รศ. พ.ญ. จิรพร เหล่าธรรมทัศน์Advanced Diagnostic and Image-Guided Minimal Invasive Therapy Center (AIMC)

Ramathibodi HospitalMahidol University

Basic Neuroimagings

AIMC

Learning Objectives The main purpose of this lesson is to stimulate the students to recognize the value of gross anatomy and physiology of the CNS as major foundations in clinical practice. The students will be able to   1.   Understand the principles of CT, MRI, Angiography PET and SPECT 2.     Recognize the multiplanar normal neuroimaging anatomy   3. Recognize the imaging of the CSF pathway, intracranial arteries and venous system

Content Outlines

1.     Basic knowledge of CT, MRI, Angiography, PET and SPECT2.     CT scan of the nervous system3.     MRI of the nervous system4.     Vascular imaging of the CNS: angiography, CT angiogram and venogram and MRA/MRV

Learning Organization

1.     Study the learning materials provided in advanced2.     Lecture 40 minutes3.     Questions and answers 10 minutes

    Self study of the following topics 1. Meninges and intracranial spaces 2.  Intracranial vascular circulation 2.1 Cervical and intracranial carotid and vertebrobasilar system 2.2       Circle of Willis 2.3       Deep and superficial cerebral veins 2.4       Dural venous sinuses  3. Structural and functional correlation of the nervous sys. 3.1       Visual pathway and cortex 3.2       Language center: Broca’s and Wernicke’s 3.3       Auditory cortex 3.4       Motor and sensory cortex 3.5       Brain stem 3.6       Pituitary gland

Imaging Modalities1. Plain films/ Tomogram2. Ultrasonogram3. CT4. MRI5. Myelogram6. Angiogram7. Venogram8. Nuclear SPECT/ PET

Magnetic Rasonance Imaging(MRI)

Computed Tomography(CT)

Ultrasonogram

Digital C-arm

Computed Radiography

Imaging Modalities

Digital Angiography

PET ScanImages in

Mices: Differences in

Thymidine kinase gene expression

Metabolic Imaging

The brain1. The cerebral hemispheres2. The posterior fossa3. The deep gray nuclei4. White matter tracts5. The ventricular system6. The meningies7. Vascular supply8. Venous drainage

Normal CT Anatomy

Normal CT Anatomy

Basal Ganglion

Normal gray-white matter

Foramen Magnum Base of Skull

The posterior fossa

C1-2

Foramen Magnum

Cervicomedullary Junction

Hypoglossal nerve canal

Brain Stem

Sagittal Midline MRI

Brain stem

pons

cerebellum

temporal lobe

cerebellar peduncle: middle

Medulla

Pons- CPA - IAC Middle Cerebellar Peduncle

Cerebellum

Cerebellar hemisphere Cerebellar vermis

Pons-Cerebellum

Infundibulum

Mid Brain

Third Ventricle Tectal Plate

Brain Parenchymal Anatomy

The cerebral hemispheres

1. Frontal lobes2. Parietal lobes3. Temporal lobes4. Occipital lobes5. Insular lobes6. Limbic lobes

Occipital lobe

frontal

Posterior FossaTemporal Lobes

Uncus: Temporal Horn

Hypothalamus Midbrain- Aqueduct

Frontal -Temporal Occipital Lobes

Frontal and Parietal Lobes

Centrum SemiovaleFronto-parietal lobes

Concept of Blood Brain BarrierNo C

+C

Central Sulcus:The Fronto-Parietal Boundary

No C

+C

BG- Pineal- Thalamus

Higher Sensitivity: fMRI

Finger tappingfMRI

Functional Brain Anatomy

1. Primary Motor cortex2. Primary Sensory Cortex3. Primary Visual Cortex4. Primary Auditory Cortex5. Language

1. Broca’s area2. Wernicke’s area

Functional Cortical Brain Mapping

Blood Oxygen Level Dectection :Bold Effect

Combined visualization of fMRI maps and EEG/MEG multiple

dipole models

Central sulcus

*

Hand motor area

Precentral gyrus

Postcentral gyrus

central sulcus

Cingulate sulcus**

Motor Cortical brain mapping:Glioma

Cognitive - Picture Encoding

Picture Encoding

Auditory cortexAuditory cortex

Internal Medicine Review November 11,2001

The Ventricular System

The ventricular system• Lateral ventricles

– Frontal horn– Body– Temporal horn– Trigone– Occipital horn

• Third ventricle• Aqueduct of Sylvius• Forth ventricle• The Foramina of Magendie and Luschka

Concept of CSF-Brain Barrier

The Lateral Ventricle:frontal horn, body,

occipital horn, trigone & temporal horn

f

b

o

tr

t

trt

fo

t

tr

f

b

o

b

The Foramen of Monro

The Third Ventricle

3rd 3rd

3rd

Basal Ganglion Frontal Horn

Pulvinar

The aqueduct of Sylvius

Suprasellar CisternTemporal horns

Aqueduct of Sylvius

The Forth Ventricle

4th 4th

4th

4th

4th

4th

The Foramina of Magendie and Luschka

4th

4th

FM

FM

FL FL

Foramen of Lushka and Magendie

Fourth Ventricle

Frontal Horns Foramen of Monroe

Third VentricleGlomus of the choroid Plexus

Aqueduct of SylviusPineal Gland

Third Ventricle Aqueduct of Sylvius

Perimesencephalic Cistern

Frontal HornsTrigone

Occipital Horns

Body of The Lateral Ventricle

Corona Radiata

Centrum Semiovale

Pituitary FossaVisual Pathway

Sellar-suprasellar Region

Sellar tursica

Sellar tursica

Hypothalamus

Suprasellar cistern

Suprasellar cistern

Infundibulum

Infundibulum

Hypothalamus

Normal CT Anatomy

Pituitary Fossa

Suprasellar Cistern Optic Apparati

Hypothalamus opticTracts-Radiations

Optic RadiationCalcarine cortex

White Matter Tracts

Commisure fibers (corpus callosum)Projection fibers (internal capsule)Cortico-cortical association fibers (IFO)

Fiber tracking: DTI

Central sulcus

*

Hand motor area

Precentral gyrus

Postcentral gyrus

central sulcus

Cingulate sulcus**

Central Sulcus

Centrum Semiovale

Body of the Lateral Ventricle

Coronal Radiata

The Corpus Callosum

ThalamusBasal Ganglion Frontal Horn

Pulvinar

Suprasellar Cistern- Optic Chiasm

Mid pons

Pons

Medulla

Cervicomedullary Junction

Fornix

Meningies

Intracranial spaces

Normal Meningeal Enhancement: CT

NORMAL DURAL ENHANCEMENT: MRI

EXTENSIVE DURAL ENHANCEMENT History:A 45 y.o. F presented with sudden onset of thunderclap headche for 1 week starting from bil. temporal areas progressing to the occiput with recent posterior right sided neck and occiput pain.

Vascular SupplyAnd

Venous Drainage

Circle Of Willis

Cerebral Angiogram

CT Angiogram of the Brain and Neck

MRA: Pipe 2DTOF MRA: Neck 3DTOF MRA: Brain

Suprasellar Cistern

Circle of willis

Sylvian Fissure

Examples of “CE-TOFMRA”

Routine 2DTOFMRA of the neck: inplane flow

artifact is demonstrated.

Contrasted TOFMRA of the neck demonstrating no inplane flow artifact

2DTOFMRA with superior saturation band showed only RVA

2DPCMRA with all directions encoded (VENC 50 cm/sec) showed bilateral VA

RVA

LVA

VENC

2DPCMRA with SI encoding direction showed bilateral

VA with different flow directions

contrasted 3DTOFMRA showed bilateral VA,complete occlusion of the left CCA and SCA origins but well visualized LVA

DIAGNOSIS SUBCLAVIAN

STEAL SYNDROME

Takayasu’s arteritis: routine and contrasted MRA

Dural Venous Sinuses

Dural Venous sinuses

MRV

2DPC

2D PC MRV

3D PC MRV

2DTOFMRV: AVM

Superior Sagittal Sinus

SSS

Third VentriclePineal Gland

Internal Cerebral Vein

Basal Vein of Rosenthal

Straight Sinus

TransverseSigmoid Sinuses

Sigmoid SinusJugular foramen

Ramathibodi Hospital