Brain MRI – Seizure search pattern

Many times when patients have a history of seizures, they undergo a workup including a physical exam, detailed EEG analysis, and finally brain MRI to try to identify any potential structural causes of seizures. In this video, Dr. Michael Hoch walks us through his approach to a brain MRI to maximize your sensitivity for finding abnormalities.

 

Dr. Hoch suggests a 4-step approach using the mnemonic “3-2-1 go to the hippocampus”. In this way, he divides his search into more digestible parts.

“3” indicates the 3 planes that you have in a non-contrast T1 weighted MP-RAGE MRI. On this you should focus on the cortex, particularly at the 3 poles, the frontal, temporal, and occipital poles.

“2” indicates the 2 planes of FLAIR and 2 window settings you should use. You should review FLAIR images in both the coronal and axial planes. You should also use a window that is normal and a window that is narrow, or aggressive, to highlight lesions, particularly in the cortex, which are hard to see.

“1” indicates the single plane of blood sensitive imaging, either GRE or SWI, which can often see areas of prior hemorrhage or cavernou

“Go” to the hippocampus last to look for signs of mesial temporal sclerosis, which is manifested as a small hippocampus with loss of internal architecture and abnormal T2/FLAIR hyperintensity. This can be either from primary epilepsy or secondary to another lesion.

See this and other videos on our Youtube channel .

Neuroradiology physics review – 1 – Computed Tomography

It’s important for the neuroradiologist to have a basic grasp of physics, particularly in the ways that it may affect image quality. In this video, Dr. Michael Hoch goes through a series of 12 CT cases on physics. Each case is followed by multiple choice questions about that physics principle.

There are a number of ways that physics principles affect images, causing various types of suboptimal images, such as:

  • partial volume averaging – when an object only takes up part of a voxel and the resulting output
  • patient motion – when patient moves during imaging, degrading image quality and causing image blurring
  • streak artifact – when high density material adversely affects CT reconstruction, causing lines across an image
  • ring artifact – when a detector fails and causes rings through the image
  • contrast staining – when breakdown of the blood brain barrier allows leakage of contrast into the brain

Other key principles discussed include:

  • pitch
  • computed tomography dose index (CTDI)
  • dose length product (DLP)
  • pre- and post-patient collimation
  • image filtration

The level of this lecture is appropriate for radiology residents, radiology fellows, and trainees in other specialties who would like to review radiology physics. This may be particularly useful when preparing for the American Board of Radiology (ABR) core and certifying exams.

https://youtu.be/OeP88BJ5Ec4

Advanced MRI imaging of the brain

There are several advanced MRI techniques for more sophisticated imaging of brain structure and function. The most common advanced imaging techniques include spectroscopy, perfusion, diffusion tensor imaging (DTI), and functional MRI (fMRI). This playlist shows some of the details of using advanced imaging techniques for brain imaging and surgical planning.

This playlist includes some of the details about using advanced MRI for surgical planning and determining additional details about brain MRI.

Functional MRI (fMRI) language localization – conjunction display

Blood oxygen level dependent functional MRI, or BOLD fMRI, is an advanced MRI technique in which level of oxygen present in an area of the brain is used to map out what parts of the brain are activated in specific tasks. In this method, repeated imaging of the brain can be performed while the patient performs a task, and the level of oxygenation changes, showing which parts of the brain are most activated.

A key application of fMRI is mapping of language areas, or language localization, for surgical planning. The patient will perform more than 1 language task while in the scanner, and the activation data is overlaid on anatomic imaging (like conventional T1 or T1 postcontrast imaging). This is used to determine which side of the brain is language dominant as well as where exactly important language areas, including Broca’s and Wernicke’s areas, are located. This way they can be avoided in complex surgical procedures. However, sometimes results can be difficult to interpret because of the high number of images and high amounts of noise.

In this video, Dr. Michael Hoch demonstrates how use a conjunction technique to increase sensitivity for mapping language areas. In this method, all the language paradigms are overlaid on a single set of images using different colors. This increases the visibility of otherwise hard to see areas, increasing reader confidence.

The level of this lecture is appropriate for radiology residents, radiology fellows, and trainees in other specialties who have an interest in advanced MRI techniques such as diffusion tensor imaging (DTI) tractography, functional MRI (fMRI), and surgical planning.

For more information, see the whole video playlist on Advanced MRI.

 

Functional MRI (fMRI) Brainlab Processing Guide

Blood oxygen level dependent functional MRI, or BOLD fMRI, is an advanced MRI technique in which level of oxygen present in an area of the brain is used to map out what parts of the brain are activated in specific tasks. In this method, repeated imaging of the brain can be performed while the patient performs a task, and the level of oxygenation changes, showing which parts of the brain are most activated.

A key application of fMRI is mapping of language areas, or language localization, for surgical planning. The patient will perform more than 1 language task while in the scanner, and the activation data is overlaid on anatomic imaging (like conventional T1 or T1 postcontrast imaging). This is used to determine which side of the brain is language dominant as well as where exactly important language areas, including Broca’s and Wernicke’s areas, are located. This way they can be avoided in complex surgical procedures. However, sometimes results can be difficult to interpret because of the high number of images and high amounts of noise.

There are a number of processing suites that you can use to process fMRI data, including Brainlab and Dynasuite. The processing can be slightly different depending on which software package you are using, but the general principles are the same. To begin, you take each functional paradigm and overlay it on anatomical imaging, selecting statistical parameters and colormapping as you go.

In this video, Dr. Michael Hoch demonstrates the use of Brainlab to process fMRI data for language processing. He goes through the step-by-step process of generating each set of overlay imaging and how to interpret the results. In the second part of the video, he demonstrates conjunction overlay technique to increase sensitivity for mapping language areas by showing only the areas which have overlapping results on multiple paradigms, increasing reader confidence.

The level of this lecture is appropriate for radiology residents, radiology fellows, and trainees in other specialties who have an interest in advanced MRI techniques such as diffusion tensor imaging (DTI) tractography, functional MRI (fMRI), and surgical planning.

For more information, see the whole video playlist on Advanced MRI.

MRI Diffusion Tensor Imaging (DTI) interpretation:
Locating the corticospinal tract (CST)

Diffusion tensor imaging, or DTI, is an advanced MRI technique in which the asymmetric motion of water is used to map out specific properties in the brain. One application of DTI is called tractography, or identifying the specific tracts of neurons which pass through the brain.

One of the most important fiber tracts in the brain is the corticospinal tract, or CST. This tract connects the motor cortex with the spinal cord, passing through the cerebral peduncles. This fiber tract is important because it is the tract most responsible for voluntary movement. It can be affected by a number of pathologies, such as tumors, cortical malformation, and stroke. For some conditions, such as tumors, it can be critically important to locate the CST before performing surgery, so that the surgeons can properly plan their surgery. That’s where DTI comes in.

In this video, Dr. Michael Hoch demonstrates how to use a two region of interest method to identify the corticospinal tract, first placing a region of interest in the cerebral peduncle and a second in the motor cortex. He also talks about some of the pitfalls of diffusion tensor imaging and what kind of problems to look out for.

The level of this lecture is appropriate for radiology residents, radiology fellows, and trainees in other specialties who have an interest in advanced MRI techniques such as diffusion tensor imaging (DTI) tractography, functional MRI (fMRI), and surgical planning.

For more information, see the whole video playlist on Advanced MRI.