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MGH Neuroradiology Review Course

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How to Acquire/interpret Head CT, H&N CTA, and Brain MRI

Michael H Lev, MD FAHA FACR Director, Emergency Radiology & ED Neuroradiology

Massachusetts General Hospital Professor of Radiology

Harvard Medical School MHL / MGH

Disclosures   GE Healthcare

  Consultant   Research support (MGH)   Common stock (< $10K)

  D-Pharm   Consultant

  MedyMatch   Consultant

  MLNM Pharm   Consultant

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Father Guido Sarducci�s Philosophy

  SNL 1980�s   �You forget 95% of everything you learn in school�   �My course only teaches the 5% you remember”

�Neurology for the House Officer� Weiner and Levitt

Last chapter: Neuroanatomy

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History Essential for both detection and interpretation … really just need the following 4 items …

  Age?   Stroke etiology

  Gender?   MS

  Acuity of Onset?   Stroke   MS, ICH vs stroke   Tumor

  Specifc sx, immune status?   Spinal level   Toxo vs lymphoma

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Other NCCT Considerations   Artifact

  Beam-hardening   �Spray�; metallic – solution dual energy?   Tilt / reconstruction plane   �Fogging�

  CORONALS – since 2008/9 at MGH …   Henson et al, AJNR 2010   MUST USE IN ALL TRAUMA

–  Tentorial, falx SDH; subtle SAH –  Blow out fracture –  Anterior temporal and frontal contusions

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Value of Reformats: Avoid False Negatives

(A rare case for which sagittal > coronals …)

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Subtle SDH   Level 30   Window 100

  Level 80   Window 200

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HU Helps: �Swirl Sign� is HIGHLY SPECIFIC For Expansion of Acute Hemorrhage

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… if it is true swirl sign … But Almost All Acute Bleeds at MGH get CTA

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CTA �Spot Sign� Predicts Hematoma Growth: High NPV!

Goldstein, …, Lev, Rosand. Neurology 2007 Mar 20;68(12):889-94 Delgado, Yoo, Romero, et al. Stroke 2010

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Sag CT

Wood is Hypodense Chopstick Injury

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“Low Tech” Pearl: Early ‘Ionic’ Edema?

Sensitivity improved from 57% to 71% Advice to non-experts: use ASPECTS!

30 mm Slabs at 5 mm Intervals

Overlapping Thick Slab MIPS*

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Checking Stroke CTA’s at the Scanner: Overlapping Thick Slab MIPS (Not for SAH!*)

•  By tech at scanner in 3 planes ~ 1min •  Triage decisions made before patient off table!

30 mm thick at 5 mm intervals

Courtesy of Stuart Pomerantz, MD

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From Brian Greene: The Hidden Reality

(Superimposition of hi freq / low freq transformed image data)

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Scan Review Layout

Leon Harmon produced the famous Lincoln illusion in 1973

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�Golfe Juan�: Paul Signac, 1884 (WAM)

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A Sunday Afternoon on the Island of La Grande Jatte, George Suerat, 1884

Courtesy Stu Pomerantz, MD MHL / MGH

FBP: 250 mA FBP: 200 mA ASIR:200 mA

ASIR: improved gray-white differentiation due to TRUE DECREASED NOISE* c/w same or higher dose FBP

The �graininess� to which radiologists have become accustomed

is not a true feature of brain anatomy!

�Waxy�?: Does the Brain have Grain?

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