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Symmetry  Central mass may be the result of a sellar or

 Symmetry of the brain is the key to radiologic suprasellar tumor.
evaluation.  Opacification of the cistern may be the result of
o Generally, the sulcal pattern should be symmetric. subarachnoid hemorrhage or meningitis
o The anterior interhemispheric fissure should be
visualized.
o Loss of sulci may result from compression owing to
mass or opacification of CSF following subarachnoid
hemorrhage or, less commonly, meningitis or
spreading of a CSF-borne tumor.
o The sulci extend to the inner table of the skull.
o In older patients, some atrophy is normal.
o Medial displacement of the sulci - compression
resulting from an extracerebral fluid collection, such
as a subdural or epidural hematoma.

Basal Cisterns
 Signs of intracranial mass:
Ventricles
o Distortion of the CSF spaces of the posterior fossa
and base of the brain.  The final structure that must be evaluated in a quick
 Key structures: quadrigeminal plate cistern and the review of a brain scan is the ventricular system.
suprasellar cistern  It is best to start with the fourth ventricle in the
 Quadrigeminal plate cistern in the axial plane has the posterior fossa, because it is the hardest to see on CT
appearance of a symmetric smile scanning
o Abnormality of this cistern represents:
o Rotation of the brain stem resulting from
transtentorial herniation
o Effacement of the cistern on account of cerebellar
or brainstem mass
o Opacification of the cistern as in subarachnoid
hemorrhage

 Suprasellar cistern looks like a pentagon or the Jewish

star with corners:
o interhemispheric fissure anteriorly
o the sylvian cisterns anterolaterally
o ambient cisterns posterolaterally
o The sixth point of the Jewish star is in the  Asymmetry or shift of the fourth ventricle may be the
interpeduncular fossa posteriorly. only sign of significant intracranial masses.
 Enlargement of the lateral ventricles and third
 The cistern has the density of CSF and the structure is ventricle in the setting of headache, or with signs of
symmetric. intracranial mass may represent hydrocephalus.
 Anatomic continuations of the cistern are the same  Hydrocephalus is distinguished from enlargement of
density as CSF. the ventricular system as the result of atrophy by:
 Significant asymmetry may be a result of uncal o discrepancy in the degree of ventricular and sulcal
 herniation. enlargement
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o characteristic pattern of frontal horn and temporal Pineal Region

horn enlargement and a round appearance of the  It is crucial to identify the midbrain, the
anterior portion of the third ventricle midbrain tegmentum, (frequently with a small
lucency representing the decussation of the
Emergency CT Checklist superior cerebellar peduncle), the aqueduct of
When confronted with a CT scan under emergency Sylvius, the midbrain tectum with superior and
conditions, radiologists must ask themselves these five inferior colliculi, the pineal gland, and the
questions: superior cerebellar vermian lobules.
1. Is the middle of the brain in the middle of the  If the precentral cerebellar vein can be seen in
head? the superior vermian cistern, a mass here is
2. Do the two sides of the brain look alike? unlikely.
3. Can you see the smile and the pentagon or
Jewish star? Craniocervical Junction
4. Is the fourth ventricle in the midline and more  The anterior arch of C1, the odontoid process,
or less symmetrical? and the cervical occipital ligaments are seen
5. Are the lateral ventricles huge, with effaced anteriorly.
sulci?  The sharp inferior edge of the clivus marks the
When stroke triage is performed, specialized imaging anterior lip of the foramen magnum.
techniques such as perfusion CT and CT angiography  The posterior lip is marked by the cortical
(CTA) supplement the initial screening CT. margin of the occipital bone.
 The cerebellar tonsils should project no more
Midline Structures than 3 mm below a line drawn between the
Structures are not duplicated – symmpetrical method is anterior and posterior lips of the foramen
not applicable. magnum.
3 Regions:  The obex, the most posterior projection of the
Suprasellar Region dorsal medulla, should lie above this imaginary
 On virtually every MR examination, it is possible line.
to localize the sella turcica, the pituitary gland,  The only structures visible at this level within
pituitary infundibulum, optic chiasm, anterior the calvarium and spinal canal are the cervical
third ventricle, mammillary bodies, and anterior medullary junction and a tiny bit of cerebellar
interhemispheric fissure. tonsilar tissue.
 The tip of the basilar artery and the posterior  Any other soft tissue in this location is
cerebral arteries are seen posteriorly, and the pathologic.
anterior cerebral arteries are visualized anterior
and superior to the sella. CURRENT NEUROIMAGING OPTIONS
 Plain radiography is useless in patient
 The anterior cerebral arteries travel in the management and is only of value in the
interhemispheric fissure. documentation of fracture for medical/legal
 Parallel to the course of the posterior reasons.
communicating artery, we frequently see the  Nuclear medicine brain scans are useful in
third cranial nerve certain specialized settings, such as medically
 In the parasagittal location, near the optic refractory epilepsy and dementia
chiasm, we see the optic nerve anteriorly and  We still must decide between CT, MR, US, and
the optic tract posteriorly. angiography in the evaluation of the acute
neurologic patient.
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 The radiologist also needs to decide whether to  Some patients are simply too sick to study easily
give intravenous contrast material and which with MR. These include multisystem trauma
special CT and MR techniques to employ. patients or those who require assisted
 Angiography is used in the acute setting based ventilation.
upon the appropriate combination of CT, MR,  Patients who cannot hold still, such as children
and clinical findings. or highly agitated adults, must be sedated for
 US may be used as the first test in infants, or for MR.
evaluation of the carotids, or with transcranial
techniques for evaluation of the intracranial Proton MR spectroscopy
vessels after initial imaging triage.  shows the distribution of brain metabolites
The only contenders for the First test for the brain are based upon the chemical shift of the protons
MR and CT. within them, which is a property determined by
 A standard MR examination generally consists the chemical environment of the protons in
of a T1WI, a T2WI, and fluid-attenuated question.
inversion recovery (FLAIR) or proton density  In practice, three normal metabolites are the
images and may be supplemented by T1WIs most interesting:
with gadolinium-based contrast agents. o Choline - marker for cell membranes
 A standard CT examination consists of axial and hence a marker for cellular density
images reviewed at brain and bone windows o N-acetyl aspartate (NAA)- found only in
and may be supplemented by repeat images neurons and therefore a marker of
with intravenous iodinated contrast. neuronal density
As a general rule in brain imaging, CT is performed for o Creatine - evenly distributed in many
acute neurologic illness and MR for the more chronic types of cells and serves as a reference
and subacute cases. standard.
 If the onset of neurologic symptoms referable Choline
to the brain was within 48 hours, start with a  May be considered a tumor marker.
CT.  Another use of the choline peak is tumor
 If the problem is older than 3 days, start with an grading-histologic grade correlates with choline-
MR. to-creatine ratio
 If the CT or MR suggest a primary vascular o biopsy of the site with the highest
lesion, such as an arteriovenous malformation choline-to-creatine ratio is likely to
(AVM) or aneurysm, do a catheter angiogram or reflect the histologic grade of the
MR or CT angiogram. tumor.
 If the CT or MR suggests tumor, give contrast. If NAA
the CT or MR fails to demonstrate an acute  A decrease in the NAA-to-creatine ratio is seen
infarct and the symptoms suggest a transient in a variety of conditions that are associated
ischemic attack or stroke, do a carotid Doppler with neuronal death.
US, or MR angiography (MRA) or CTA.  Focally decreased NAA is seen in mesial
 Don’t use intravenous iodinated contrast for CT temporal sclerosis and infarcts.
in the acute setting unless brain abscess or  Global depletion of NAA can be seen in multiple
tumor is a strong consideration or if needed for sclerosis and dementing diseases such as
your stroke triage protocol. Alzheimer's disease (AD), which also
 Give gadolinium for MR whenever there is a demonstrates elevated myoinositol.
clinical finding that suggests a specific  Any space-occupying mass that replaces brain
neurologic localization, a seizure, or a strong will also have a small NAA peak.
history of cancer or infectious disease.  Abscesses and metastatic lesions will have
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lower NAA-to-creatine ratios than primary brain

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tumors, which tend to infiltrate rather than MR Angiography

replace brain.  depends upon the phenomenon of flow-related
 Markedly elevated NAA levels are seen in enhancement, in which moving spins behave
Canavan's disease as a result of a specific defect differently than stationary spins.
in the enzyme that metabolizes it.  First-pass gadolinium-enhanced MRA provides
superior quality images that enhance diagnostic
 A characteristic doublet peak of lactic acid can confidence but not necessarily accuracy.
help make the diagnosis of ischemia.  the conspicuity of aneurysms and other vascular
 This has been useful in infants with suspected lesions is excellent, though artifacts resulting
hypoxemic ischemic encephalopathy. This may from patient motion, in-plane vascular flow,
also aid in diagnosis of mitochondrial and susceptibility artifacts can be problematic.
encephalopathies. MRA is most useful when patients are not
acutely ill.
Noninvasive angiographic techniques  Intracranial vascular stenoses and aneurysms
CT Angiography are reliable depicted.
 depends upon the rapid bolus injection of Both MRA and CTA are very useful extracranially as well.
iodinated contrast, rapid imaging with a
multidetector spiral CT, and rapid data Diffusion-weighted MR imaging (DWI)
processing to produce clinically useful images of  exploits the phenomenon of diffusion, which is
the cerebral vessels. related to Brownian motion at the molecular
level.
Two major classes of images are produced with these  The more restricted the movement of water,
studies: the brighter it will be on DWI sequences.
 relatively thick cross-sectional images using  In stroke, ischemic areas tend to swell following
maximum intensity projection (MIP) osmosis of free water into the dying cells, and
 shaded three-dimensional surface renderings these areas become bright on DWI as a result of
the increased ratio of intracellular to
 In subarachnoid hemorrhage, use the sagittal extracellular water.
MIP for the carotid ophthalmic aneurysm, the  This change on DWI precedes changes on T2
posterior communicating artery (Pcomm) and and FLAIR, making DWI a key sequence in the
the posterior inferior cerebellar artery (PICA) early detection of stroke.
origin  CSF contains the least restricted water in the
 The coronal MIP for the anterior brain and will be dark on DWI.
communicating artery (Acomm), carotid and
basilar tip, and the axial MIP for the Acomm and Tensor diffusion imaging (TDI)
Pcomm.
 exploits the fact that within elongated cell
 Remember that the middle cerebral artery
processes such as axons, water can diffuse
(MCA) is a relative blind spot so it must be
more freely down the tube than sideways,
inspected carefully on all images.
allowing for tractography.
 In suspected infarct, use the symptoms as a
guide and carefully follow the appropriate
MR and CT perfusion techniques
vessels to an abrupt halt or significant
narrowing.  extremely useful for the depiction of regions of
relatively diminished flow in ischemic cerebral
tissue and perfusion.
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MR Perfusion Scan distribution of the lesion and the age of the

 Most MR perfusion scans rely on a first-pass patient.
bolus gadolinium injection, during which the  Subarachnoid hemorrhage requires further
brain is imaged sequentially. workup by MR and/or angiography to search for
 The signal on highly T2*-weighted images is an aneurysm or AVM.
decreased in a manner proportional to  The absence of hemorrhage visible on CT allows
perfusion. the clinician to perform anticoagulation or
 The abnormally perfused brain does not thrombolytic therapy to prevent progression or
demonstrate this flow-related phenomenon as even reverse the neurologic deficit.
much or as soon.
 Increased relative cerebral blood volume within Prethrombolytic Evaluation
a tumor appears to correlate with tumor  Loss of gray/white distinction, low attenuation
angiogenesis and hence tumor grade. in the basal ganglia, and poor definition of the
insula on CT may contraindicate thrombolytic
CT perfusion scan therapy
 Relies on the principle that perfused areas of  In some centers, stroke triage is performed to
the brain will attenuate the x-ray beam more evaluate the potential for salvaging an ischemic
than the ischemic brain during an iodinated brain.
contrast injection.  CT is more readily available within the stroke
 Delayed arrival of contrast and transit of treatment time window, is almost never
contrast documents ischemia, and other contraindicated, detects virtually all acute
parameters may predict infarct. hemorrhage, and provides almost all of the
information potentially available with MRI
Functional MR imaging (FMRI) rapidly and safely.
 refers to studies of the brain using blood
oxygen level dependent imaging (BOLD). Seizure
 These images rely upon the fact that  patient's first seizure  an intracranial tumor,
deoxyhemoglobin produces changes in infection, or other acute process must be
magnetic susceptibility that are proportional to excluded.
the metabolic activity in a given brain structure. o For this reason, contrast enhanced MR
or contrast-enhanced CT is the
IMAGING STRATEGY FOR COMMON CLINICAL preferred approach.
SYNDROMES  immediate postictal state, or if a residual
Acute trauma neurologic deficit is present at the time of
Noncontrast enhanced CT scan is preferred imaging  a noncontrast CT scan should be
The most important abnormalities to be detected are obtained as the first study.
extracerebral hematomas.  If the seizure disorder is chronic, and
Intracerebral contusions are of secondary interest particularly if it is refractory to medical therapy,
because they are more difficult to treat surgically, and  detailed MR examination, including
the results of treatment are less encouraging. highresolution coronal images of the medial
temporal lobes and other clinically suspected
Stroke abnormal brain structures, is performed.
 Noncontrast CT scan is the preferred initial
imaging study. Infection and Cancer
 Cerebral hematoma presenting as a stroke  In patients wth suspected infectious disease or
suggests hypertensive encephalopathy or cancer is a consideration, contrast-enhanced
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amyloid angiopathy, depending upon the MR is the preferred study.

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o Parenchymal tumor or metastatic  The sulci adjacent to the mass may be effaced,
disease will be demonstrated with this since the CSF in the sulci is displaced by the
study mass.
o contrast-enhanced MR has the  Ipsilateral ventricular structures may be
advantage of depicting meningeal compressed by a mass, rendering the ipsilateral
disease much better ventricle smaller than the contralateral
ventricle.
Headache
 Patients with severe acute headaches should be Atrophy
imaged with noncontrast head CT.  widening of the ipsilateral sulci or enlargement
o Acute severe headaches may be the of the ventricle adjacent to the lesion.
result of subarachnoid hemorrhage,  If the patient is demented, a diagnosis of AD
acute hydrocephalus, or an enlarging may be made on clinical grounds.
intracranial mass. o focal atrophy of the hippocampal
 Chronic headache patient is generally evaluated regions of the medial temporal lobe
by MR scanning.
 If the headache is not accompanied by local Reversible Atrophy
neurologic symptoms, a noncontrast MR scan is Three common causes of reversible cerebral atrophy:
usually sufficient. if the headache is associated 1. dehydration and starvation
with focal neurologic complaints, then 2. Addison's disease
gadolinium enhanced MR scanning is indicated. 3. Other causes of dehydration or abnormal fluid
balance
Coma Alcoholism may also occasionally result in reversible
 The comatose or acutely confused patient cerebral atrophy.
should be imaged to detect an intracranial
hemorrhage. Mass Lesion: Intra-axial or Extra-axial
o These patients are studied urgently  intra-axial - within the brain and expanding it
with noncontrast CT. o Intra-axial masses are, most commonly,
metastases, intracranial hemorrhages,
Dementia primary intracranial tumors such as
 The chronic dementia patient is generally glioblastoma, and brain abscesses.
studied by noncontrast MR  extra-axial - outside the brain and compressing
o may also demonstrate small vessel it
ischemic changes in the cerebral white o Extra-axial masses are, most commonly,
matter and small infarcts, which also subdural or epidural hematomas,
may clinically mimic AD. meningiomas, neuromas, and dermoid
 PET studies may play a role in assessing or epidermoid cysts.
prognosis and guiding therapy, especially in the
clinical setting of mild cognitive impairment. Solitary or Multiple
 Single lesion is more likely to be the result of
ANALYSIS OF THE ABNORMALITY isolated primary cerebral disease
Mass  multiple lesions are more likely to be
 An object occupying space. manifestations of widespread or systemic
 The normal midline structures may be shifted diseases.
contralateral to the mass.  single ring-enhancing lesion within the brain
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may suggest a glioblastoma.

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 Multiple ring-enhancing lesions within the brain trigeminal and olfactory ganglion cells and then
more likely represent metastases or abscesses. transdurally to the brain.
 Single infarct is identified  it is likely to be The most common locations for involvement are:
caused by a lesion within the carotid circulation (1) the medial temporal lobes adjacent to the trigeminal
ipsilateral to the lesion. ganglia
 If multiple infarcts are seen, they may represent (2) the orbital frontal regions adjacent to the olfactory
border zone infarcts resulting from global bulbs
hypoperfusion or they may be a result of a
cardiac source of emboli. Contrast Enhancement
Enhancement of the brain parenchyma means that the
Gray Matter or White Matter blood-brain barrier has broken down and that the
 Lesions involving gray matter are usually a process is biologically active.
result of infarct, trauma, or encephalitis. astrocytoma tumor line  increase in enhancement
 If the lesion has mass effect, these conditions correlates with higher tumor grade
are likely acute. If the lesion is atrophic, it is nonneoplastic processes  enhancement appears only
likely chronic. in the acute phase and resolves with time.
 If the white matter is exclusively involved and
the lesion is expansile, a pattern of edema is
most likely present.
 gray matter pattern – cytotoxic edema

Lesion Distribution
 wedge-shaped lesion involves the opercula of
the sylvian fissure and the underlying white
matter and basal ganglia  middle cerebral
artery
 territory infarct
 medial aspect of the cerebral hemisphere
anteriorly and over the convexity is involved 
anterior cerebral infarct
 between two major vascular territories 
border zone or watershed infarct
 multiple border zone infarcts  global
hypoperfusion because of cardiac arrest must
be suspected
 Deep gray matter structures bilaterally  pure
anoxia owing to carbon monoxide poisoning or
respiratory arrest should be considered.

 A direct blow produces injury beneath the site

of blow and opposite the site  contra-coup
injury
 Penetrating brain wounds are distributed
according to the path of the missile or the
location of the trauma.
 Herpes simplex encephalitis  disease spreads
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from the oral and nasal mucosa to the