Imaging

Headache

Prof.M.Tameem Akhtar
Director, Deptt of Radiology
Dr.Ziauddin University
Karachi
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 Headache

 80% people have HAs ?? types

 40% severe & disabling
 Only 5% present to a doctor for help

 Ofpts presenting in ED,

 10% have 2° causes: -- of these:
Aneurysm: 2 - 5%
Brain tumour: 1%
A/V malformation: 0.8%

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CAUSES 4
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 Common Causes of headache

Primary causes:
 Tension headache ------ 90%
 Migraine ----- 2nd most common
 Cluster Headaches – very severe but more
unusual

Radiology, little role to play, ?? exclusional 6

 Common Causes of headache

Secondary
2. Sinusitis
3. Dental, TMJ abnormalities
4. Neck anomalies
5. Post concussion
6. Trigeminal neuralgia
7. Hypertension
8. Viral infections – colds, influenza
9. Alcohol withdrawal – hangover
10. Dehydration

Radiology, direct, specific, exclusional, role 7

 Other causes of headache


 Cerebral abscess
 Cerebral tumour
 Intracranial haematoma
Subdural/ Epidural/ Extradural
 Meningitis
 Aneurysm
 Arteritis

Radiology, essential... CT or MRI 8

 Causes of headache in kids

 DON’T FORGET BABIES:

1. Ischemia
2. Haemorrhage
3. Mass
4. Developmental

Radiology, US in 1st instance ... CT scan or MRI later on

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 RADIOLOGICAL
Investigation techniques

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 Investigation techniques

 PlainX-ray >>> role??

 Angio therapeutic; embolization

 CROSS SECTIONAL
 CT / MDCT/ CTA/ 3D
 MRI/MRA/MRV
 US (infant)

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ULTRASOUN
D

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 US choice

 Pre-natal & neonatal neurology screening

 Definitive in infants:
1. ICH
2. HIE
3. Infection
4. Developmental malformations of brain
5. SOL

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 ULTRASOUND

Advantages Disadvantages

1. Non-invasive. 1. Cranial exams limited

to infants.
2. Inexpensive.
2. Operator dependent.
3. Portable.
3. View limited by probe
4. Fast.
size.
5. Multiplanar.
4. Needs a “window”.
6. No contrast agents.
5. Artefacts can mimic a
7. No sedation ??. pathology.

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 Neonates: US vs other
Neuro-imaging

 US superior to CT.
CT for extracerebral hge – SAH / SDH.
CT for posterior fossa collections.
 MRI superior to all CT applications.
 some problems in early neonatal period.

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 CT
SCAN

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 CT is of choice

1. Acute trauma.
2. Acute hge.
3. Infection.
4. Infarction/Stroke.
5. Malformations.
6. Atrophy.
7. Hydrocephalus.
8. Skull lesions.
9. Calcified lesions.
10. Orbits, sinuses, petrous bones.
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 CT
Advantages Disadvantages

1. Radiation dose !
1. Fast
2. Sedation in restless pts &
2. Easily accessible most
hospitals in emergencies young children
3. Fine bone resolution 3. I.V. contrast risks
4. Modern scanners
4. Not portable
– multiplanar imaging??
○ Orbits 5. Metallic artefacts due to
○ Sinuses
beam hardening –
○ TMJs
○ Sellar masses surgical clips

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MRI

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 MRI indications

1. Brain maturation
2. Encephalitis 6. Neurodegenerative
3. Vasculitis diseases.
4. Small lesions: 7. Neuromigratory
1. abscesses, disorders.
2. trauma (NAI) 8. Infarction, early detection
5. Tumours: 9. AVMs.
1. Aqueduct.
10. Myelination.
2. Brainstem.
3. Pituitary.

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 MRI

Advantages Disadvantages
1. Slower
2. Motion sensitive
1. Versatile 3. Claustrophobia………… ?
2. Non-ionising radiation Open magnet
3. Non-invasive 4. Sedation for children &
4. Multi-planar anxious adults
5. Difficult access
5. High resolution – emergency & ICU
6. Expensive???

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 Conclusio
n

Neuro-imaging useful to identify a

structural lesion
Tests should be avoided if they will
not lead to a change in management;

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 PNS X-
RAYS
Sinusitis

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Sinusitis

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Cholesteatoma
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Aneurysm

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 CTA

Aneurysm
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Aneurysm/embolism

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 Analysis of Brain
Tumor
 Age of pt.
 Localization
 Intra vs extra-axial
 What compartment
 Mid line crossing
 CT & MR characteristics:
 Calcifications, fat, cystic
 T1, T2, DWI
 Contrast enhancement
 Mass effect – edema
 Solitary – Multiple
 Pseudo-tumour ?

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 Skull X-
rays

Acoustic Neuroma
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Meningio
ma

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SO
L

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SO
L

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Ring enhancing
lesions

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SOL

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SO
L
SOL

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SO
L

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 OBSTRUCTIVE
HYDROCEPHALUS
 SAH
SAH

STROK
E

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SAH

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SAH

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STROK
SAH

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STROK
E

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SDH

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BONY METS 47
 Summary

Most HAs will be 1°, but must

recognize the “Red Flags” of serious
2° HA.
Use of correct modality…..

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Thank you 49