Tumors and Vascular
diseases of the Brain
April 3, 2008
Jennifer Villa Frabizzio,
M.D.
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Abington Memorial Hospital
Radiology Group of Abington, PC
Board Certified in Diagnostic Imaging
with Added Qualifications in
Neuroradiology
Topics for Discussion
Neuroimaging
Then and Now
Neuroanatomy
Vascular and Nonvascular
Vascular Disorders
Diagnosis and Treatment
Tumors
Primary and Metastatic Disease
Neuroimaging- Then
Standard Radiograph
Pneumoencephalography
Direct Cerebral Angiography
Pneumoencephalograhy
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Introduced in 1919 by American Surgeon Dandy
Walker
Primary method of Neurodiagnosis used late until
late 1970’s early 1980’s
Lumbar puncture performed in sitting position
Patient placed in somersault chair with head
suspended in harness
CSF removed and 10-15 mls of air introduced
Patient is tilted upside down and 50-60 mls more
air introduced
Pneumonecephalography
cont.
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Air outlined brainstem structures and supra tentorial
structures to diagnose masses, tumors and cerebral
atrophy
Very time consuming, could take from one to two
hours to perform
Following the procedure patients invariably
developed severe headache and maybe a fever
Sampling of CSF post procedure showed high
protein and white blood cells, which seemed to be a
response to the air
Symptoms would usually resolve within 48hrs
Direct Cerebral
Arteriography
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Pioneered in 1927 by Dr. Egas Moniz
Needle was inserted directly into the
common carotid artery in the neck and
contrast material injected
Rapid series of radiographs were taken of
the skull in numerous projections
Currently studies are preformed by inserting
a catheter into the femoral artery
Remains as gold standard for imaging
arterial and venous structures
Neuroimaging-Now
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Computed Axial Tomography
– CAT SCAN
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Magnetic Resonance Imaging
– MRI
Computed Tomography
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From Greek tomos (slice) and graphein (to write)
Generation of three dimensional images for a series of two
dimension Xrays taken around a single axis of rotation
Computer generated images produce an axial image
Early CT scans in early 1970’s had single slice, allowing
imaging of the brain in four minutes
Modern state of the art scanners can have up to 200 slices
and can image the whole body in 30 seconds
Iodine base contrast material in injected in an arm vein to
optimize visualization of vessels and solid organs
Uses ionizing radiation to obtain images, and should be used
with caution in pregnant or pediatric patients
CT cont.
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Advanced techniques
CT angiography and venography
– Contrast rapidly injected into an arm vein and timed to
visualize arteries and veins
– Has become first line minimally invasive procedure to
image the intracerebral vasculature and coronary arteries
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CT perfusion
– Rapid imaging of the brain after contrast injection followed
by computer post processing can generated area in the
brain at risk for stroke
Magnetic Resonance
Imaging (MRI)
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Powerful magnetic field used to align hydrogen atoms in the
body
Radiowaves are activated that alter the alignment of this
magnetization, allow for the atoms to relax at different rates
according to their chemical composition
These signals are manipulated to reconstruct images of the
body
Greater soft tissue contrast than CT
No ionizing radiation
Must be extremely careful to remove all metal from patients
Contraindicated in patients with pacemakers
MRI cont.
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Advanced techniques
– MR Angiography
detection of moving molecules done without the
injection of contrast to visualize flowing blood
excellent to visualize head and neck vessels
– Gadolinium based contrast agent is injected into
an arm vein, mixed with flowing blood and
allows for visualization of vessels especially in
the chest and abdomen
MRI cont.
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Diffusion imaging
– For visualization of acute stroke, damaged cells
swell and cause restricted diffusion
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MR spectroscopy
– Separating the chemical composition of brain
lesions into different peaks to determine
chemical composition
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Functional MRI
– Using changes in blood flow to monitor neural
activity
Neuroimaging
Nonvascular
Neuroimaging
Vascular
Vascular diseases
Stroke
Trauma/Intracranial Hemorrhage
Aneurysm
Arteriovenous Malformations
Stroke
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Acute episode leading to a neurologic
deficit
– 80% are due to ischemia (either
thrombotic or embolic)
– 20% other
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Transient ischemic attack (TIA)
– Focal events that resolve in 24hrs
Stroke cont.
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Of the 80%, three quarters are due to
atherosclerotic disease or occlusion of
vessels.
Diagnosis can be made by both CT and MRI,
as well as the advanced images techniques
– MRI is more sensitive, it can age strokes and can
detect an acute stroke within thirty minutes.
– CAT scan can detect a stroke within 6 hrs, and is
useful to determine if there is underlying
hemorrhage
71 year old white
female
Found by husband in the bathroom on the
floor, unable to move left side of her body
Brought by EMS to AMH and had a CAT scan
Cont.
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Admitted to intensive care
CAT scan performed 6 hrs later after
worsening of symptoms
Cont.
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Patient continues to deteriorate,
despite supportive measures
CAT scan performed 24 hrs after
admission
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No improvement
CAT scan performed 12 hrs later, 48
hrs after admission
19 year old white male
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Found unconscious in dorm room by
roommate after drinking all night at a
fraternity party
Friends had seen him take some pills,
found later to be valium
(benzodiazepine-tranquilizer)
Anoxic brain injury
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Lack of blood flow to the brain affects
deep grey matter structures and can
cause irreversible damage
Can also be seen in near drowning,
carbon monoxide poisoning
Intracranial Hemorrhage
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Non Traumatic
– Hypertension (most common)
– Tumor
– other
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Traumatic
– Epidural and subdural Hematomas
– Hemorrhagic contusions
Hemorrhage cont.
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Hypertensive type most common in
small arteries off of the middle
cerebral artery
High mortality depending on size and
location
81 year old black male
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Found at breakfast with difficulty
speaking
Brought to AMH by son
Ran out of blood pressure medicine
last week
Vital signs in ER
Blood pressure 210/80
CAT scan upon arrival
Cont.
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ICU Staff was unable to control blood
pressure, symptoms worsened
Hemorrhage cont.
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Traumatic
– Subdural hematomas
Common in the elderly or in children due to
child abuse
 Tearing of bridging veins along the edge of
the brain
 Can grow large and may need neurosurgical
evacuation
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Hemorrhage cont.
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Epidural hematoma
– Mostly due to injury to the middle
meningeal artery, superficial vessel that
runs along the skull
– Commonly associated with skull fractures
– Large ones are neurosurgical
emergencies
Aneurysms
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Most common type is the berry or saccular
aneurysm
– Are usually congenital or degenerative
– Focal outpouching of a artery
– Occur in specific locations along the Circle of
Willis
– Once diagnosed, the risk of rupture is 1.3% per
year
– A ruptured aneurysm requires urgent diagnosis
and treatment, due to a high risk of rebleeding
and 50% mortality
Aneurysms cont.
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Patients present with “worst headache
of life” and can have varying stages of
consciousness
CAT scan of the brain show diffuse
subarachoid hemorrhage, “crab of
death”
Aneurysms cont.
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Treatment
Conventional-crainiotomy and
aneurysm clipping
Neurointerventional-intravascular
coiling
Arteriovenous
Malformations (AVM)
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Network of arteries connected directly to
veins with no intervening brain tissue or
capillaries
Can hemorrhage because of high flow state
Treatment
– Endovascular coiling
– Glue
– Stereotactic Radiosurgery
58 year old female
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MVA, crashed car into a tree because
she “blacked out”
Arrives at AMH with headache,
bruising but awake
CAT scan performed
Brain Tumors
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Primary brain tumors are 70% of all
intracranial neoplasms
The remaining 30% represent
metastases from primary tumors
elsewhere in the body, common ones
include lung and breast cancer
MRI with Gadolinium in the modality
of choice for diagnosis
Brain tumors cont.
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Primary Brain Tumors
– 80% are gliomas, the most aggressive is
the Gliomblastoma Multiforme (GBM)
– 20% are all others, which include
meningiomas from the brain surface,
nerve sheath tumors and lymphoma
– Treatment is a combination of surgery,
radiation and chemotherapy
Thank you
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jvfrabizzio@amh.org
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