Brain Masterclass

Question 1

What is 1st line when looking at the brain?

Answer 1

CT; fast, well tolerated, with or without IV contrast

Question 2

What is MRI better for in terms of brain imaging?

Answer 2

Better soft tissue resolution
Longer duration
Contra-indicated for some
With or without TV contrast

Question 3

What is an ischaemic stroke?

Answer 3

Suddent cessation of adequate amounts of blood to the brain

Can be divided according to the territory affected or mechanism

Question 4

How do ischaemic strokes tend to present?

Answer 4

Rapid onset neurological deficit, which is determined by the area of brain involved
Deprivation of oxygen and glucose
Initiates a cascade of events at a cellular level which can lead to gliosis and liquefactive necrosis

Question 5

What is the end point of a stroke?

Answer 5

Gliosis

Liquefactive necrosis

Question 6

What conditions can lead to cardiac embolism?

Answer 6

Atrial fibrillation
Ventricular aneurysm
Endocarditis

Question 7

What can lead to embolisms?

Answer 7

Cardiac emoblism 
Paradoxial 
Atheroscelrotic
Fat
Air

Question 8

What area of the brain is most affected by hypertensive haemorrhagic strokes?

Answer 8

Basal ganglia

Question 9

Imaging of choice in acute stroke?

Answer 9

Non contrast CT

Question 10

Why is a non contrast CT performed in acute stroke?

Answer 10

Exclude haemorrhage and confirm ischaemia

Permits RAPID treatment e.g. thrombolysis or thrombectomy

Question 11

Early findings on CT of an ischaemic stroke?

Answer 11

Hyperdense segment of a vessel, direct visualisation of the intravascular thrombus/ embolus and as such is visible immediately

Question 12

What findings are seen within a few hours of an ischaemic stroke?

Answer 12

Loss of grey white matter differentiation and hypoattenuation of deep nuclei
Cortical hypodensity with assoc parenchymal swelling with resultant gyral effacement

Question 13

What will happen with the hypodensity seen in ischaemic stroke as time progresses?

Answer 13

More marked resulting in a mass effect

Question 14

What are the end stages appearances of an ischaemic stroke on CT?

Answer 14

Gliosis as a region of low density with volume loss

Question 15

What are the different types of extra-axial intracranial haemorrhages?

Answer 15

Extradural
Subdural
Subarachnoid

Question 16

What colour will blood appear on a CT scan?

Answer 16

White

Question 17

What will an intra-axial hemorrhage appear like on a CT?

Answer 17

LOBAR haematoma

Midline shift may be present

Question 18

Where is the blood in an extradural haemorrhage?

Answer 18

Between inner layer of skull and outer layer of dura

Question 19

What are extradural haemorrhages commonly assoc with?

Answer 19

Trauma

Skull #

Question 20

What is the source of bleeding in an extradural haemorrhage?

Answer 20

Arterial

Torn middle meningeal artery

Question 21

What shape is the haemorrhage seen in an extradural haemorrhage?

Answer 21

BICONVEX
Can cause mass effect with herniation
Limited by cranial sutures

Question 22

Where is the blood collection in a subdural haemorrhage?

Answer 22

Subdural space, the potential space between the dura and the arachnoid mater

Question 23

What is the mainstay of investigation in subdural haemorrhages?

Answer 23

CT

Question 24

What causes subdural haemorrhages?

Answer 24

Infants; NAI (shaken baby syndrome)
Young Adults; RTA
Elderly; falls (tearing of bridging veins)

Question 25

What shape is the subdural haemorrhage?

Answer 25

Semilunar
Crosses sutures
Mass effect

Question 26

Where is the blood in a SAH?

Answer 26

Subarachnoid space;

Between arachnoid and pia

Question 27

What are 85% of SAH due to?

Answer 27

Ruptured berry aneurysm

Question 28

Where will blood be seen in a SAH?

Answer 28

Suprasellar cistern
Sylvian fissure
Sulci

Question 29

What is the gold standard for SAH?

Answer 29

CT cerebral angiogram

Question 30

What are common complications of SAH?

Answer 30

Hydrocephalus
Vasospasm
Infarction

Question 31

What make up the majority of brain tumours in adults?

Answer 31

Metastatic disease

Question 32

What makes up the majority of brain tumours in children?

Answer 32

Primary tumours

Question 33

What areas of the body will metastasise to the brain?

Answer 33

Lung
Breast
Melanoma
Renal cell
Colorectal

Question 34

What is the first test when suspected intracranial mass?

Answer 34

CT
Hypo or hyperdense
Determines oedema/ mass effect

Question 35

What are the features of mets in the brain?

Answer 35

Supra or infra tentorial 
Usually multiple
Lots of oedema
Lots of mass effect
Avidly enhance

Question 36

What type of herniation results in “coning”?

Answer 36

Tentorial herniation; descent of cerebellar tonsils below the foramen magnum compressing the brain stem against the clivus

Question 37

What is the spinal cord contained within?

Answer 37

Thecal sac

Question 38

Where does the spinal cord extend to - from?

Answer 38

Corticomedullary junction at the foramen magnum of the skull down to the tip of the conus medullaris (L1)

Question 39

What can cause spinal cord compression?

Answer 39

IV disc; protrusion, extrusion, discitis, osteomyelitis 
Vertebral; trauma, tumour 
Epidural space; abscess, haematoma 
Dura; spinal meningioma 
Intradural space; nerve sheath tumour

Question 40

What is the investigation of choice in spinal cord compression?

Answer 40

MRI spine

Question 41

What are red flags in terms of back pain?

Answer 41

History of malignancy 
Major trauma
Thoracic/ radicular pain 
Constant, progressive, non-mechanical pain
Widespread neurological signs
Loss of power in lower limbs
Loss of sensation; saddle anaesthesia
Urinary retention