Neuroimaging for the Primary Care Physician

Home , Peter Mansfield, Raymond Damadian

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. History 2. Tools at your disposal 3. Pros and cons of modalities 4. Clinical symptoms 5. Case Scenarios 6. 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 • Royalty the German – hand x-rays Physics Society • 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

• 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 Cons • Painless • Radiation exposure • Fast • Contrast reactions • Cost effective • Contrast induced • Detail nephropathy • Bone • Blood vessels • Soft tissue Pros and Cons MRI

Pros Cons • Painless • Metal can be safety • No radiation hazard • Excellent • Availability spatial and • Costs temporal resolution • No side effects from B0 or RF

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

• 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 Rontgen̈ Museum October 2012 • http://www.schoolphysics.co.uk/age16- 19/Medical%20physics/text/CT_scanning/index.html • http://web.stanford.edu/group/hopes/cgi- bin/hopes_test/neuroimaging/#advantages-and-disadvantages-of-ct • http://staugustine.com/living/sunday-life/2015-01-24/beauty-black-and- white-wilderness-photographer-clyde-butcher-coming#.VWOcSs5j7dl • http://radiopaedia.org/articles/internal-carotid-artery-dissection-1 References

• 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.