MRI OF THE BRAIN, HEAD, NECK AND SPINE

MRI OF THE BRAIN, HEAD, NECK AND SPINE SERIES IN RADIOLOGY J. Odo Op den Orth, The Standard Biphasic-Contrast Examination of the Stomach and Duodenu...
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MRI OF THE BRAIN, HEAD, NECK AND SPINE

SERIES IN RADIOLOGY J. Odo Op den Orth, The Standard Biphasic-Contrast Examination of the Stomach and Duodenum: Method, Results and Radiological Atlas. 1979. ISBN 90 247 2159 8 J.L. Sellink and R.E. Miller, Radiology of the Small Bowel. Modern Enteroclysis Technique and Atlas. 1981. ISBN 90 247 2460 0 R.E. Miller and J. Skucas, The Radiological Examination of the Colon. Practical Diagnosis. 1983. ISBN 90 247 2666 2 S. Forgacs, Bones and Joints in Diabetes Melitus. 1982. ISBN 90 247 2395 7 G. Nemeth and H. Kuttig, Isodose Atlas. For Use in Radiotherapy. 1981. ISBN 90 247 2476 7 J. Chermet, Atlas of Phlebography of the Lower Limbs, including the Iliac Veins. 1982. ISBN 90 247 2525 9 B. Janevski, Angiography of the Upper Extremity. 1982. ISBN 90 247 2684 0 M.A.M. Feldberg, Computed Tomography of the Retroperitoneum. An Anatomical and Pathological Atlas with Emphasis on the Fascial Planes. 1983. ISBN 0 89838 573 3 L.E.H. Lampmann, S.A. Duursma and J .H.J. Ruys, CT Densitometry in Osteoporosis. The Impact on Management of the Patient. 1984. ISBN 0 89838 633 0 J.J. Broerse and T.J. MacVittie, Response of Different Species to Total Body Irradiation. 1984. ISBN 0 89838 678 0 C. L'Hermine, Radiology of Liver Circulation. 1985. ISBN 0 89838 715 9 G. Maatman, High-resolution Computed Tomography of the Paranasal Sinuses, Pharynx and Related Regions. 1986. ISBN 0 89838 802 3 C. Plets, A.L. Baert, G.L. Nijs and G. Wilms, Computer Tomographic Imaging and Anatomic Correlation of the Human Brain. 1986. ISBN 0 89838 811 2 J. Valk, MRI of the Brain, Head, Neck and Spine. A Teaching Atlas of Clinical Applications. 1987. ISBN 0 89838 957 7 J.L. Sellink, X-Ray Differential Diagnosis in Small Bowel Disease. A Practical Approach. 1987. ISBN 0 89838 351 X T.H.M. Falke, ed., Essentials of Clinical MRI. 1988. ISBN 0 89838 353 6

MRI OF THE BRAIN, HEAD, NECK AND SPINE A teaching atlas of clinical applications

JAAP VALK Department of Neuroradiology, Academic Hospital, Free University of Amsterdam, The Netherlands

with contributions by

JONAS A. CASTELIJNS and MARJO S. VAN DER KNAAP

.It

1987 MARTINUS NIJHOFF PUBLISHERS ~ ... a member of the KLUWER ACADEMIC PUBLISHERS GROUP

DORDRECHT / BOSTON / LANCASTER

Distributors

jonhe United States and Canada: Kluwer Academic Publishers, P.O. Box 358, Accord Station, Hingham, MA 02018-0358, USA jor the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited, Falcon House, Queen Square, Lancaster LA1 1RN, UK jor all other countries: Kluwer Academic Publishers Group, Distribution Center, P.O. Box 322, 3300 AH Dordrecht, The Netherlands

Library of Congress Cataloging in Publication Data Valk, J. MRl of the brain, head, neck. and spine. (Series in radiology) Bibliography: p. I. Magnetic resonance imaging. 2. Brain--Diseases-Diagnosis. 3. Head--Radiography. 4. Neck--Diseases-Diagnosis. 5. Spine--Diseases--Diagnosis. I. Castelijns, Jonas A. II. Knaap, Marjo S. van der. III. Title. IV. Series. [DNLM: I. Brain--pathology-atlases. 2. Head--pathology--atlases. 3. Neck-pathology--atlases. 4. Nuclear Magnetic Resonance-diagnostic use--atlases. 5. Spine--pathology--atlases. WB 17 VI7ml

RC386.6.M34V35

1987

617' .510754

ISBN-13: 978-94-010-8005-7

87-16854

e-ISBN-13: 978-94-009-3351-4

001: 10.1007/978-94-009-3351-4

Copyright © 1987 by Martinus Nijhoff Publishers, Dordrecht. Softcover reprint of the hardcover 1st edition 1987 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publishers, Martinus Nijhoff Publishers, P.O. Box 163, 3300 AD Dordrecht, The Netherlands.

CONTENTS XIII

ABBREVIA TIONS FOREWORD

l. INTRODUCTION l.l. Introduction

3

1.2. Basic principles of MRI 2. TECHNICAL CONSIDERATIONS

2.1. Pulse sequences 5. MRI cisternography 6. Tissue differentiation, same slice, different techniques, IR, SE, SE with Gd-DTPA 7. Tissue differentiation in complex pathology 8. 'Anatomical' sequence, short TR, short TE 9. Application of' anatomical' sequence

2.2 Artefacts 10. Artefacts (l) 11. Artefacts (2) 12. Artefacts (3)

2.3. Functional studies 13. Functional studies on MRI systems

2.4. Flow related phenomenons 14. 15,16. 17. 18. 19. 20.

Signal void in aqueduct Flow-void in aqueduct; NPH Flow-void in aqueduct; hydrocephalus in infants CSF flow obstruction Arteriovenous malformation Flow phenomena, carotid artery

2.5. Surface coils 21,22, 23. 24. 25. 26.

Surface Surface Surface Surface

coils (1) coils (2) coils (3), coronal and oblique images coils (4), orbit, oblique sagittal views

3. SPECIAL PROCEDURES

3.1. Sellar and parasellar regions 27. 28, 29. 30. 31. 32.

Empty sella Pituitary adenomas Chromophobe adenoma Parasellar lesion Para sellar lesion

3.2. Mesencephalon, region pineal gland 33. Pinealoma

5 5 9 10 10 12 14 16 18 20 20 22 24 26 26

28 28 30 32 33 34 35

36 36 36 38 39

40 43 44 45

46 48 50

52

54 54

VI

3.3 Pontocerebellar cisterns 34. 35. 36,37. 38.

Coronal T2W, thin section series Pontocerebellar cistern: T2W images; MRI cisternography Acustic neurinomas Acustic neurinoma

4. INTRACRANIAL TUMOURS

4.1. Diagnostic problems 4.2. Cerebral tumours 39. 40. 41. 42. 43. 44. 45. 46.

Localization; intraventricular meningeoma Cyst or solid? Oligodendroglioma; large linear calcifications Low grade glioma Malignant glioma Malignant glioma, patchy enhancement Multifocal astrocytoma Posterior fossa tumour

4.3. Extracerebral tumours 47. Medulloblastoma 48. Suprasellar lesion, craniopharyngeoma 49. Parasellar meningeoma

4.4. High SI lesions in pons and mesencephalon 50. 51. 52. 53. 54.

Intrapontine haematoma; glioma Intrapontine haemorrhage, dd. dermoid cyst Same patient as in 51; follow-up Dermoid cyst Same patient as in 53; follow-up

4.5. Metastases 55. Metastases and Gd-DTPA 56. Metastasis of adenocarcinoma with haemorrhage 57. Tissue characterization; adenocystic carcinoma, metastasis

4.6. Gliomatosis cerebri 58. 59. 60. 61. 62. 63. 64. 65.

Multifocal astrocytoma or gliomatosis cerebri Gliomatosis diffusa Gliomatosis diffusa Gliomatosis diffusa Vasculitis simulating gliomatosis diffusa Gliomatosis diffusa Gliomatosis diffusa; cerebellar involvement Gliomatosis diffusa

5. SPINAL LESIONS

5.1. Spondylarthrotic and disc related disease 66. 67. 68, 69. 70. 71.

Spondylarthrotic and disc related disease Spondylarthrotic and disc related disease Myelopathy due to compression Herniated disc L5-S 1 Postoperative lumbar spine

56 56 58 60 62 65 68 70 70 72 74 76 78 80 82 84 86 86 88 90 92

92 94 96 98 100

102 102 104

106 109 110 112 114 116 118

120 122 122 127

130 130 131 132 134 136

VII

5.2. Orthopedic problems 72. Orthopedic problems 73. Orthopedic problems

5.3. Spinal tumours 5.3.1. Intramedullary tumours 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87.

Intramedullary tumour, lipoma/dermoid Intramedullary tumour Cystic tumour, craniovertebral region Intramedullary tumour and syrinx Intramedullary tumour (metastasis) Intramedullary tumour and cysts Recurrent intramedullary astrocytoma Gd-DTPA Intramedullary tumour, ependymoma with calcifications Whole cord spinal tumour, astrocytoma, grade 2, recurrence Intramedullary tumour, astrocytoma grade 1 Intradural dermoid cyst and lipoma Cystic ependymoma (post-operative) Intramedullary tumour without and with Gd-DTPA Mutiple lesions; intramedullary tumour

5.3.2. Vascular malformations 88. Intramedullary lesion. Cryptic angioma? 89. Intramedullary arteriovenous malformation

5.3.3. Extramedullary and extradural lesions 90. 91. 92. 93. 94. 95. 96. 97.

Meningeoma at the Cl level Osteochondroma of posterior arch Extradural expanding lesion, Schwannoma Post-laminectomy Th 1-2 for metastasis of adenocarcinoma of the breast Metastasis of breast carcinoma Giant cell tumour in sacrum Extramedullary compression. Non Hodgkin lymphoma Extradural lesion with cord compression. Osteoporosis of vertebral column

5.3.4. Congenital malformations, Myelodysplasia 98. Chiari 1+, syrinx 99. Chiari I and syringomyelia 100. Spondylolysis and listhesis 101. Tethered cord, lipoma, syrinx 102. Tethered cord, intra-extradural lipoma 103. Tethered cord, hydronephrosis 104. Myelodysplasia; diastematomyelia 105. Myelodysplasia; diastematomyelia 106. Sacral cyst 6. CONTRAST AGENTS 107. Virus infection 108. Metastatic disease 109. Metastatic disease 110. Low grade astrocytoma 111. Glioma, grade 3; postoperative, postradiotherapy 112. Glioblastoma multiforme, distinction between tumour/oedema

138 138 140

143 144 144 146 148 150 152 154 156 158 160 162 164 166 168 170

172 172 174

176 176 178 180 182 184 186 187 188

190 190 192 194 196 198 200 202 204 206 209 211 216 218 220 222 224

VIII

113. 114. 115. 116. 117. 118. 119. 120. 121.

Cystic or solid lesion Meningeoma of the foramen magnum Tentorium meningeoma Intramedullary tumour Recurrent spinal meningeoma Intramedullary tumour Intra- or extramedullary lesion with arachnoiditis Intramedullary lesion in Wegener's disease Same patient as in 120, follow-up after treatment

7. INFECTIONS 7.1. General 122. N eurocysticercosis 123. Viral encephalitis 124. Tuberculoma with partial epileptic seizures 125. Tuberculous meningitis 126. Postencephalitic changes; herpes simplex encephalitis 127. Empyema, infectious sinus thrombosis, infarctions 128. Septicaemia, meningoencephalitis 129. Transverse myelitis 7.2. AIDS encephalopathy 130. AIDS related disease 131. AIDS dementia-complex; encephalitis 132. AIDS encephalopathy 133. AIDS encephalopathy 134. AIDS encephalitis 135. AIDS dementia-complex 8. VASCULAR LESIONS 8.1. Cerebral infarctions 136. Infarction or astrocytoma 137. Middle cerebral artery infarction 138. Multiple infarctions 139. Anterior cerebral artery infarction; lymphoma; haemorrhage 140. Anterior cerebral artery infarction; recurrent artery of Heubner infarction 141. Old deep middle cerebral artery infarction 142, 143. Border zone infarctions 144, 145. Border zone infarction; dd. MS 146. Border zone infarction 147. Old infarction of middle cerebral artery (MCA); recent infarction of the basilar artery territory

226 228 230 232 234 236 238 240 242 245 247 248 250 252 254 256 258 260 262 264 264 266 268 270 272 274 277 278 280 282 284 286 288 289 290 292 294

296

8.2. Cryptic 148. 149. 150, 151.

angiomas Cryptic angiomas Cryptic angiomas; multiple echoes Cryptic angiomas

298 298 300 302

8.3. A VM's, 152. 153. 154.

aneurysms, intracerebral haemorrhage Arteriovenous malformation Basilar artery aneurysm or suprasellar tumour Intracerebral haematoma

304 304 306 308

IX

8.4. Deep white matter infarctions, Binswanger's disease, Multi infarct dementia 155. 156. 157. 158. 159.

Psychiatric syndrome and white matter abnormalities Binswanger's disease? Multi-infarct dementia Binswanger's disease Binswanger's disease; Fe++ in basal ganglia

9. WHITE MATTER DISORDERS-MYELINATION

9.1. De- and dysmyelination 160. Adrenoleukodystrophy 161. Fukuyama's disease; congenital musclular dystrophy, leukodystrophy 162. Leukodystrophy post-irradiation

9.2. Multiple sclerosis 163. 164. 165. 166. 167. 168. 169. 170.

Multiple sclerosis Multiple sclerosis, multiple echoes Multiple sclerosis? Multiple sclerosis Multiple sclerosis. Cervical cord lesions Multiple sclerosis. Acute hemiparesis Gd DTPA Multiple sclerosis (and Normal Pressure Hydrocephalus) Internuclear ophthalmoplegia

9.3. Toxic encephalopathy 171. 172. 173. 174. 175. 176. 177.

Toxic encephalopathy Toxic encephalopathy Toxic encephalopathy Toxic (allergic) encephalopathy Toxic encephalopathy after heroin Toxic encephalopathy Alcohol abuse

9.4. Myelination 178. 179. 180a, b. 181a. 181 b. 18le. 181d. 182. 183a. 183b, 184. 185. 186a,b. 187a. I 87b,c. 188. 189. 190. 191.

Standard series Myelination at 6 weeks in IR Myelination at 3 months, IR and SE Myelination at 6 months, IR Myelination at 8 months, IR Myelination at 8 months, SE, TE 30 Myelination at 6 months, TE 120 Myelination at 9 months, IR Myelination at 18 months, IR Myelination at 18 months, SE Myelination at 2 years" IR Congenital malformation. Myelination in accordance with age Microcephaly, partial holoprosencephaly. Myelination Microcephaly, partial holoprosencephaly. Myelination Hypomyelination, Pelizaeus Merzbacher's disease Hydrocephalus, retrocerebellar cyst, delayed myelination (?) Hydrocephalus and retarded myelination Mental retardation, physically handicapped

310 310 312 314 316 318 321 322 324 326 328 331 332 334 336 338 340 342 344 346 348 348 350 352 354 356 358 360 362 364 366 368 370 371 372 373 374 375 376 378 380 382 383 384 386 388 390

x 192. Pelizaeus Merzbacher 193. Pelizaeus Merzbacher 194. Metachromatic leukodystrophy

392 394 396

10. CONGENITAL ANOMALIES with Marjo S. van der Knaap 195. Total vermis aplasia, hydrocephalus, abnormal optic chiasm 196. Schizencephaly 197. Encephaloclastic schizencephaly 198. Lissencephaly, pachygyria 199. Multiple congenital malformations; periventricular leukomalacia 200. Holoprosencephaly 201. Hemimegencephaly 202. Hemimegencephaly 203. Bourneville-Pringle's disease, tuberous sclerosis 204. Unclassifiable. Congenital hydrocephalus? 205. Agenesis of corpus callosum. Cerebellar infarction 206. Arachnoid cyst 207. Peri ventricular leukomalacia 208. Peri ventricular leukomalacia 209. Post encephalitic remains 210. Chiari II malformation 211. Congenital muscle dystrophy and leukodystrophy (Fukuyama) 212. Corpus callosum agenesis. Plexus papilloma 213. Lipoma of the corpus callosum

399 404 406 408 410 412 414 416 418 420 422 424 426 428 430 432 434 436 438 440

11. LESIONS OF THE HEAD AND NECK 214. Adenocystic tumour nasopharynx 215. Follow-up after cytostatic treatment of adenocystic tumour of the nasopharynx 216. Adenocarcinoma of nasopharynx 217. Tumour of the palatum 218. Tumour of the palatum 219. Parotid gland disease 220. Tumour os temporale; metastasis in skull 221. Cyst in the neck region 222. Pleomorph adenoma of submandibular gland 223. Rhabdomyosarcoma of the neck 224. Palatum tumour 225. Clivus chordoma? Grawitz tumour metastasis? 226. Chordoma 227. Chordoma

441 445 452 454 456 456 458 459 460 462 464 466 468 470 472

12. LARYNGEAL CANCER by Jonas A. Castelijns 228. Hypopharyngeal tumour 229. Small supraglottic tumour with lymphatic spread 230. Small glottic tumour

475 478 480 482

13. ORBITAL AND OCULAR LESIONS 231. Retinoblastoma 232. Melanotic melanoma 233. Amelanotic melanoma

485 487 488 490

XI 234. 235. 236,237. 238,239, 240,241. 242. 243. 244.

Optic glioma Carcinoma of the lacrimal gland Reduced size of eye: persistent hyperplastic vitreous; post-radiotherapy

492 494 496

Various lesions Aplasia of orbital roof Coloboma of the eye Outer ridge meningeoma

498 500 502 503

14. TEMPOROMANDIBULAR JOINT 245. Anterior luxation with reduction 246. Rotational dislocation

505 508 510

15. TRAUMA 247. Chronic subdural haematoma 248. Bilateral subdural haematomas; tentorial herniation 249. Haemorrhagic contusions

513 516 518 520

16. EPILEPSY 250. 251. 252. 253. 254.

523 526 528 529 530 532

Fronto-opercular gliosis with calcification and retraction Low-grade astrocytoma; no progression in two years Peri-insular gliosis Refractory partial epilepsy; gliosis of the temporal lobe Partial complex epilepsy; temporal lobe atrophy

17. POSTOPERATIVE CONDITIONS 255. Haemochromatosis and Normal Pressure Hydrocephalus 256. Postoperative control parana sal squamous cell carcinoma 257. Oligodendroglioma postoperative 258. Non Hodgkin lymphoma in pre-existent intraventricular cyst 259. Intramedullary haemangioblastoma with syrinx 260. Spinal syrinx after compression

535 536 538 540 542 544 546

18. GRADIENT ECHOES 261. Gradient echoes 262. Gradient echoes

547 549 549

ACKNOWLEDGEMENTS

552

REFERENCES

554

INDEX

569

ABBREVIATIONS In this book the following abbreviations are frequently used:

= InVerSIOn recovery IR SE = spin echo TI = inversion time TE = echo time TlW = Tl weighted IW = intermediate weighted (balanced image) T2W = T2 weighted RF = radio frequency M z = magnetization along the z-axis; M represents the net magnetization of the magnetizations of the protons, aligned parallel or anti parallel to the main magnetic field. NSQ = number of sequences EEG = electro encephalography VER = visual evoked response BER = brain stem evoked response SI = signal intensity CT = computed tomography US = ultrasonography VPD = ventriculo peritoneal drainage TMJ = temporomandibular joint DSA = digital subtraction angiography IACA = inferior anterior cerebellar artery lAC = internal auditory canal CE = contrast enhancement

FOREWORD With the growing number of MR installations, clinicians and radiologist are being confronted more and more with visual information they do not feel as confident with as with the more 'mono-form' information of conventional radiographs, CT and US. The freedom of parameter choice ofthe MR operator allows the same object to be depicted in various ways and the contrast in the images to be changed and inverted at will. For those not experienced in interpreting MR images, this may cause confusion and uncertainty about their diagnostic content. This will sometimes lead to an unnecessary retreat to other diagnostic modalities. The purpose of this book is to help close the gap between MR operators and readers and clinicians. A variety of cases is presented, together with the MRI considerations. In nearly all these cases, confirmation of diagnosis was obtained by histological examination. Quite deliberately, this book only includes the occasional CT scan or angiography for comparison, to avoid the temptation of falling back on other modalities and of escaping from the often more difficult to interpret, but in the end more rewarding MR images. All the MR images in this book were made with a 'first-generation', unsophisticated Teslacon I, 0.6 T, superconducting magnet system. Hopefully, they will reflect the quality of the machine. Some people will agree with me that it is sad that investments in expensive health care systems are subject to the whims of those who are mainly interested in satisfying their stockholders. I would like to express my gratitude to all the colleagues who have referred their patients to our department and in so doing have contributed to our experience with MRI. The many discussions have certainly helped to shape our knowledge. The form of a teaching atlas has been chosen: cases are presented with relevant images within a certain context. It does not boast full coverage of every subject, but tries to stimulate thinking about the MR imaging process in relation to pathology. It is to be hoped that this volume will reach many colleagues who are also interested in this fascinating medium, MRI.

Amsterdam; 1987, J. Valk