Preface xv Acknowledgements xvii

Contents

PART 1 IMAGING PROTOCOLS AND GUIDELINES KF# CT Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Brain without Contrast 2 Brain with Contrast Administration 2 Deep Brain Stimulator Head Protocol 3 Paranasal Sinus, Screening 3 Paranasal Sinuses with Contrast 4 Paranasal Sinuses, Preoperative for Computer Navigation 4 Maxillofacial without Contrast 5 Max~llofacial with IV Contrast 5 Orbits 6 Temporal Bones 6 Neck 7 CSF Leak 7 Craniosynostosis 8 Routine C-Spine 8 Routine T/L-Spine 8 CTAHead 9 CTA Neck/Carotids 9 CT Perfusion 10 Pituitary Protocol 10

2 MRIProtocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Brain without and with Contrast 12 Neonatal Brain 12 Brain, Stroke 13 Brain, Tumor 13 Brain, Trauma 14 Brain, Contrast Enhanced Perfusion 14 Carotid Arteries, Neck 14 Venogram, No Contrast 14 Brain, Pulsatile Tinnitus 15 Pituitary 15 Neck General 15 Temporomandibular Joints 16 Cervical Spine 16 Thoracic Spine 16 Lumbar Spine 17 Brachial Plexus 17

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Contents

3 Myelography Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 General Guidelines 18

4 Digital Subtraction Angiography Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 General Guidelines 22

5 Sedation and Anxiolysis Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Conscious Sedation 26 Anviolysis 30

6 Medications in Neuroradiology.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Medications for Contrast Media Reactions 32 Endotracheal Tubes 33 Prevention of Contrast Reactions in Allergic Patients 33 Management of Contrast Reactions 33 Medications that may Affect the Performance of Invasive Procedures 35 Medications (Generic Names) that may Lower Seizure Threshold 35 Over-The-Counter Medications that Increase Bleeding Time 36 CT Contrast Allergy 37 Iodinated Contrast in Renal Insufficiency 38 MR Contrast Administration in Adults (>I8 Years of Age) 39 MR Contrast Administration in Children (<I6 and >2 Years of Age) 39 Contrast Extravasation 39

7 Sample Dictations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Normal Dictations 40 MR Brain, Contrast Enhanced, Normal 40 MR Brain, No Contrast, Normal 40 MR Brain, Patient w t h Multlple Sclerosis 41 MRA Circle of Willis, Normal 41 MR Spectroscopy, Normal 41 MR Pituitary Gland, Normal (Remember to D~ctate the Rest of

Brain if Included as Part of the Examination) 41 MR, Post Deep Brain Stimulator Placement, Normal 41 MR. Cranial Nerve VIII, Normal 42 MRA, Neck Contrast Enhanced, Normal 42 MRA, Neck No Contrast, Normal 42 MR, Cervical Spine, No Contrast, Normal 42 MR, Cervical Spine, Contrast Enhanced, Normal 42 MR, Thoracic Spine, No Contrast, Normal 43 MR, Thoracic Spine, Contrast Enhanced, Normal 43 MR, Lumbar Spine, No Contrast, Normal 43 MR, Lumbar Spine, Contrast Enhanced, Normal 43 MR, Lumbar Spine, Structured Report 43 MR. Total Spine, Contrast Enhanced, Normal 44

CT, Brain, No Contrast, Normal 44 CT, Brain, Contrast Enhanced, Normal 44 CTA, Brain, Normal 44 CT, Head, Craniosynostosis (Absence of) 45 CT, Face, No Contrast, Normal 45 CT Face, Contrast Enhanced, Normal 45 CT, Orbits, No Contrast, Normal 45 CT, Orbits, Contrast Enhanced, Normal 46 CT, Paranasal Sinuses, No Contrast, Normal No Prior Surgery 46 CT, Paranasal Sinuses, Contrast Enhanced, Normal 46 CT, Paranasal Sinus, Post Surgery 46 CT, Neck Contrast Enhanced, Normal 47 CTA, Neck Normal 47 CT, Temporal Bones, No Contrast, Normal 47 CT, Cervical, Thoracic, and/or Lumbar Spine,

No Contrast, Normal (Acute Trauma) 47 Lumbar Puncture 48 Lumbar Puncture for CSF Leak Study 48 Lumbar Puncture for Opening Pressure Measurement 48 Myelogram, Cervical, Normal (From Lumbar Approach) 49 Myelogram, Lumbar, Normal 49 Cerebral Angiograrn, Normal 49 Ultrasound, Head, Normal 50 Ultrasound, Lower Spine, Normal 50

PART 2 IMAGING FUNDAMENTALS

SECTION A BRAIN IMAGING

8 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Skull Fractures 52 Epidural Hematoma 54 Subdural Hematoma and Hygroma 56 Diffuse Axonal Injury and Intermediary Injuries 58 Contusions 60 Traumatic Subarachnoid Hemorrhage 62 Child Abuse 64 Pneurnocephalus 66 Arterial Dissection 68

9 Stroke.. . . . . . . . . . . . . . . . . . . . .. . .. . . . ... . ... . .... . .... . . ... . . . . . . . . . . . . 72 Acute (<24 Hours) Middle Cerebral Artery Infarct, Computed Tomography 72

Contents

Acute (<24 Hours) Middle Cerebral Artery Infarct, Magnetic Resonance Imaging 74

Subacute (2 To 21 Days) Middle Cerebral Artery Infarct, Computed Tomography 76

Subacute Infarction, Magnetic Resonance Imaging 78 Acute Anterior (ACA) and Posterior (PCA) Cerebral Artery Infarcts 80 Lacunar Infarctions 82 Watershed Cerebral Infarctions 84 Hemorrhwc Infarct and Hemorrhagic Transformation 86 Wallerian Degeneration 88 Acute Cerebellar Infarct 90 Basilar Artery Occlusion 92 Generalized Brain Hypoxia/Ischemia 94 Cortical Vein Thrombosis 96 Deep Venous System Occlusion 98 Venous Sinus Occlusion 100 Corpus Callosum Infarctions 102 Hypertensive Encephalopathy 104 Cerebral Vasculitis 106 Moyamoya 108 Cadasil 110 Stenosis, Extra-Cranial ICA 112 Fibromuscular Dysplasia (FMD) 114

10 Nontraumatic Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Acute Hypertensive Hemorrhages 116 Cerebral Microhemorrhages 118 Arnyloidosis 120 Hemorrhage in the Premature Brain 122 Periventricular Leukomalacia 124

11 Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Anterior Communicating (AComm) Artery Aneurysms 126 Posterior Communicating Artery Aneurysms 128 Middle Cerebral Artery Bifurcation Aneurysms 130 Basilar Artery Tip Aneurysms 132 Infratentorial Aneurysms 134 Multiple Intracranial Aneurysms 136 Giant Aneurysms 138 Extradural Aneurysms (Pseudoaneurysms) 140 Vasospasm (After SAH) 142

12 Vascular Malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Arteriovenous Malformations 144 Cavernous Malformations 146

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Contents

Developmental Venous Anomalies 148 Capillary Telangiectasias 150 Dural Arteriovenous Fistulas 152 Carotid Artery-Cavernous Sinus Fistulas 154 Vein of Galen Malformations 156

Extra-Axial Masses. . . . . . . . . . . . . . . Meningioma 158 Epidermoid 160 Dermoid 162 Lipoma 164 Choroid Plexus Tumors 166 Pituitary Adenoma 168 Craniopharyngioma 170 Pineal Gland Tumors 172 Colloid Cyst 174 Arachnoid Cyst 176

14 Intra-Axial Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Astrocytoma, Low Grade 178 Anaplastic Astrocytoma 180 Glioblastoma 182 Gliomatosis Cerebri 184 Oligodendroghoma 186 Ependymomas and Subependymomas 188 Neuronal Tumors 190 Metastases 192 Lymphoma 194 Pylocytic Astrocytoma 196 Brain Stem Astrocytoma 198 Medulloblastoma 200 Ependyrnoma and Subependyrnoma 202 Hemangioblastoma 204 Dysplastic Cerebellar Gangliocytoma (Lhermitte-Duclos Disease) 206

15 Infections and Inflammations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .208 Meningitis (Uncomplicated) 208 Meningitis, Complications 210 Cerebral Pyogenic Abscess 212 Viral Encephalitis 214 Human Immunodeficiency Virus Infection 216 Progressive MuItifocal Leukoencephalopathy 218 Toxoplasmosis 220 Cryptococcus 222 Tuberculosis 224

Contents

Cysticercosis 226 Sarcoidosis 228 Multiple Sclerosis 230 Neuromyelitis Optica 232 Acute Disseminated Encephalomyelitis (ADEM) 234 Creutzfeldt-Jakob Disease 236 Rasmussen Enceph J t i s 238

16 Leukodystrophies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240 Adrenoleukodystrophy 240 Metachromatic Leukodystrophy 242 Alexander Disease 244 Canavan Disease 246 Krabbe Disease 248 Pelizaeus-Merzbacher Disease 250

17 Metabolic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252 Amino Acid Disorders 252 Mucopolysaccharidoses 256 Mitochondrial Disorders 258 Wilson Disease (Hepatolenticular Degeneration) 260 Wernicke Encephalopathy and other Alcohol-Related Disorders 262 Cerebral Calcifications 264

18 Degenerative and Latrogenic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .266 Pantothenate Kinase Deficiency (Hallervorden-Spatz Syndrome) 266 Hippocampal Sclerosis 268 Huntington Disease (Chorea) 270 Amyotrophic Lateral Sclerosis 272 Alzheimer Disease 274 Multisystem Atrophy 276 Carbon Monoxide and Methanol Intoxication 278 Radiation Injury 280 Liver Insufficiency and Total Parenteral Nutrition 282 Pontine and Extrapontine Osmotic Myelinolysis 284 Hyperglycemia 286 Intracranial Hypotension 288 Pseudotumor Cerebri 290 Postshunting Corpus Callosurn Lesions 292

19 Congenital Malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .294 Aqueductal Stenosis 294 Chiari Malformation Type I 296 Chiari Malformation Type TI 298 Posterior (Occipital and/or Parietal) Encephaloceles 300 Anterior Nasal Masses 302

Contents

Dandy-Walker Complex 304 Joubert Syndrome 306 Holoprosencephalies 308 Agenesis of Corpus Callosum 310 Septo-Optic Dysplasia 312 Schizencephalies 314 AgyriaIPachygyria Complex and Band Heterotopia 316 Focal Gray Matter Heterotopias 318 Cortical Dysplasias 320 Craniosynostoses 322

20 Neurocutaneous Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .324 Neurofibromatosis Type 1, Astrocytomas and Neurofibromas 324 Neurofibromatosis Type 1, Dysplastic Myelin 326 Neurofibromatosis Types 1 and 2, Spine Abnormalities 328 Neurofibromatosis Type 2, Schwannornas and Meningiomas 330 Tuberous Sclerosis, Hamartomas 332 Tuberous Sclerosis, Subependymal Giant Cell Astrocytoma 334 Von Hippel-Lindau Disease 336 Sturge-Weber Syndrome 338 Cowden Syndrome 340 PHACE(S) Syndrome 342

SECTION B SPINAL IMAGING

21 Degenerative Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .344 Annular Fissures 344 Herniated Disc, Lumbar Spine 346 Free Herniated Disc Fragment, Lumbar Spine 348 Schmorl Nodes 350 Herniated Disc, Cervical Spine 352 Recurrent or Residual Herniated Discs and Scar 354 Arachnoiditis 356 Enhancing Lumbar Nerve Root Related to Degenerative Disease

(Other than Posttreatment Arachnoiditis) 358 Facet Cysts 360 Spondylolysis, Lumbar Spine 362 OsslGed Posterior Longitudinal Ligament 364 Paget Disease 366

22 Tumors and Tumorlike Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .368 Vertebral Metastases 368 Spinal Cord and Leptomeningeal Metastases 370 Spinal Cord Astrocytoma 372 Spinal Cord Ependymoma 374

Contents

Spinal Schwannoma and Meningioma 376 Vertebral Body Hemangioma 378 Aneurysmal Bone Cyst 380 Osteoid Osteoma 382 Eosinophilic Granuloma 384 Chordoma 386 Spinal Cord Cysts, Nonneoplastic 388 Perineural (Tarlov) Cysts 390 Epidural Lipomatosis 392 Subacute Combined Degeneration 393

23 Vascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .394 Spinal Cord Cavernous Malformation 394 Spinal Cord Arteriovenous Malformations 396 Spinal Dural Arteriovenous Fistula 398 Spinal Cord Infarction 400 Spinal Epidural and Subdural Hematomas 402

24 Infection Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .404 Ankylosing Spondylitis (Seronegative Spondyloarthropathy) 404 Spondylitis and Discitis, Pyogenic 406 Epidural and Subdural Abscesses and Phlegrnon 408 Tuberculosis 410 Guillain-Barre Syndrome 412 Hypertrophic Polyneuropathies 414 Rheumatoid Arthritis 416

25 Trauma ... . . . . . . ..... . . .... . .... . . . . . . .. . .... . ... . . . .. . . . ... . . ... . .418 Occipitoatlanto Separation 418 Jefferson Fracture 420 Odontoid Fractures 422 Hangman's Fracture 424 Unilateral Facet Dislocation 426 Bilateral Facet Dislocation 428 Benign Compression Fractures 430 Pathologic (Malignant) Compression Fractures 432 Chance-Type Fractures 434 Spinal Cord Contusion 436 Acute Traumatic Spinal Cord Hematoma and Transection 438 Vertebral Artery Injury 440

26 Congenital Malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .442 Myelomeningocele and Myelocele 442 Lipomyelomeningocele and Lipomyelocele 444 Lipomas 446

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Contents

Dermoid and Epidermoid 448 Diastematomyelia 450 Caudal Agenesis (Regression) Syndrome 452

27 Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trauma: Avulsion and Stretch Injuries 454 Brachial Plexus Schwannomas 456 Brachial Plexus Plexiform Neurofibromas 458 Brachial Plexus, Fatty Tumors 460 Brachial Plexus Metastases 462 Pancoast Tumor Involving the Brachial Plexus 464 Vascular Injuries and the Brachial Plexus 465 Viral and Idiopathic PIexitis 466 Radiation-Induced Brachial Plexitis 467

SECTION C HEAD AND NECK

28 Neck Masses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .468 Nasopharyngeal Masses 468 Parapharyngeal Space Masses 470 Parotid Space Masses 472 Retropharyngeal Space Masses 474 Oral Cavity and Oropharyngeal Space Masses 476 Masticator Space Masses 478 Buccal Space Masses 480 Sublingual and Submandibular Space Masses 482 Nodal Metastases 484 Carotid Space Masses 486 Laryngeal Masses 488 Nasopharyngeal Angiofibroma 490 Paragangbomas (SM1 Base) 492 Hemangiomas 494 Venolymphatic Malformations 496 Brachal Cleft Cysts 498 Thyroglossal Duct Cyst 500 Thyroid Masses 502 Sialolithiasis 504 Tornwaldt Cyst 506 Fissural Cysts 508

29 Sinonasal Cavities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510 Choanal Narrowing 5 10 Developmental Anomalies of the Ostiomeatal Complex 512 Ostiomeatal Unit, Obstruction 514

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Contents

Mucous Retention Cysts 516 Slnonasal Polyps 518 Acute (Uncomplicated) S~nusitis 520 Fungal Sinusitis 522 Paranasal Sinus Malignancy 524 Mucocele 526 Papilloma 528 Fibro-Osseous Lesions of Sinonasal Cavltles 530 CSFLeaks 532 Wegener Granulomatosis 534

30 Temporal Bone.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536 Temporal Bone Fractures 536 Vestibular Schwannoma 538 Facial Nerve Schwannoma 540 Enlarged Endolymphatic Sac (Large Vestibular Aqueduct) Syndrome 542 Bell Palsy 5r14 Labyr~nth~tis Obliterans 546 Glomus Tympanicum 548 Vascular Anomalies and Variants, Middle Ear 550 Cholesteatoma, Acquired (Secondary) 552 Cholesterol Granuloma 554 Otospongiosis 556

31 Orbits ... .. . . . ..... . .. ... .. . .. ... . . .... . . . . . . . .. . .. . . . .... . .. . .. .. . .558 Persistent Hyperplastic Primary Vitreous 558 Globe Calc~ficatlons 560 Retinoblastoma CPNET-RB) 562 Orbital Cavernous Hemang~oma (Adult Type) 564 Orb~tal Capillary Hemangiomas 566 Orbital Lyrnphangioma 568 Melanoma 570 Lacrimal Gland Masses 572 Orbital Dermoid 574 Inflammatory Pseudotumor 576 Graves Ophthalmopathy 578 Orb~tal CelluIitis and Abscess 580 Optic Neuritis 582 Detachments and Effusions 584 Orbltal Cavlty Trauma 586 Ocular Trauma 588 Posttreatment Flndings 590