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Making the best use of MRI/CT
in the emergency setting
Adaptation: TW Stadnik MD,PhD*
Hôpitaux IRIS SUD
Universitair Ziekenhuis UZ Vrije Universiteit Brussel
(*) Radiology Department
Laarbeeklaan 101 1090 BRUSSEL
tel. 32-2-4775319, fax. 32-2-4775362
e-mail [email protected]
Collège Radiologie/Médecine d’urgence
Société Française de Radiologie
The Royal College of Radiologists
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•Ischemic vascular stroke?with onset of symptoms <>6 h•Acute disorders of behavior,
consciousness or delirium?
•Cerebral venous thrombosis?•Carotid dissection?•Rapidly progressive neurological deficit with immunosuppression or fever•Head and spine trauma•Take Home Points
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1h deadline or less if IV thrombolysis possible
Examinations:
MRI (T2, Flair, Diff, Perfusion, Angio MRI)
or CT scan without injection followed by Perf CT and CT
angiography
MRI is superior to CT imaging (diffusion weighted
imaging)
CT is clearly superior to MRI if the patient is agitated
Ischemic vascular stroke?with onset of symptoms <6 h
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Ischemic vascular stroke?with onset of symptoms <6 h
Good candidate for thrombolysis
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Ischemic vascular stroke?with onset of symptoms <6 h
Patient after thrombolysis
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Ischemic vascular stroke?with onset of symptoms <6 h
Poor candidate thrombolysis
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Deadline: 24 hourshours
Exams: Scanner without injection
or non enhancedCT followed by angioCT
or MRI with angio sequences.
Deadline: 24 hourshours
Exams: Scanner without injection
or non enhancedCT followed by angioCT
or MRI with angio sequences.
Ischemic vascular stroke?with onset of symptoms >6 h
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Ischemic vascular stroke?with onset of symptoms >6 h
A691124DR00W
41 year old man with acute paresis
right hand, dysarthria
Known hyperlipidemia, smoking,
recent history of a traumatic fracture
of a rib
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A691124DR00W
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A691124DR00W
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1. assessment of brain parenchyma
Deadlines: 24h - 72h
Exam: MRI (T2, FLAIR, Diff, Angio PCA),
MRI-the most sensitive examination.
If MRI not available ->, scanner but frequent false
negative for ischemic injury.
2. search for the cause
Deadlines: 24h – 72h
Exam: Echo-Doppler carotid.NB: If significant stenosis or unreliable, perform angio-
CT or dynamique angio-MRI
Transient ischemic attack?
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Deadline: 4h Unless known toxic metabolic or endocrine
cause.
Sought Pathology : subdural hematoma,
hydrocephalus, brain tumor
Exams: CT or MRI
Deadline: 4h Unless known toxic metabolic or endocrine
cause.
Sought Pathology : subdural hematoma,
hydrocephalus, brain tumor
Exams: CT or MRI
Acute disorders of behavior,
consciousness or delirium?
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B800401MA00G
26 Nov 2009
had sex this morning,
subsequently headache, half
hours later generalized seizure,
loss of urine, stool and
immediately coma
CT performed 3h later
Acute disorders of behavior,
consciousness or delirium?
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Acute disorders of behavior,
consciousness or delirium?
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Acute disorders of behavior,
consciousness or delirium?
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Acute disorders of behavior,
consciousness or delirium?
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B800401MA00G
Diagnosis?
-aggressive brain tumor?
-pseudotumoral venous thrombosis
versus
cerebritis complcated by venous
thrombosis?
Acute disorders of behavior,
consciousness or delirium?
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B800401MA00G
After a full recovery, she left
the hospital Dec. 31, 2009
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Deadline: 4h
Exams: Scanner without injection and if
possible angioCT
-The sensitivity of this test decreases with time, a normal
examination can not exclude a subarachnoid hemorrhage
MRI not unless:
- clinical signs dating back several days, normal CT and
lumbar puncture inconclusive
Subarachnoid hemorrhage?(Sudden acute headache)
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Deadline: 4h or less if possible
Exams: MRI and PC Angiografie
Key sequences: PC Angiografie,
if non-diagnostic GRE T1 + Gd
Or
CT without injection + CT angiography
(As reliable as MRI and more accessible)
Cerebral venous thrombosis?
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MR Angiography:
Angiography Phase
Contrast
Angiography
Time
Of
Flight
Gd enhanced
(dynamic)
Angiography
Principle Shift of
protons
phase
Inflow of
fresh protons
T1 effect of
Gadolinium
Artifacts +++ ++ +
Draw-backs Acquisition
time
Limited Field
of View
Require Gd
injection
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Clinical presentation:
Clinical
symptom
Arterial
dissection
Venous sinus
thrombosis
Pituitary
apoplexy
Headache +++++(75%)
(+ neck ache)
+++++
(70-90%)
+++++
Seizures + ++
(10-60%)
++
Neurologic
deficit
+++
(Horner 15%)
+++
(30-80%)
+++
(3d nerve)
Papilledema +++
(30-80%)
++
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Dural sinus thrombosis
Diagnostic considerations
•Can be confused on clinical
grounds with migraine headache
and pseudotumor cerebri.
•Venous infarction is one of the feared
complications of dural
sinus thrombosis
•marked increases in intracranial
pressure as a result of venous outflow
obstruction can lead to coma and
death
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Dural Sinus ThrombosisDiagnostic considerations – MR imaging
•On unenhanced
T2,T1-weighted
images
the replacement of
the flow void by
increased signal is
highly diagnostic
However, this sign
is visible only a
week after the
onset of thrombosis
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On enhanced (Gd) T1 GRE
(Gradient Echo)(not Spin Echo),
the thrombus in the sinus
typically fails to enhance
Typical MR venography show
absence of signal in the
affected dural sinus
Dural Sinus ThrombosisDiagnostic considerations – MR imaging
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Deadline: 4h or less if possibleExams: MRI with PCA (T2, Flair, Diff, Angio PCA
T1 Fat Sat and / or Angio TOF Fat Sat on the stenosis
Or CTscanner
without injection +
CT angiography(Less reliable than MRI, but more accessible)
Carotid dissection?
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Dissection of the carotid and
vertebral arteries was once
considered uncommon.
•Dissection of the cervicocephalic
arteries is a neurologic emergency
because of the increased risk of
cerebral infarction.
•Before development of MR imaging,
catheter angiography was considered
the study of choice for depiction of
carotid and vertebral dissection.
Arterial dissectionDiagnostic considerations
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•Because of its noninvasive nature, MR
imaging has replaced catheter angiography
for the diagnosis of arterial dissection at
many institutions
•Diagnostic clue: intramural hematoma
(remains isointense compared
with muscle on both
T1- and T2-weighted images
during the first few days
after dissection!)
Arterial dissectionDiagnostic considerations
Fat-suppressedT1-weighted image
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•Multidetector CT angiography
•rapid thin-section depiction of vessels
•excellent anatomic detail
•three-dimensional reconstructed images.
Arterial dissectionDiagnostic considerations
Multisection CT Angiography Compared with Catheter Angiography in
Diagnosing Vertebral Artery Dissection Chi-Jen Chen, Ying-Chi Tseng, Tsong-Hai Lee, Hui-Ling Hsu and Lai-Chu See
American Journal of Neuroradiology 25:769-774, May 2004
The sensitivity, specificity, accuracy, and positive and
negative predictive values of multisection CT angiography
in diagnosing VA dissection were 100%, 98%, 98.5%, 95%,
and 100%, respectively.
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•Findings of arterial dissection on CT angiography
Arterial dissection
Diagnostic considerations
On source images:•narrowing or occlusion of the
contrast-filled lumen
•may be combined with a
contrast-filled pseudoaneurysm
•the hematoma appears
isodense relative to soft tissue
•the residual lumen is generally
eccentric in location relative to
the hematoma
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•Findings of arterial dissection on CT angiography
•Generallty diagnosis
obvious on source
images
Arterial dissection
Diagnostic considerations
MIP reconstruction
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•Findings of arterial dissection on CT angiography
•Reconstrucions only may be not diagnostic
Arterial dissectionDiagnostic considerations
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•Findings of arterial dissection on CT angiography
•Always check the native pictures
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•Findings of arterial dissection on CT angiography
•In case of thrombosis, superiority of MRI
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•Findings of arterial dissection on CT angiography
•In case of thrombosis, superiority of MRI
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Deadline: 24h or less if possible
Exams: MRI. If abscess suspected: 4h
or less (Diffusion!)
Rapidly progressive neurological deficitwith immunosuppression or fever
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Rapidly progressive neurological deficitwith immunosuppression or fever
Deadline: 24h or less if possible
Exams: MRI. If abscess suspected: 4h or
less (Diffusion! DD with necrotic tumor )
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Exams:
RX skull not indicated
Brain scan and cervical spine:not indicated unless (1 hour) neurological
signs, vomiting or progressively worsening
headache , impaired consciousness, risk of
hematoma (anticoagulant therapy, bleeding
disorders), neck pain or severe trauma
Exams:
RX skull not indicated
Brain scan and cervical spine:not indicated unless (1 hour) neurological
signs, vomiting or progressively worsening
headache , impaired consciousness, risk of
hematoma (anticoagulant therapy, bleeding
disorders), neck pain or severe trauma
Head trauma without loss of consciousness
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Head trauma with loss of consciousness
Exams:
RX skull not indicated
Brain scan and cervical spine: 4h
Shortened time to 1h if neurological signs
NB: attention to the association of a
cervical spine injury to install in the
scanner
NB: scanner until the cervico-dorsal
junction
Exams:
RX skull not indicated
Brain scan and cervical spine: 4h
Shortened time to 1h if neurological signs
NB: attention to the association of a
cervical spine injury to install in the
scanner
NB: scanner until the cervico-dorsal
junction
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NOTE: Inform the patient that he must return to
the clinic in case of persistent pain, while the
initial radiograph was normal.
Exams:
xr spine? 4h
May be falsely reassuring, frequent false neg
F + P supine; cervico-occipital junction
Favor Scanner 4h
Especially if diagnostic doubt
Spine trauma without neurological signs
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Exams:
Scanner: 1h
MRI: 1h
Necessary if no osteo-articular injury on
scanner
if discordance between CT and clinical
findingss.
After neurosurgical opinion?
Spine trauma with neurological signs
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Spine trauma with neurological signs (fallen from his
horse, paresis fingers right hand). XR the day of trauma
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Spine trauma with neurological signs (fallen from his horse,
paresis fingers right hand). MR 2 days after trauma
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Spine trauma with neurological signs (fallen from his horse,
paresis fingers right hand). CT 2 days after trauma
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Spine trauma with neurological signs (fallen from his horse,
paresis fingers right hand). MR angio 5 days after trauma
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Imaging:
Imaging is indicated only in patients with "red flag" conditions or
in whom disc surgery is considered.
Consensus is that initial treatment is conservative for about 6-8
weeks.
("red flags" – suspicion of infection, malignancy, severe
symptoms who fail to respond to conservative care, neurologic
deficit, osteoporotic fractures)
IRM>Scanner
BMJ 2007;334(7607):1313 (23 June), doi:10.1136/bmj.39223.428495.BE
Diagnosis and treatment of low back pain
and sciatica
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("red flags" – suspicion of infection, malignancy, severe symptoms who fail to
respond to conservative care, neurologic deficit, osteoporotic fractures)
suspicion of infection – discitis
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•in pituitary tumour
•hemorrhagic apoplexy
•acute necrosis
Pituitary apoplexy
26 nov 99
Clinical symptoms: heavy headache, vomiting and neck stiffness
Clinical diagnosis: subarachnoid haemorrhage or meningitis
09 dec 99; MR 1.5T
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•clinical symptoms
•headaches often bitemporal
•fever
•visual field defects
•cranial nerve palsies
•photophobia, stiff-neck, altered consciousness, convulsions
! DD with meningitis/ subarachnoid haemorrhage!
•in normal pituitary:
•Sheehan's syndrome (postpartum necrosis) (secondary to
hemorrhagic shock)
•diabetes ( with cerebro-vascular disease)
•sickle-cell disease (rarely)
•in pituitary tumour
•hemorrhagic apoplexy
•acute necrosis
Pituitary apoplexy
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Clinical presentation:
Clinical
symptom
Arterial
dissection
Venous sinus
thrombosis
Pituitary
apoplexy
Headache +++++(75%)
(+ neck ache)
+++++
(70-90%)
+++++
Seizures + ++
(10-60%)
++
Neurologic
deficit
+++
(Horner 15%)
+++
(30-80%)
+++
(3d nerve)
Papilledema +++
(30-80%)
++
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•in pituitary tumour
•hemorrhagic apoplexy
•acute necrosis
Pituitary apoplexy
Clinical symptoms: heavy headache, oedema periorbital soft tissues
Clinical diagnosis: cavernous sinus thrombosis or meningitis
22 sep 99;CT Normal
27 sep 99;1.5 Tesla MRI
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•in pituitary tumour
•hemorrhagic apoplexy
•acute necrosis
Ppituitary apoplexy
American Journal of Neuroradiology 23:1240-1245,
August 2002
© 2002 American Society of Neuroradiology
Pituitary Apoplexy: Early Detection
with Diffusion-Weighted MR
Imaging
Jeffrey M. Rogga, Glenn A. Tunga, Gordon
Andersonb and Selina Cortezc
Nonenhanced CT scan shows a
homogeneous, nonhemorrhagic, hyper
attenuated intrasellar mass.
Histological analysis revealed the presence
of a necrotic pituitary adenoma with
haemorrhage
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•The emergency neuroimaging is not warranted.
•However, up to 2.1% will have clinically
important findings on neuroimaging
•MRI will be superior to CT
•If Axial FLAIR (5mm), coronal T2 (3mm) reveal
no abnormality, the probability to find any
pathological condition by multiplying the
sequences is very low
Practical guidlines for imaging in chronicor recurrent headache
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B710731DR00Q
22 Nov 2010
Headache since 1 week.
Today, loss of visual acuity and
anisocorie
CT and MR performed 22 Nov 2010
Headache with neurological
signes
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B710731DR00Q CT performed 22 Nov 2010 13:28
Headache with neurological signes
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B710731DR00Q MR performed 22 Nov 2010 17:23
Headache with neurological signes
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B710731DR00Q MR performed 22 Nov 2010 17:23
Headache with neurological signes
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B710731DR00Q
Radiologist report: normal CT and MREvolution: progressive blindness, paralysis n.
abducens
Diagnosis: idiopathic intracranial hypertension
What you need in such a situation:
Headache with neurological signes
•New CT?
•New MR?
•Second opinion?
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B710731DR00Q 23 Nov 2010
further neurological deterioration
MR performed 23 Nov 2010 11:56
Radiologist report: normal MRDiagnosis: idiopathic intracranial
hypertension, pseudotumor cerebri
Treatement: attempt to place VP shunt
Headache with neurological signes
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B710731DR00Q 23 Nov 2010 20h
Transfert UZ VUB
Teleradiolgy Second opinion: venous
sinus thrombosis
Treatement: anticoagulation
Headache with neurological signes
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B710731DR00Q 24 nov 2010
neurological deterioration
no response to question or command
difficult endotracheal intubation
induction with Pentothal, high dose
required for loss of consciousness
MRI:
Headache with neurological
signes
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B710731DR00Q 24 nov 2010 20h
Clinical death
Headache with neurological
signes
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Take Home Points
Ischemic vascular stroke?with onset of symptoms <6 hin the context of thrombolysis
MRI is superior to CT imaging (diffusion
weighted imaging)
CT is clearly superior to MRI if the patient
is agitated
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Take Home Points
Ischemic vascular stroke?with onset of symptoms >6 hin the context of headache,young patient
Consider non enhanced CT
followed by angioCT
or MRI with angio sequences
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Deadline: 4h or less if possibleExams: MRI with PCA (T2, Flair, Diff, Angio PCA
T1 Fat Sat and / or Angio TOF Fat Sat on the stenosis
Or CTscanner
without injection +
CT angiography(Less reliable than MRI, but more accessible)
Carotid dissection?
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Dural sinus thrombosis
Diagnostic considerations
•Can be confused on clinical
grounds with migraine headache
and pseudotumor cerebri.
•Venous infarction is one of the feared
complications of dural
sinus thrombosis
•marked increases in intracranial
pressure as a result of venous outflow
obstruction can lead to coma and
death
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Deadline: 4h or less if possible
Exams: MRI and PC Angiografie
Key sequences: PC Angiografie,
if non-diagnostic GRE T1 + Gd
Or
CT without injection + CT angiography
(As reliable as MRI and more accessible)
Cerebral venous thrombosis?
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Head trauma with loss of consciousness
Exams:
RX skull not indicated
Brain scan and cervical spine: 4h
Shortened time to 1h if neurological signs
NB: scanner until the cervico-dorsal
junction
Exams:
RX skull not indicated
Brain scan and cervical spine: 4h
Shortened time to 1h if neurological signs
NB: scanner until the cervico-dorsal
junction
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Take Home Points
If discrepancy between radiological findings and the clinical situation?
feel free to request a second opinione-mail [email protected]