height
Spinal cord lesion types: Demyelination; Cysts; Infarction; Tumor
Demyelination on MRI patchy T2 signal; may be d/t: MS; Post infectious Myelitis; Compressive Myelopathy; Post Radiation
Spinal cord infarction on MRI Gray Matter Affected Preferentially: H-pattern high T2 signal
Edema on MRI T1: dark; T2: bright
Purpose of CT in CVA Not dx; only to r/o other conditions that would CI some tx (tumor, bleed)
Brain neoplasm: imaging of choice MRI
Brain neoplasm: imaging Gray-white matter junction; marked edema; can be multiple, bilateral
AIDS-related CNS infxn: imaging of choice MRI; 2/3 develop CNS infxn
MS imaging MR sensitive, but not diagnostic; Periventricular T2 bright signal: inflammation
NPH on CT Ventriculomegaly out of proportion to sulcal prominence
Imaging findings assoc w/ 4 stages of brain abscess evolution early cerebritis (swollen/edema; high T2); late cerebritis (inc central necrosis; vasogenic edema at edges); early capsule; late capsule (well define ring)
Meningioma: imaging Often along brain surface; hyperdense, homogeneous enhancement
Ulnar neuropathy: Dx Hx; EMG/NCS can help find site of lesion
Sciatic n. palsy: Dx tests EMG/NCS (distinguish from peroneal neuropathy); xray
Charcot-Marie-Tooth Dx: H&P; DNA testing; Nerve/mx bx (confirmatory); EMG/NCS
Charcot-Marie-Tooth: EMG/NCS CMT I: segmental demyelination; reduced motor & sensory conduction velocity; CMT II: axonal loss; normal/sl dec motor conduction, dec SNAPs; chronic partial denervation in affected mx
Dejerine-Sottas Dz: Dx high CSF pro; EMG/NCS: dec motor velocity, sensory conduction
Refsum dz: Dx findings CSF protein normal; nerve bx; EMG/NCS: dec motor velocity, sensory conduction
Guillain-Barre dx studies NCS: slow S/M nerve conduction velocities; poss denervation/axonal loss; CSF high pro
MG dx studies NCS: decrementing mx response; CXR to r/o thymoma; serum acetylcholine Ab
Huntington dz on CT atrophy of cerebrum & caudate nucleus
Huntington dz on MRI/PET decreased glucose metab
Neuroimaging not needed when: No focal neuro findings; Pt has stable pattern of recurrent HA; No h/o seizures
HA: Consider neuroimaging when: Neuro exam abnormal; progressively worsening HA; new persistent HA; new, rapid onset HA (thunderclap headache); HA does not respond to standard tx
lemon sign on US Myelomeningocele: 2 frontal bones appear convex inward
banana sign on US Myelomeningocele: elongated and curved posterior fossa 2/2 Chiari malformation
5 steps to dx & tx pt w/suspected brain tumor MRI is TOC to confirm; Pan CT of chest/abd/pelvis to detect other tumors; Bx of distant tumor or Br tumor resection to confirm patho; xrt/CTx for malig; F/U MRI, PET
Fisher grade is used to: classify appearance of SAH on scan
Hunt Hess scale is used to: classify severity of symptoms in SAH
Alzheimer dx dx of exclusion (neuropsych eval); MRI/CT: hippocampal atrophy; amyloid on PET (Pittsburgh B); LP: inc tau, dec amyloid-beta 42
NCS uses electrodes; record response to shock (amp & timing)
EMG uses needle; electrical activity observed during rest & activitation
NCS / EMG utility: suspicion of peripheral nerve or mx injury; detect CTS; investigate polyneuropathy /poss etiology or radiculopathy
Evoked potential studies to study conduction of CNS pathways; electrodes on scalp; brain potentials recorded in response to stim
Evoked potential studies: 3 kinds: Visual; Brainstem (auditory); Somatosensory
Evoked potential studies: useful to dx: MS (VEP, SSEP), spinal cord diseases
Visual evoked potential: optic neuritis: After optic neuritis, the VEP will often remain abnormal indefinitely even after recovery of vision
SSEP record potentials from stimulus at wrist or ankle
Acoustic neuroma (vestibular schwannoma): dx with: CT or MRI; surgical tx
Causes of fing-enhancing lesion (mnemonic) MAGIC DR: metastases, abscess, glioblastoma, infection (HIV/toxo, parasite) / infarct, contusion, demyelinating dz, radiation necrosis / resolving hematoma
Created by: Abarnard