Transcript MRI
Curriculum Vitae NAME BORN : Dr. ANGGRAINI DWI S.,dr.,Sp.Rad (K) : PASURUAN, SEPTEMBER 12, 1961 EDUCATION : GP, MEDICAL FACULTY OF AIRLANGGA UNIVERSITY, 1987 RADIOLOGIST, AIRLANGGA UNIVERSITY, 1996 ATTACH PROGRAM NNI SINGAPORE, 2002 NEURORADIOLOGIST CONSULTANT, 2004 DOCTOR , MEDICAL FACULTY OF AIRLANGGA UNIVERSITY, 2013 POSITION : STAFF OF DEPT. RADIOLOGY MED. FAC. AIRLANGGA UNIVERSITY HEAD OF DIPLOMA PROGRAM FOR RADIOGRAPHER MEMBER OF NEURORADIOLOGICAL DIVION. MEDICAL FACULTY AIRLANGGA UNIV. MEMBER OF IDI MEMBER OF DKJ FORUM MEMBER OF PDSRI MEMBER OF AONHCR MEMBER OF ASCI OFFICIAL JOURNAL OF INDONESIAN NEURORADIOLOGY OF THE EUROPEAN NEURORADIOLOGY JOURNAL SENIOR CONSULTANT IN NEURORADIOLOGY , SOETOMO HOSPITAL AND SEVERAL HOSPITALS IN SURABAYA HEAD OF RADIOLOGY, HUSADA UTAMA HOSPITAL MEDICAL MANAGER, HUSADA UTAMA HOSPITAL Differential Diagnosis of Brain Infection, Tumor, Metastatic Process on CT Scan and MRI Dr. dr. Anggraini Dwi S.,Sp.Rad.(K) Radiology Dept., Medical Faculty, Airlangga University/Soetomo Hospital, Surabaya Clinical findings? Atlas Scott, 2007 Techniques in Neuroimaging Plain X-ray USG CT Scan MRI PET Scan Radiation exp. + - ++ - +++ Tissue contrast + ++ ++ +++ - Calcification + + +++ + - Hydrocephalus - ++ +++ ++++ - Contrast - - ++ ++++ - Uptake rad farm - - - - +++ Metabolite - - - +++ - Tissue Perfusion - - ++ ++ - Tissue Diffusion - - - + - Brain lesion (infection, primary, metastatic): 1. Initial recognition and characterization of the lesion 2. The mechanical effects and structural deformities resulting from intracranial neoplasm 5 The Most effective Uses of CT in Neuroradiology Rulling out SAH Acute head trauma Fracture of skull, face, orbits Sinusitis Salivary gland calculous disease Subtle bony irregularities Detection of calcification in lesion Odontoic lesion Degenerative disease CTA CT perfusion Bony spinal stenosis MR is contraindicated Immediate postop evaluation Temporal bone disease MR imaging has the most potential of any imaging technique to allow a complete and accurate diagnosis and initial management strategy to be formulated for a brain tumor Brain Tumor Imaging with MR: Objectives Specific Diagnosis Neoplasma VS other Histology (Grading) Therapy Planning Localize for biopsy Delineate extent or spread RT portal design Guide minimally invasive surgery - Define peritumoral “eloquent” - Define neuroanatomic pathway involvement Post Treatment Residual Tumor Reccurent tumor VS treatment-related necrosis Fundamentals of lesion localization and characterization: -The age of the patient -Single or multiple? -Intraaxial or extra axial? -Density/intensity? -Presence of contrast enhancement? -Hemorrhage -Calcification -Necrosis? Basic protocol brain MRI 1. T1 2. T2 3. T2FLAIR 4. Gre T2* 5. DWI 6. 2-3 planes post Gad T1 7. Pefusion CBV 8. MR Spectroscopy (?) 9. DTI (?) 10.Functional MRI (?) Brain Lesions MedScape, 2011 Multiple Small Ring Enhancing Lesions Tuberkuloma CT • Isodense or slight hyperdense basal cistern • Basal homogenous meningeal enhancement • Hydrocephalus (C and NC) • Tuberculoma, rim enhancement, 1/3 with target sign (central calcification) MRI • Cisternal enhancement ++ • Meningeal enhancement (better in FLAIR than T2), patchy meningitis • Hydrocephalus (C and NC) • Tuberculoma, rim enhancement, 1/3 with target sign (central calcification) Metastatic CT • Hyperdense, hypodense or isodense • Small, round zones • Extensive collateral edema • Intratumoral hemorrhage • 80% enhancement, sometimes a ring MRI • Detects 2-3x> MRI • Typically hypointense on T1 • Hyperintense on T2 • Melanoma? • Enhancement: uniform, punctate, ring • T2FLAIR: perifocal edema • MRS: No Cho↑ at perifocal edema, NAA↓ Neurosarcoidosis • • • • • CT Leptomeningitis Suprasellar manifestation (diabetes incipidus) Hydrocephalus Single or multiple granuloma slightly hyperdense foci up to 1cm Up to 60% negative • • • • • • MRI T1: iso or hypointense T2: variable T1+C: homogenous enhancement Pituitary + hypothalamic Leptomeningeal involv. Cranial nerve (II,VIII) Cerebral Abscess CT •Varies with stage of abscess •Early cerebritis: hypodense •Subacute: ring-like structure •Necrotizing tissue •Gas forming +/•Enhancing ring: 3-6mm, uniform •Dughter abscess • • • • • • • MRI Varies with stage of abscess T1W T2W FLAIR DWI (+) : hypercellularity, brain ischemia, cellular swelling due to cytotoxic edema Central liquefactive necrosis MRS : NAA, Cho,Cr ↓, LL↑ Multiple Large Enhancing Lesions Abscess Metastatic Glioma MR Spectroscopy Tumeactive Demyelinating Lesion HIV? Toxoplasma? Unenhanced CT Scan MRI T1 WI T1 WI T1 WI T2W axial T2W axial Enhanced T1W Before Tx After Tx Lymphoma? Intraaxial Brain Mass Conventional CE MRI Does the lesion enhance? NO YES MR Spectroscopy Is the elevation of Cho/NAA over 2,2? DWI, diffusing facilitated > 1,1/100 mm2/ADC? NO YES •Low grade neoplasm or •encephalitis YES Is there necrosis On CE MRI? YES NO Lymphoma Perfusion MR Is perfusion over 1,75 rCBV? YES YES High grade neoplasm NO Low grade neoplasm NO •TDL or abscess •Abscess MR Spectroscopy Is there perienhancement infiltration Over 1 Cho/NAA ? NO YES Metastase TDL: tumeactive demyelinating lesion High grade glioma Diffusion Weighted Image Diffusion Weighted Image MR Spectroscopy MR Spectroscopy The Peritumoral region (PTR) demonstrated most significant differences in metabolite ratios. • The Cho/Cr ratio in glioblastomas was significantly higher than that in metastases. • PCLs significantly elevated Cho/Cr levels were also noted in compared with those in metastases . • PCLs also demonstrated significantly higher lipids+lactate/Cr levels compared with glioblastomas and metastases. Proton magnetic resonance spectroscopy in differentiating glioblastomas from primary cerebral lymphomas and brain metastases. Chawla S1, Zhang Y, Wang S, Chaudhary S, Chou C, O'Rourke DM, Vossough A, Melhem ER, Poptani H. MR Perfusion Take home message 1. CT Scan plays in emergency cases and some abnormality (blood, calcification, hemorrhage) 2. MRI play a better role than CT in differentiate infection, primary and metastatic tumor 3. MR imaging has the most potential of any imaging technique to allow a complete and accurate diagnosis and initial management strategy to be formulated for a brain tumor 4. Advanced imaging help enhancing the specifity of the lesions Thank You