Brain CT MR Brain tumor impaired blood flow

Brain CT, MR Brain tumor, impaired blood flow Ágnes Nemeskéri 2014 Semmelweis University Department of Human Morpholgy and Developmental Biology Clinical Anatomy Research Laboratory nemeskeri. agnes@med. semmelweis-univ. hu

Imaging methods using ionizing radiation: radiography (Rtg), digital radiography (CT) CT pictures are depending on the density of the structures HRCT – High Resolution Computed Tomography -lung, delicate bony structures -longer examination time, higher radiation dose Hypo-density: -fat, air Hyper-density: -bone, metallic Tissue resolution: 1. air 2. fat 3. fluid 4. soft tissue 5. bone chairleg - metal acute hemorrhage + edema Low density: air - black Fluid: CSF - lower density than brain tissue Fresh blood clot: density is higher than brain tissue

CT angiography (CTA) – minimally invasive contrast material • Rapid injury assessment, no time wasted • less discomfort because contrast material is injected into an arm vein • CT can be performed having an implanted medical device, unlike MRI. • CT imaging provides real-time imaging • No radiation remains in a patient's body after a CT examination. http: //www. radiologyteacher. com/index. cgi? &nav=view&Dat. ID=1296

Imaging method without ionizing radiation Magnetic resonance imaging - MR MRI provides good contrast between the different soft tissues, especially useful in imaging the brain, muscles, the heart, and cancers strong oscillating magnetic field Excited hidrogen atoms emit a radio frequency signal -body is mostly made up of water and fat -60 -80% of the body tissues is water: H 2 O ! strong MR-density: water fluid accumulation cysta inflammatory cancer weaker MR-density : soft tissue weakest MR-density: bone, air Highest resolution among the imaging methods -advantage of MRI over CT is better tissue contrast, -fewer artifacts than CT when viewing the brain stem -MRI is also superior for pituitary imaging CSF in the ventricles on the brain surface

Functional MRI (f. MRI) -cerebral blood flow and neuronal activation are coupled - an area of the brain is in use, blood flow to that region also increases -primary form of f. MRI uses blood-oxygen-level-dependent (BOLD) contrast -higher oxy. Hemoglobin – higher signal intensity -f. MRI is used in research, and to a lesser extent, in clinical world Clinicians map the brain with f. MRI - to identify regions linked to critical functions: speaking, moving, sensing - to plan for surgery and radiation therapy of the brain - to anatomically map the brain and detect: - effects of tumors, stroke, head and brain injury, Alzheimer MRI provides a valuable tool in studying early-stage AD patients http: //brain. oxfordjournals. org/content/brain/128/4/773. full. pdf Alzheimer’s disease subjects had significantly poorer recognition memory for the previously presented stimuli than the normal control subjects https: //encrypted-tbn 2. gstatic. com/images? q=tbn: ANd 9 Gc. TZ 4 Vp. Clm 7 HCLi 5 Rvqvcra. Rqub. CT 3 b 1 x. N 4 t. V 0 Vas. QWTk. LATBXF

Stroke (~bleeding? ischemia? ) Recently it was shown that the number of stroke events in Europe would increase from 1. 1 million per year in 2000 to more than 1. 5 million per year in 2025 1. Ischaemic stroke: 88% (most frequent) a. Thrombotic stroke b. Embolic stroke 2. Intracerebral hemorrhagic stroke: 9% 3. Subarachnoidal bleeding: 3%

Stroke thrombosis, embolism After the onset of stroke syndromes: only 3 hours for fibrinolysis! -gaze deviation to right – complete left hemiplegia, hemisensory loss Hypodense area: • Ischemic area with edema, swelling • Indicates >3 hours old - chronic http: //cjem-online. ca/sites/cjem-online. ca/files/image/81 -54 -3. gif • No fibrinolytics! http: //cjem-online. ca/sites/cjem-online. ca/files/image/81 -54 -1. gif Tissue plasminogen activator -thrombolytic therapy !!: Infarction or hemorrhage? ? CT MR

Left middle cerebral art. - stroke CT and MR http: //emedicine. medscape. com/article/323120 -overview 1 day after stroke ischaemic demage 3 day after stroke . 5 day after stroke MR!!!!!

Acute stroke – MRI 35 min after the onset of symptoms http: //emedicine. medscape. com/article/1155506 -overview#aw 2 aab 6 c 12 Advantage of MRI in acute stroke Left: Diffusion-weighted MRI 35 min after the onset of symptoms Right: Apparent diffusion coefficient (ADC) map

Acute stroke – intracerebral BLEEDING - CT (white area hyperdensity = blood) Large left frontal intracerebral hemorrhage Intraventricular bleeding fibrinolyticum is forbidden!

Acute stroke subarachnoidal BLEEDING - CT Diffuse hyperdense areas Blood in the ventricles On the brain surface

Treatment of Hemorrhagic Stroke • Subarachnoideal bleeding – neurosurgical intervention – Nimodipine – prevents the development of cerebral vasospasm and ischaemia • Intracerebral bleeding – treatment of increased intracranial pressure – neurosurgical decompression • Cerebellar – neurosurgical intervention – remove blood clot • Lobar – neurosurgical intervention

CT or MR? CT • easily available • cheap: CT imaging cost approximately half that of MR imaging • better for blood detection • CT is ready to use in 5 min • only way when patient has pacemaker • Interpretation of early ischemic changes on CT images requires extensive training!!!! MRI • much less MR centers • more expensive • better anatomical image • preferable for scan of post. cranial fossa • it can be used in acute stroke (DWI=diffusion-weighted MR) • Interpretation of early ischemic changes on MRI easy

Stroke - neuroanatomy Anterior brain circulation internal carotid artery occlusion cerebral hemispherium Posterior brain circulation vertebro-basilar artery occlusion brainstem or cerebellum

Art. cerebri anterior (ACA) occlusion distal from anterior comm. a. Art. cerebri media (MCA) occlusion MCA - striato-capsular occlusion Sensory deficit -a contralateral foot, leg -less involved shoulder, arm (paresis) -hand, face not involved Motor deficit -contralateral foot, leg paralysis - less involved thigh, hip Mental deficit -perseveration, amnesia Sensory deficit -hemianesthesia -homonyme hemianopia (CGL) Motor deficit -contralateralis hemiplegia: face, arm, leg -global aphasia (Left side) Left side -head, eyes deviate towards lesion side Incomplete motor deficit -arm hand -no speach disorder

Intracranial tumors

Pontocerebellar tumor

-homonym hemianopsia http: //img. medscape. com/pi/emed/ckb/emergency_medicine/756148 -779664 -324 tn. jpg Glioma in the occipital lobe CT http: //o. quizlet. com/i/o. YDGTj-fc. Er. Db. NBdnk 1 wv. Q. jpg

Pituitary tumor MR http: //images. radiopaedia. org/images/1919577/f 1919743 a 75011651390 c 0 a 0 c 140 ca_big_gal lery. jpg enlarged sella X-ray!!!!!!

ÚJ! PROMISING FUTURE!!!!!! A JÖVŐ Nanotechnology ("nanotech") -manipulation on an atomic and molecular scale. -nanotechnology works with materials, devices, and other structures with at least one dimension sized from 1 to 100 nanometres Nanomedicine -use of nanorobots - introduced into the body, to repair or detect damages and infections. -a typical blood borne medical nanorobot would be between 0. 5 -3 µm in size -nanodevices could be observed at work inside the body using MRI -used to identify and destroy cancer cells Drug Delivery System - drug can be targeted to a precise location

Advances in development of bevacizumab, a humanized antibevacizumab angiogenic therapeutic monoclonal antibody targeting Vascular Endothelial Growth Factor in cancer cells S. S. Parikh et al, Int J Pharm Biomed Sci 2012, 3(4), 155 -163

DCE-MRI in a Phase I Study of an Anti-Vascular Agent. A significant decrease in Ktrans (pharmacokinetic parameter) was observed in the tumor at the end of a 4 h drug infusion. In this study, DCE-MRI showed promise as a pharmacodynamic marker of drug activity. - standardized MRI imaging protocols for single-site and multi-site cancer clinical studies - advanced image processing to extract quantitative biomarker information from radiological images Natarjan Raghunand

ÚJ! Personalized molecular medicine Endoglin (CD 105) -a member of TGF-β family of receptors -required for endothelial cell proliferation -standard method for quantifying tumor angiogenesis is to assess microvessel density based on endoglin staining -“the visualization, characterization and measurement of biological processes at the molecular and cellular levels in humans”

f. MR image – ventral striatum Dopamin release Orange areas of a PET/CT image indicate the uptake of 18 F-fluoro-2 -deoxy -D-glucose in a primary cancer lesion and a lymph node. 3 D CT image – lung, trache bifurcation

CT 3 D reconstruction complex bony structures, traumatological cases, for the surgical planning

References Lynn Wittwer, MD, MPD Clark County EMS Stroke ppp presentation http: //classes. midlandstech. com/carterp/courses/bio 210/chap 12/lecture 1. htm Nick Ward: Assessment and diagnosis in stroke DEPARTMENT OF HEADACHE, BRAIN INJURY, AND NEUROREHABILITATION NATIONAL HOSPITAL FOR NEUROLOGY AND NEUROSURGERY INSTITUTE OF NEUROLOGY UNIVERSITY COLLEGE LONDON http: //emedicine. medscape. com/article/343207 -overview Hon-Man Liu: Basic interpretation of CT Scan