Neuroimaging for
the Primary Care
Physician
April 29, 2016
Sukhwinder Johnny Singh Sandhu, M.D.
Neuroimaging for the
primary care provider
Disclosures
No relevant disclosures
Objectives
1. Enumerate the different types of
neuroimaging options.
2. Choose the appropriate imaging
modality for particular clinical
scenarios.
3. Decide when further imaging is
indicated.
Outline
1.
2.
3.
4.
5.
6.
History
Tools at your disposal
Pros and cons of modalities
Clinical symptoms
Case Scenarios
Summary
Part one
HISTORY
1895
Wilhelm
Conrad
Rontgen
Father of
Radiology
X-ray
•
•
•
•
•
•
Tube
Gas
Voltage
Fluorescent green ray
Unknown
Bertha
“Now, all hell can break loose”
Presented at
the German
Physics Society
• Royalty
– hand x-rays
• Queen Amelia
– Effects of corsets
• French
– Tight fitting shoes
• Lancet
– swallowed penny
• NJ Opera Glasses Bill
• Underwear
1896
Thomas Edison
Pure scientists
would never
earn a single
dollar on their
discoveries
Stopped 1904
after assistant
died
Shoe Fluoroscope
Better to see
than feel
Medical Applications
• Foreign body localization
– Lancet 1896
– Swallowed 3 penny piece
• Skeletal evaluation
• Chest
• Limited GI/Vascular
GI/Vascular
• Lead acetate – bismuth – barium
• Sodium iodine – IVP and cardiac
CT
• Sir Godfrey Hounsfield
• Presented in 1972
Computed Tomography
EMI
Godfrey
Hounsfield
October 1971 – First Case of cystic mass confirmed in the OR
1979
Isidor Rabi
1938: Nuclear
magnetic resonance
1944: awarded the
Nobel Prize in physics
1898 –1988
Raymond Damadian
1971 Raymond Damadian's
"Apparatus and method for
detecting cancer in
tissue.“ journal Science
1972. He filed the first patent
for an MRI machine, U.S.
patent #3,789,832
Damadian, Minkoff and
Goldsmith
1977 performed
the first MRI
body scan of a
human being
Nobel Prize
2003
Paul Lauterbur
Sir Peter Mansfield
Prize in Physiology or Medicine for their
"discoveries concerning magnetic resonance
imaging”
Vigorous protest by Raymond Vahan Damadian
He claimed that he invented the
MRI, and that Lauterbur and
Mansfield had merely refined the
technology.
"The Friends of Raymond
Damadian“ took out full-page
advertisements in the New York
Times and The Washington Post
Part two
MODERN DAY
Pros and Cons CT
Pros
• Painless
• Fast
• Cost effective
• Detail
• Bone
• Blood vessels
• Soft tissue
Cons
• Radiation exposure
• Contrast reactions
• Contrast induced
nephropathy
Pros and Cons MRI
Pros
• Painless
• No radiation
• Excellent
spatial and
temporal
resolution
• No side effects
from B0 or RF
Cons
• Metal can be safety
hazard
• Availability
• Costs
CT HEAD
CTA Head
CTA Neck
CT
Venogram
MRA
MRS
PWI
DTI
Part three
TOOLS AND UTILITY
Heavy hitters
• CT
• CTA
• MRI
• MRA
• CE-MRA
• MRV
• Conventional Angiography
Vascular Imaging
• Time of flight
• Phase contrast
• Contrast enhanced MRA
Time of Flight
• Signal from flight unsaturated
blood
• No contrast
• Motion artifact
• Non-uniform blood signal
Time of Flight
Time of Flight
Digital Subtraction
Phase Contrast
• Phase shifts in moving blood are
measured
• Phase is proportional to velocity
• Allows quantification of blood
flow and velocity
Phase Contrast
Contrast enhanced MRA
• T1 shortening Gadolinium
• Reduces T1 relaxation
• TR << T1 reduces background
signal
• Single breath hold
Part four
CLINICAL SCENARIOS
Case 1
HEADACHE
Case 2
WEAKNESS
Case 3
NECK PAIN
Part five
SUMMARY
Spectrum of Vascular Imaging
• MRA
• CTA
• Conventional Angio
References
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•
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•
•
http://www.slideshare.net/DrTusharPatil/mri-sequences?next_slideshow=1
The story of radiology. ublished by the
ESR – European Society of Radiology In cooperation with
ISHRAD – The International Society for the History of Radiology
Deutsches Röntgen Museum
October 2012
http://www.schoolphysics.co.uk/age1619/Medical%20physics/text/CT_scanning/index.html
http://web.stanford.edu/group/hopes/cgibin/hopes_test/neuroimaging/#advantages-and-disadvantages-of-ct
http://staugustine.com/living/sunday-life/2015-01-24/beauty-black-andwhite-wilderness-photographer-clyde-butcher-coming#.VWOcSs5j7dl
http://radiopaedia.org/articles/internal-carotid-artery-dissection-1
References
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Douglas AC, Wippold FJ, Broderick DF, et al. ACR Appropriateness Criteria®
Headache. Available at https://acsearch.acr.org/docs/69482/Narrative/.
American College of Radiology. Accessed March 1, 2016.
Frishberg BM, Rosenberg JH, Matchar DB, et al. Evidence-Based Guidelines
in the Primary Care Setting: Neuroimaging in Patients with Nonacute
Headache. Available at
http://tools.aan.com/professionals/practice/pdfs/gl0088.pdf. American
Association of Neurology. Accessed March 1, 2016.
Filippi M, Rocca MA, Ciccarelli O, et al. MRI criteria for the diagnosis of
multiple sclerosis: MAGNIMS consensus guidelines. Lancet Neurol. 2016
Mar;15(3):292-303.