BRAINSTORM

1. BRAINSTORM Understanding Diagnostic Scans: MRI, CT, PET AND MORE Stanley Lu, MD Director, Neuroradiology Monmouth Medical Center March 5, 2012

2. Neuroradiology • What is a Neuroradiologist? • Design imaging protocols • Interpret scans - make diagnosis • Provide reports • Consult with the Brain Tumor Team • Suggest follow-up plan

3. Neuroradiology • Imaging of the brain • Tumors • Stroke • Infection • Imaging of the spine

4. Neuroradiology • Imaging modalities • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Advanced techniques • Positron emission tomography (PET) • Diagnosis - Different appearances for different tumors

5. Neuroradiology • Post-operative assessment • Tumor monitoring • Challenges

6. CT Technique

7. CT Technique

8. CT Technique

9. CT Technique

10. CT Technique

11. MRI Technique

12. MRI Technique • What is MRI? • How does it work?

13. MRI Technique

14. MRI Technique Z-axis

15. MRI Technique Z-axis

16. MRI Technique

17. MRI Technique

18. MRI Advantages • Superior contrast resolution • especially for soft tissue • Multiplanar • No ionizing radiation

19. MRI Disadvantages • Higher cost • Lower availability • Longer study • increased chance of patient motion • Claustrophobia • Metallic implants contraindicated • pacemakers, aneurysm clips, etc.

20. Brain Tumors

21. Brain Tumors • Metastatic disease • Meningioma • Primary brain tumors • Astrocytoma • Oligodendroglioma • Lymphoma

22. Brain Tumors • Metastatic disease • Meningioma • Primary brain tumors • Astrocytoma • Oligodendroglioma • Lymphoma

23. Metastatic Disease • Pt with melanoma

24. Brain Tumors • Metastatic disease • Meningioma • Primary brain tumors • Astrocytoma • Oligodendroglioma • Lymphoma

25. Meningioma

26. Brain Tumors • Metastatic disease • Meningioma • Primary brain tumors • Astrocytoma • Oligodendroglioma • Lymphoma

27. Brain Tumors • Astrocytoma WHO Grading • Grade I: small subset • Grade II: Low-grade astrocytoma • Grade III: Anaplastic astrocytoma • Grade IV: Glioblastoma multiforme (GBM)

28. Low-grade Astrocytoma

29. Anaplastic Astrocytoma

30. GBM

31. Gliomatosis Cerebri

32. Management of GBM • Pre-operative • Full brain MRI with STEALTH • MR tractography • Post-op day #1 • Follow-up at 2-3 months, and further • As needed, with new symptoms

33. Management of GBM • Pre-operative • Full brain MRI with STEALTH • MR tractography • Post-op day #1 • Follow-up at 2-3 months, and further • As needed, with new symptoms

34. Management of GBM • Pre-operative • Full brain MRI with STEALTH • MR tractography • Post-op day #1 • Follow-up at 2-3 months, and further • As needed, with new symptoms

35. MR Tractography

36. MR Tractography Disorganized water Water organized along neurons

37. MR Tractography

38. MR Tractography

39. MR Tractography

40. Management of GBM • Pre-operative • Post-op day #1 • Follow-up at 2-3 months, and further • As needed, with new symptoms

41. Management of GBM • Pre-operative • Post-op day #1 • Follow-up at 2-3 months, and further • As needed, with new symptoms 18 mo.

42. Pt #2: Two follow-up scans Dec 2007 Jan 2008

43. Pt #3: Multiple follow-up scans Pre-op Post-op 1 mo.

44. Pt #3: Multiple follow-up scans Pre-op Post-op 1 mo. 4 mo. 8 mo.

45. Pt #4: Follow-up scan

46. Pt #4: Follow-up scan ?

47. Pt #4: Follow-up scan

48. Challenge of Pseudo-progression • We have great difficulty distinguishing real from pseudo • Modalities that we utilize • PET • MR spectroscopy • MR perfusion

49. Positron Emission Tomography (PET)

50. Positron Emission Tomography (PET)