MRI of The Brain

3.
07
MRI of the Brain
A Horska and DDM Lin, Johns Hopkins University, Baltimore, MD, USA
2014 Elsevier B.V. All rights reserved.
3.07.1
Introduction
3.07.2
MR-Based Modalities for Assessing Brain Anatomy
3.07.3
MRI in Normal Brain Development
3.07.4
MRI in Normal Brain Aging
3.07.5
MRI of the Brain in Pathologic Conditions
3.07.5.1
Ischemic Stroke
3.07.5.2
Hypoxic Ischemic Injury in Neonates
3.07.5.3
Intracranial Hemorrhage and Traumatic Brain Injury
3.07.5.4
Brain Tumors
3.07.6
Conclusion
Acknowledgment
References
Glossary
Angiography Imaging of blood vessels, usually arteries.
Apparent diffusion coefficient The modified coefficient,
which depends on the direction of observation and its value
becomes lower than the diffusion coefficient that would be
measured in the same media without obstacles.
Cerebrovascular accident (stroke) Interruption of vascular
supply of adequate blood nutrients to the brain can be
due to ischemia (lack of blood supply) caused by
thrombosis or embolism, or due to a hemorrhage
(rupture of blood vessels).
Nomenclature
ADC
Apparent diffusion coefficient
APT
Amide proton transfer
ASL
Arterial spin labeling (perfusion)
Static magnetic field
B0
BMI
Body mass index
BOLD Blood oxygenation level dependent (contrast)
CBF
Cerebral blood flow
Cho
Choline
CNS
Central nervous system
Cr
Creatine
CT
Computer tomography
DAI
Diffuse axonal shearing injury
DSC
Dynamic susceptibility contrast
DTI
Diffusion tensor imaging
DVA
Developmental venous anomaly
DWI
Diffusion-weighted imaging
FA
Fractional anisotropy
FLAIR Fluid attenuation inversion recovery
fMRI
Functional MRI
Comprehensive Biomedical Physics
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Diffusion-weighted MRI A noninvasive technique able

for imaging the human brain white matter, with the
capability to accurately describe the geometry of
the underlying microstructure and its integrity.
Fluid attenuated inversion recovery (FLAIR) A sequence
used to null the signal from cerebrospinal fluid based upon
its longitudinal relaxation time T1.
Hypoxic-ischemic encephalopathy Prolonged oxygen
deprivation of the brain, due to reduced oxygen delivery
(hypoxemia) frequently caused by perinatal asphyxia or to
cerebral blood flow (ischemia).
FOV
GBM
GRE
Ins
Lac
MCA
MD
MRA
MRS
MRSI
NAA
NEX
NPV
PLIC
PPV
rCBV
SWI
TE
DTE
TR
http://dx.doi.org/10.1016/B978-0-444-53632-7.00307-5
Field-of-view
Glioblastoma multiforme
Gradient echo
Myo-inositol
Lactate
Middle cerebral artery
Mean diffusivity
Magnetic resonance angiography
Magnetic resonance spectroscopy
Magnetic resonance spectroscopic imaging
N-Acetylaspartate
Number of excitations
Negative predictive value
Posterior limb of the internal capsule
Positive predictive value
Relative cerebral blood volume
Susceptibility weighted imaging
Echo time
Echo spacing
Repetition time
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3.07.1
MRI of the Brain
Introduction
Magnetic resonance imaging (MRI) is a noninvasive technique

providing multiplanar images of neuroanatomy and vascular
anatomy. Advanced techniques of MRI further enable interrogation of brain function, connectivity, hemodynamic properties, and diffusion-related phenomena.
In clinical neuroimaging, MRI is a complementary technique to computerized tomography (CT). CT is fast, more
widely accessible, lower in cost, and provides better detail on
bone structures and has high sensitivity for acute hemorrhage;
it has therefore been routinely used in brain trauma and emergency situations to detect bleeding. CT has a much higher
sensitivity than conventional MRI for intracranial calcifications. On the other hand, MRI offers superior intrinsic contrast
of soft tissues compared to CT. MRI is generally more sensitive
than CT for detection of pathologic changes in brain tissue in
the early stages of disease processes, for example, in cerebral
infarctions, brain tumors, or brain infections. MRI is highly
sensitive for detecting white matter pathology, such as in multiple sclerosis, progressive multifocal leukoencephalopathy,
leukodystrophy, and postinfectious encephalitis. In contrast,
patients with obvious white matter abnormalities may have an
entirely normal CT, in particular in the early stages of the
disease. MRI is preferable to CT for evaluating temporal lobe
epilepsy, nonhemorrhagic brain contusions, traumatic shear
injuries, posterior fossa disease, defining congenital malformations, and imaging vascular disease. MRI is the imaging procedure of choice in situations when early diagnosis is critical for a
favorable outcome, for example, in suspected herpes encephalitis (Klein and Hesselink, 1996). In the evaluation of children,
MRI has distinct advantage over CT because of the lack of
ionizing radiation.
This chapter provides an overview of the applications of
clinical and advanced MRI techniques to examine brain anatomy, study brain development and aging, and diagnose common brain pathologies.
3.07.2 MR-Based Modalities for Assessing

Brain Anatomy
Conventional morphological MR images of the brain can differentiate among four main brain tissue constituents white
matter, gray matter, cerebrospinal fluid (CSF), and blood.
Depending on the imaging sequence used, one or more of
T1
T1
these constituents can dominate the image. The basic MRI

contrast relies mainly on proton density, and spinlattice
(T1) and spinspin (T2) relaxation times. Figure 1 illustrates
the contrast among gray matter, white matter, and CSF on an
axial T1-weighted, T2-weighted, and fluid attenuation inversion
recovery (FLAIR) image.
MRI provides detailed views of brain anatomy, previously
unachievable in vivo. Introduction of high-field MRI scanners
accompanied by recent advancements in magnet technology,
detector technology, and application of contrast mechanisms
including flow, diffusion, and T*
2 opened new possibilities in
studies of brain anatomy (Duyn, 2010). Compared with 3.0-T
MRI systems, scanners operating at ultra-high magnetic fields
of 7.09.4 T enable a two- to threefold improvement in the
signal-to-noise ratio. This improvement is somewhat diminished by increases in T1 and reduction in T*
2 at higher magnetic
fields, but a small gain is achieved from the synergistic effect
from high field and array detectors. Employing multidetector
array coils with parallel imaging techniques can result in scan
time reduction, or improvement in temporal or spatial resolution. Spatial resolution below 0.1 ml of voxel volume can be
achieved at ultra-high fields (Cho et al., 2008a,b; Duyn, 2010),
comparable with resolution of thin slices in vitro (Cho et al.,
2008a,b). Ultra-high field MRI can therefore provide fine details of brain anatomy and visualize brain structures that were
previously difficult or impossible to delineate (Cho et al.,
2008a,b; Strotmann et al., 2011). At ultra-high fields, images
obtained with gradient echo (GRE) appear more uniform than
spin echo images (Haacke et al., 2009). The T*-weighted
im2
ages allow delineation of venous structures (Robitaille et al.,
2000), iron-rich structures, blood products (Novak et al.,
2005), myelinated white matter fiber bundles (Li et al.,
2006), and cortical layers (Duyn et al., 2007) with high resolution. The origin of the T*
2 contrast may stem from differences
in iron concentrations, variations in myelin content, and, possibly, from variations in density and orientations of venous
microvascular elements (Li et al., 2006). High-field MRI of the
brain may therefore enable studies of cytoarchitecture across
functional areas, disease processes, and populations. Figure 2
shows striking contrast differences in the white matter at 7.0 T,
illustrating that the T*-weighted
contrast can be used to differ2
entiate among specific fiber bundles. The border between gray
and white matter appears dark in cortical regions, possibly due
to local U-fibers or blood vessels that follow these fibers.
Figure 3 demonstrates excellent susceptibility contrast that
can be achieved at 7.0 T.
T2
FLAIR
Figure 1 Sagittal T1-weighted, axial T1- and T2-weighted spin echo and FLAIR images obtained at the level of the basal ganglia in a 5-year-old
healthy child.
MRI of the Brain
Tapetum
PCR
SLF
U-fiber
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Tapetum
PCR
Splenium
SLF
Splenium
U-fiber
Figure 2 Left: A T2*-weighted axial image acquired at 7.0 T with repetition time/echo time (TR/TE) 800/30 ms, 30 flip angle, receiver bandwidth
32 kHz, matrix size 1024 768, field-of-view (FOV) 220 165 mm2, slice thickness 1 mm, and number of excitations (NEX) 1. Right:
A magnified display of the region outlined in the image to illustrate the contrast difference between the fiber bundles. The following fiber bundles
are labeled: tapetum, posterior corona radiata (PCR), superior longitudinal fasciculus (SLF), splenium of the corpus callosum, and local U-fibers.
Color-coded representation of fiber directionality (red: left-to-right, green: anterior-to-posterior, blue: out of plane) was obtained from DTI
experiments performed at 3.0 T in a different participant at a similar location, with spatial resolution 0.9 0.9 0.9 mm3. Reproduced from Li TQ,
van Gelderen P, Merkle H, Talagala L, Koretsky AP, and Duyn J (2006). Extensive heterogeneity in white matter intensity in high-resolution T2*-weighted
MRI of the human brain at 7.0 T. Neuroimage 32(3): 10321040, with permission from Elsevier.
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Figure 3 A quantitative susceptibility map reconstructed from a 3D

multiecho gradient echo (GRE) acquisition (1 1 1 mm3 resolution,
TR 70 ms, TE/DTE 2/2 ms, flip angle 9 ). The GRE phase
images were acquired with four different head orientations.
The image clearly depicts the iron-rich globus pallidus (arrow).
The scale is in units of ppm. Courtesy of Xu Li, Issel Anne Lim, Craig
Jones, Deepti Vikram, Jonathan A.D. Farrell, Peter C.M. van Zijl; F. M.
Kirby Center for Functional Brain Imaging, Kennedy Krieger Institute,
Baltimore, MD, USA.
Figure 4 Depiction of human cerebrovasculature, color-coded, from a

3D atlas (Nowinski et al., 2011). The orientation box is located in the
left upper corner; the anterior (A) and left (L) orientations are shown.
Reproduced from Nowinski WL, Chua BC, Marchenko Y, Puspitsari F,
Volkau I, and Knopp MV (2011) Three-dimensional reference and
stereotactic atlas of human cerebrovasculature from 7 Tesla.
Neuroimage 55(3): 986998, with permission from Elsevier.
High-field MRI also offers opportunity for more detailed

studies of brain vasculature, including small vessels (Cho et al.,
2008a,b; Nowinski et al., 2011). Using data from 3.0 to 7.0 T
acquisitions, an updated version of the atlas of human cerebrovasculature was introduced recently (Nowinski et al.,
2011). The atlas includes a total of 1325 vessels, with the
smallest vessel of 80 mm in diameter. A representation of a
detailed three-dimensional (3D) model of complete cerebrovasculature in human brain is shown in Figure 4.
Improved contrast and resolution at ultra-high magnetic

fields may result in better accuracy of anatomical localization,
central to the success of functional imaging (Devlin and
Poldrack, 2007). In order to facilitate the transition of ultrahigh field MRI of the brain into widespread clinical use, more
studies need to be carried out to establish the underlying
mechanisms affecting the MRI tissue contrast. In order to take
advantage of the improved resolution achievable at higher
fields, techniques for corrections of physiological factors
102
MRI of the Brain
affecting signal stability, such as subtle head motion, brain

pulsations, and respiration need to be integrated in the imaging systems (Duyn, 2010).
3.07.3
MRI in Normal Brain Development
Both conventional MRI and advanced MRI techniques are

effective tools for studies of brain development and maturation. The nonionizing, noninvasive nature makes MRI an
attractive technique to study brain development, permitting
longitudinal investigations. Knowledge of patterns of normal
age-related differences in MRI-derived parameters is important
to understand healthy maturation and to interpret findings
associated with abnormal neurodevelopment. Measurement
of developmental changes across brain regions and studying
concurrent development of cognitive and motor function
may further enhance ones understanding of the relationship
between brain structure and brain function. Advanced MRI
techniques have been widely applied in neuropsychological
disorders, many of which originate during childhood and
adolescence (Knickmeyer et al., 2008; Saitoh et al., 2001).
On conventional MRI, postnatal brain development can
be visualized as progress of myelination manifesting as
changes in white matter contrast on T1- and T2-weighted images (Barkovich, 2000; Ertl-Wagner and Rummeny, 2008;
Leppert et al., 2009). The process of myelination, following
specific chronologic regional patterns, is most active during the
first 2 years after birth. T1-weighted images are more sensitive
to the changes in myelination during the first year, while the
T2-weighted images are more helpful in assessing the degree of
myelination during the second year of life. At term birth, the
following structures are usually myelinated: the medial and
lateral lemnisci, the medial longitudinal fasciculus, the superior cerebellar peduncle, and the posterior part of the posterior
limb of the internal capsule (PLIC). In general, myelination
progresses from caudal to cranial and from dorsal to ventral
and myelination of functional systems used early in life precedes myelination of systems that become activated later.
At 2 years of age, the process of myelination appears nearly
complete as visualized on conventional MRI, with the exception of the terminal zones of myelination (peritrigonal zones
dorsal and superior to the ventricular trigones).
Quantitative MRI has been instrumental in assessment of
total brain volumes and volumes of gray matter, white matter,
and subcortical structures during brain development (Giedd
et al., 1996, 1999; Pfefferbaum et al., 1994). Age-related differences in brain tissue volumes are highly dynamic during the
first 2 years of life. During the first year of life, total brain
volume doubles and increases by an additional 15% during
the second year of life (Knickmeyer et al., 2008). By 2 years of
age, the brain volume reaches 8090% of adult volume
(Knickmeyer et al., 2008; Pfefferbaum et al., 1994) and by
6 years, 95% of adult volume (Giedd, 2008). Total cerebral
volume further increases until about the age of 10.5 years in
girls and 14.5 years in boys; mean total cerebral volume
is 10% larger in boys than in girls (Giedd, 2008). The growth
of cerebral volume during the first 2 years of life is largely
dominated by increase in gray matter volume while the increase in white matter volume is small (Knickmeyer et al.,
2008). Cortical gray matter volumes increase during preadolescence and decrease in the postadolescence period. The maximum cortical gray matter volumes are reached around the age
of 10 years in girls and 12 years in boys in the frontal lobes,
around 10 years in girls and 12 years in boys in the parietal
lobes, and around 17 years in girls and 16 years in boys in
the temporal lobe (Lenroot and Giedd, 2006); the volumes
of occipital cortical gray matter decrease during late childhood
and adolescence (Giedd, 2008). The volumes of white matter
increase linearly during childhood and adolescence, with a
relatively small variability among cerebral lobes (Giedd et al.,
1999, 2010). Dynamic changes in maturation of cortical
regions are illustrated in Figure 5.
Diffusion tensor imaging (DTI) can evaluate age-related
differences in white matter structural integrity and organization. Since the DTI contrast is based on structural properties
(water diffusion along white matter tracts), white matter fibers
can be delineated with a better contrast on fractional anisotropy (FA) maps than on conventional T1- and T2-weighted
images, despite a lower resolution of DTI (Huang et al.,
2006). Early myelinating fiber tracts can be differentiated
with DTI even in the fetal brain (Huang et al., 2006;
Figure 6). The most prominent age-related differences in FA
and apparent diffusion coefficient (ADC) are observed within
the first year of life (Gao et al., 2009; Hermoye et al., 2006).
Continuing white matter maturation can be detected during
childhood, adolescence, and adulthood (Bonekamp et al.,
2007; Faria et al., 2010; Giorgio et al., 2008; Lebel et al.,
2008). A recent atlas-based DTI study of age-related developmental differences from infancy to adulthood reported the
largest increases in FA in the brainstem and midbrain white
matter, the thalamus, and the anterior limb of the internal
capsules (Faria et al., 2010). Increase in white matter FA,
as measured with DTI, and increase in white matter volumes,
as measured with quantitative morphometric MRI, may be
attributed to continuing myelination and other factors, including increase in the diameter of white matter fibers (Giorgio
et al., 2010a,b). Application of DTI is not limited to white
matter; age-related increases in FA were reported in deep nuclei
(caudate, putamen, and globus pallidus; Lebel et al., 2008).
The study showed relatively prominent increases in white
matter FA over the age range of 530 years; the observed agerelated differences may reflect changes in organization or
degree of myelination of white matter tracts associated with
the deep nuclei (Lebel et al., 2008).
Arterial spin-labeled (ASL) perfusion MRI can provide
a measure of baseline regional function in the developing
brain. However, pediatric perfusion MRI studies in healthy
children have been sparse. In a study of 15 healthy children
(from age 4), 8 adolescents, and 21 adults (up to age 78),
a higher cerebral blood flow (CBF) has been reported in children and adolescents than in adults. The differences in CBF
between children and adults were more pronounced in the
gray matter than in the white matter (Biagi et al., 2007). In a
cross-sectional study of infants examined while asleep, without
sedation, ASL perfusion MRI detected relative perfusion increase in the prefrontal cortex and relative perfusion decrease
in the primary motor cortex in 13-month-old children compared with 7-month-old children, using a region-of-interest
(ROI)-based approach (Wang et al., 2008). Using a method
MRI of the Brain
5y
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20
yea
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0.2
0.1
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Gray
matter
volume
Figure 5 Right lateral and top views of sequence of gray matter maturation over the cortical surface. The scale shows a color representation in units
of gray matter volume. Fifty-two scans from 13 participants, each examined four times at approximately 2-year intervals, were used. Reproduced
from Lenroot RK and Giedd JN (2006). Brain development in children and adolescents: insights from anatomical magnetic resonance imaging.
Neuroscience and Biobehavioral Reviews 30(6): 718729, with permission from Elsevier.
that can extract differences over the whole brain (support

vector machine algorithm), increases in relative CBF were
detected in anterior cingulate gyri, amygdalae, hippocampi,
lateral orbitofrontal cortex, auditory region, and parietal and
occipital regions (Wang et al., 2008). It was suggested that ASL
perfusion MRI may be used for the assessment of functional
localization in the developing brain, by evaluating the relationship between resting CBF and behavioral performance.
Developmental changes in brain neurometabolism can
be studied with proton magnetic resonance spectroscopy
(1H MRS). The most prominent resonances in the spectrum
are those of N-acetylaspartate (NAA), choline (Cho), creatine
(Cr), and myo-inositol (Ins; Barker et al., 2010). NAA, located
both in the neurons, is considered a marker of neuronal integrity and function. Compounds associated with cell membrane
turnover (mainly glycerophosphocholine, phosphocholine,
and free choline) contribute to the Cho resonance. The Cr
resonance includes Cr and phosphocreatine, compounds involved in high-energy metabolism of the cell. Ins, located
primarily in glial cells, is considered a glial marker (Brand
et al., 1993). Similarly, as in the morphometric MRI or DTI
studies, age-related metabolic differences are most prominent
within the first 2 years of life. In newborns, NAA concentration
is very low and Cho concentration is high, twice of that observed in adults. Increases in NAA and Cr levels and decreases
in Cho and Ins levels were detected in both gray and white
matter regions (Kreis et al., 1993; Panigrahy et al., 2010).
In late childhood, adolescence, and early adulthood, age-related metabolic differences are less prominent (Horska et al.,
2002; Pouwels et al., 1999). Consistent with anteriorposterior
differences in rates of white matter myelination, the white
matter NAA/Cho ratio measured in the centrum semiovale
reached a maximum around 16 years in the posterior regions,
18 years in the central regions, and 22 years in the anterior
regions (Kadota et al., 2001).
3.07.4
MRI in Normal Brain Aging
As average longevity continues to increase, the number of

people at risk of developing neurodegenerative diseases of the
brain is also increasing. While these debilitating diseases are
associated with devastating, progressive loss of neurons, only
a small percentage (10%) of cortical neurons are normally
lost over the lifespan (Pakkenberg and Gundersen, 1997;
Pannese, 2011). The cortical volume loss in aging brain can
be accounted for by neuronal shrinkage (Terry et al., 1987).
There is no reduction in the number of glial cells with age
(Pakkenberg et al., 2003). The total length of myelinated fibers
reduces with age, by 4050% (Pakkenberg et al., 2003), reflecting loss of small nerve fibers (Marner et al., 2003). While the
postmortem stereology studies are naturally limited to crosssectional examinations, noninvasive MRI studies of normal
aging can be of longitudinal design. The main role of advanced
104
MRI of the Brain
2 cm
2 cm
2 cm
(a)
(b)
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-0.40
-0.60
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(c)
Figure 6 Axial images of a 19-gestational-week fetal (top row), 0-year

(middle row), and 5-year-old (bottom row) brains at the midbrain
level with anatomical assignment. Abbreviations: ac: anterior
commissure; alic: anterior limb of the internal capsule; cg: cingulum;
cp: cerebellar peduncle; cr: corona radiata; dscp: decussation of the
superior cerebellar peduncle; ec: external capsule; Fminor: forceps
minor; fx: fornix; GE: ganglionic eminence; ifo: inferior fronto-occipital
peduncle; ilf: inferior longitudinal fasciculus; oc: optical chiasm; or: optic
radiation; ot: optic tract; plic: posterior limb of internal capsule; ss:
sagittal stratum; st: stria terminalis; and unc: uncinate fasciculus.
Reproduced from Huang H, Zhang J, Wakana S, et al. (2006)
White and gray matter development in human fetal, newborn
and pediatric brains. Neuroimage 33(1): 2738, with permission
from Elsevier.
MRI in studies of aging is to identify biomarkers that can

potentially differentiate between normal brain aging and
early onset of neurodegenerative disorders (Bonekamp et al.,
2010; Burggren et al., 2008). Introduction of quantitative techniques such as voxel-based morphometry has allowed for
detection of patterns of regional gray and white matter volume
reductions over the entire brain. Analyses of age-related
regional patterns or morphological changes may help understand the relationship between brain structure and cognitive
function over the lifespan (Sowell et al., 2004).
On conventional MRI, morphologic changes related to normal aging manifest as increased sulcal prominence, cortical
and white matter volume loss, and ventricular enlargement. A
cross-sectional study using conventional MRI with a 1.5 T
scanner among 76 healthy male and female volunteers aged
3091 revealed a significant inverse effect of age upon total
volumes of the cerebral hemispheres, frontal and temporal
lobes, and the amygdalahippocampal complex and increasing volumes of the third and lateral ventricles with age (Coffey
et al., 1992). However, no or extremely minimal cortical atrophy or lateral ventricular enlargement scores were reported in
(e)
(d)
(f)
Figure 7 A typical outer cortical surface with the mean cortical

thickness trends for the entire population used to color the entire
corresponding gyral region. The color scale is in mm/decade.
A total of 66 healthy volunteers, 6084 years old at baseline
participated in the study and each individual completed at least six
annual follow-up scans. Frontal and parietal regions show greater rates
of cortical thickness decline than the temporal and occipital regions.
Reproduced from Thambisetty M, Wan J, Carass A, An Y, Prince JL,
and Resnick SM (2010) Longitudinal changes in cortical thickness
associated with normal aging. Neuroimage 52(4): 12151223,
with permission from Elsevier.
over 40% of the participants aged 60 and above. Thus, it was

concluded that such changes are not inevitable consequences
of advancing age (Coffey et al., 1992).
A cross-sectional study of 176 healthy individuals
787 years old reported dramatic nonlinear decline in gray
matter density until 60 years of age, with relatively stable or
slightly declining values thereafter (Sowell et al., 2003). The
effect of age was most prominent in the dorsal aspects of
the frontal and parietal association cortices on both the lateral
and interhemispheric surfaces, and in the orbitofrontal cortex
(Sowell et al., 2003). A greater rate of cortical thickness decline
in the frontal and parietal regions than in the temporal and
occipital regions was also detected in a recent longitudinal study in cognitively normal individuals 6084 years old
(Thambisetty et al., 2010). Figure 7 shows a representation of
outer cortical surface with depiction of mean cortical thickness
trends (Thambisetty et al., 2010). The regional and temporal
MRI has also been used to assess whether sex-related differences exist in the process of brain aging. An early crosssectional study reported that volume reductions in the whole
brain and the frontal and temporal lobes were more prominent
MRI of the Brain
in men, while in the hippocampus and the parietal lobes,

volume reductions were larger in women (Murphy et al.,
1996). However, longitudinal study design and more advanced data analysis of regional volumes examined in normalized space permitted for the first time calculations of rates
of tissue loss of gray matter and white matter, and of ventricular enlargement in a group of very healthy participants
5985 years old (Resnick et al., 2003). There were no overall
differences in rates of gray and white matter loss between men
and women (Resnick et al., 2003).
DTI has become a widely applied technique in studies
on brain tissue microstructure and integrity in the aging
brain. Both ROI-based analyses and whole brain voxel-based
approaches have been used. With increasing age, white matter
FA tends to decrease and mean diffusivity (MD) tends to increase (Abe et al., 2002; Charlton et al., 2006; Giorgio et al.,
2010a,b; Pfefferbaum et al., 2000; Salat et al., 2005; Wu et al.,
2011). The pattern of age-related DTI abnormalities is more
pronounced in the frontal regions than in the posterior or
inferior brain regions (Michielse et al., 2010; Pfefferbaum
et al., 2005) and association fibers connecting cortical regions
are more affected by age than projection fibers (Sullivan
et al., 2010). DTI tractography revealed differences in the effect
of age among anatomical subdivisions of the same structure
(corpus callosum, cingulum; Michielse et al., 2010; Sullivan
et al., 2010). In several DTI studies, detected impairment
in white matter integrity was reported to be associated with
deterioration of cognitive performance (Bendlin et al., 2010;
Charlton et al., 2006; Voineskos et al., 2010). One study
examined age-related differences in FA and MD in deep
gray matter nuclei (Pfefferbaum et al., 2010). In the caudate
and the putamen, FA and MD were higher in the older group
(6579 years) than in younger participants (2237 years), possibly related to age-related increase in brain iron (Pfefferbaum
et al., 2010). In contrast, FA increases and MD decreases in the
caudate and the putamen between 5 and 30 years of age (Lebel
et al., 2008).
Pulsed ASL in conjunction with high-resolution structural
MRI was used to evaluate regional cortical and subcortical
resting CBF measures in a group of cognitively healthy
volunteers 2388 years old (Chen et al., 2011). Age-related
reductions in cortical perfusion were detected throughout the
cortex, while no significant age-related differences in CBF were
detected in subcortical regions. The most important finding,
highly relevant for interpretations of age-related cognitive decline, was that the age-related patterns of CBF reductions were
different from patterns of cortical thinning (Chen et al., 2011).
1
H MR spectroscopic studies on normal aging have provided variable results, mainly due to differences in populations
and used spectroscopic techniques. A recent meta-analysis of
MRS literature data in healthy volunteers older than 60 years
concluded that normal aging is associated with decreased frontal NAA and increased parietal Cho and Cr concentrations
(Haga et al., 2009). The finding of lower frontal NAA levels
in normal aging (Haga et al., 2009) is suggestive of impairment
in neuronal integrity, function, or, potentially, with neuronal
loss. A positive correlation between MRS-detected NAA concentration and DTI-derived FA in healthy 5090-year-old
volunteers is in agreement with the interpretation of NAA as
a measure of neuronal integrity (Charlton et al., 2006).
3.07.5
3.07.5.1
105
MRI of the Brain in Pathologic Conditions

Ischemic Stroke
A stroke, or cerebrovascular accident, is the rapid loss of brain

function as a result of interruption of vascular supply of
blood to the brain. Stroke can be due to ischemia (lack of blood
supply) caused by thrombosis or embolism, or due to a hemorrhage (rupture of blood vessels). Acute stroke is a medical emergency, and imaging is important in confirming the clinical
diagnosis and identifying underlying etiology. While CT has
been the traditional imaging modality of choice because of its
accessibility, speed, and lower cost, MRI is gaining wider utilization because of its superb tissue contrast offering a greater sensitivity in acute ischemic stroke, and ability of providing
information on vascular status.
In the evaluation of acute stroke, MRI has been proven in
multiple studies to be more sensitive compared to CT, particularly in the setting of ischemic stroke (Bryan et al., 1991;
Fiebach et al., 2002; Mohr et al., 1995; Warach et al., 1995).
In the case of hemorrhagic stroke, MRI, by the use of hemosiderin sensitive GRE sequence or susceptibility-weighted
imaging (SWI), is at least as sensitive as CT in revealing the
presence of hemorrhage (Bryan et al., 1991; Fiebach et al.,
2002; Kidwell et al., 2004). In a prospective series of blind
comparison of CT and MRI in a consecutive 356 patients
presenting to the emergency department with acute stroke
symptoms, MRI has an estimated sensitivity of 83% as opposed
to 26% by CT for the diagnosis of any acute stroke (Chalela
et al., 2007). In the critical hyperacute stage within 3 h of
symptom onset, MRI detected acute stroke in 46% of cases
compared to 7% by CT in the same study (Chalela et al.,
2007). The ability of MRI to offer such useful information is
in large part owing to the development of diffusion-weighted
imaging (DWI) in the mid-1990s (Warach et al., 1992). DWI is
able to depict the restriction of diffusion of water molecules as
a result of bioenergetic failure and cytotoxic edema, showing
up as hyperintensity on DWI, allowing an immediate diagnosis
of stroke (Gonzalez et al., 1999; Mullins et al., 2002). In the
same MRI session, the inclusion of magnetic resonance angiography (MRA) allows assessment of the status of the intracranial blood vessels, and perfusion-weighted imaging (PWI) to
visualize regional CBF and hemodynamics.
The signal intensity on DW trace image and ADC map
provides a means of dating the acuteness of infarct. Typically,
an acute ischemic stroke shows DWI hyperintensity that lasts
for 1014 days and hypointensity on ADC map for about
710 days, after which the signal gradually normalizes, and
ADC eventually increases above normal in chronic stroke.
Furthermore, by analyzing the evolution of signal changes on
both DWI and T2-weighted/FLAIR sequence allows further
characterization of the stage of evolution of the ischemic injury
(Petkova et al., 2010). This helps establish the time elapsed
since the initial ischemic insult in patients with unknown
onset of symptoms (Petkova et al., 2010), and may help determine whether the stroke is amenable to thrombolytic treatment or not.
The pattern of infarct on MRI further provides a clue to
the underlying mechanism. For example, a vascular territorial
ischemic infarct indicates a proximal intracranial arterial
thrombosis, while multifocal small infarcts in a bilateral
106
MRI of the Brain
hemispheric distribution suggest a cardiogenic embolic phenomenon. Alternatively, a unilateral watershed infarction pattern may result from a high-grade stenosis in the ipsilateral
internal carotid artery, and more extensive bilateral watershed
infarcts could indicate a hypotensive or hypovolemic state.
These clues to the underlying pathophysiology can be important in directing acute therapy as well as further workup for risk
management.
As mentioned earlier, on the same MRI examination,
PWI (most frequently performed with gadolinium contrast
administration, so-called dynamic susceptibility contrast MR
perfusion imaging) may also offer additional information.
An imaging penumbra is represented by the area of abnormal
perfusion (most commonly depicted as increased time-to-peak
contrast arrival), whether due to vascular occlusion or stenosis,
excluding the ischemic core (DWI abnormality) and indicates
tissues at risk for infarction but still viable and salvageable if
there is timely intervention. Delineating this penumbra has
been useful in widening the window for therapeutic intervention in a number of studies assessing the efficacy of intravenous versus intra-arterial thrombolytics or neuroprotective
agents (Del Zoppo et al., 2009; Schellinger et al., 2007).
Figure 8 illustrates a 74-year-old patient with multifocal
ischemic stroke presenting with acute symptoms. Head CT
and conventional MR T2-weighted image identify multiple
areas of ischemia, the age of which is difficult to determine
on these images. By using the information provided by DWI
and ADC, one can discriminate acute infarction from the background of subacute to chronic infarct as well as chronic small
vessel ischemic disease.
Figure 9 shows a case of carotid dissection and thrombosis,
resulting in abnormal perfusion to the entire ipsilateral middle
cerebral artery (MCA) territory (preserved flow to the anterior
CT
T2
DWI
cerebral artery and posterior cerebral artery territories likely

results from cross filling from the contralateral side via the
communicating arteries). Compared to the large area of perfusion deficit, only small foci of acute infarction are identified
on DWI. This leaves a large area of diffusionperfusion
mismatch, for which the term imaging penumbra has been
coined.
Occasionally, perfusion-weighted images may show a perfusion deficit even in the absence of DWI lesions indicating
acute infarction. This may indicate the need for urgent intervention (e.g., thrombolysis or clot retraction). This is illustrated in Figure 10, in a 68-year-old female presenting with
left-sided weakness. MRI shows only subacute infarct and
bilateral chronic small vessel ischemic change, but there is a
much more extensive area of perfusion abnormality involving
the entire right MCA territory, directly related to critical stenosis or occlusion of the right M1 segment and likely responsible
for her acute symptoms.
3.07.5.2
Hypoxic Ischemic Injury in Neonates
DWI provides a highly sensitive evaluation of acute stroke in

adults. In addition, arterial and venous infarction in children is
also well visualized on DWI. However, interpretation of DWI
becomes more challenging in the evaluation of neonatal asphyxia where there is a more diffuse pattern of hypoxic ischemic injury. Hypoxicischemic encephalopathy (HIE) is caused
by prolonged oxygen deprivation, and may be due to reduced
oxygen delivery (hypoxemia) or CBF (ischemia). In perinatal
asphyxia, which is the most common cause of HIE, hypoxia
rather than ischemia is the primary insult. HIE in neonates is a
major cause of mortality and long-term neurological morbidity
including seizures, motor deficits, and cognitive impairment.
MRA
ADC
TTP
Figure 8 Seventy-four-year-old male with multiple episodes of stroke. Noncontrast head CT shows foci of hypoattenuation in the right temporal
and occipital lobes, in addition to periventricular white matter. T2-weighted MRI confirms these two areas of infarction. Restricted diffusion with
diffusion-weighted imaging (DWI) hyperintensity and apparent diffusion coefficient (ADC) hypointensity is demonstrated in the right temporal lobe
indicating an acute to subacute ischemic infarction (within 1 week old). The right occipital lobe infarct, on the other hand, shows mild DWI and
corresponding ADC hyperintensity indicating a subacute to chronic infarction that is at least beyond 2 weeks of age. Time-to-peak (TTP) map of PWI
shows the same area of perfusion deficits in the right temporal lobe. MRA shows absence of flow-related enhancement in the right MCA (arrow).
MRI of the Brain
DWI
107
MRA
ADC
TTP
1
2
Figure 9 Sixty-year-old male with right carotid dissection. On MRA, there is a complete lack of flow-related signal in the right internal carotid artery,
proximal and distal MCA branches (arrow). On diffusion-weighted imaging, there are small foci of restricted diffusion indicating acute infarction
involving the right basal ganglia and right centrum semiovale. On PWI, a much larger area of abnormal perfusion (with prolonged TTP) is identified
throughout the right MCA territory. Signal intensity versus time series shows delayed contrast bolus arrival to the right hemisphere compared to
the left side.
FLAIR
DWI
ADC
TTP
MRA
Figure 10 Sixty-eight-year-old female presenting with left-sided

weakness. On FLAIR images, there are small areas of signal abnormality
scattered in the bilateral striatocapsular regions and the right centrum
semiovale, demonstrating vague DWI hyperintensity but no evidence of
restricted diffusion on ADC maps, confirming that these lesions
represent subacute and/or chronic small vessel ischemic changes. TTP
images demonstrate a much more extensive area of perfusion deficit
involving the right MCA territory, directly corresponding to the abrupt
cutoff of the right M1 segment demonstrated on MRA (arrows).
Management of HIE is mainly supportive care and prevention

of secondary central nervous system (CNS) insults such as
due to seizures and metabolic derangement; however, various
neuroprotective strategies including hypothermia and pharmacologic agents that curtail the effects of excitatory neurotoxicity
are under investigation (Gluckman et al., 2001; Shalak and
Perlman, 2004; Vannucci and Perlman, 1997). Prompt and
accurate diagnosis is hence critical for directing neuroprotective
agents and therapeutic intervention as many of these measures
should most effectively be targeted to prevent the onset of

secondary deterioration (i.e., secondary energy failure).
The majority of infants sustain hypoxicischemic injury in
the immediate perinatal period (Gunn and Bennet, 2008).
Various brain regions are particularly susceptible to injury
depending on the maturity of brain, as well as severity and
duration of the insult (Huang and Castillo, 2008). Two major
patterns of injury have been noted in term infants with HIE
(Barkovich et al., 1995). Mild to moderate injury usually produces a pattern of parasagittal white matter injury occurring in
the vascular boundary zones, and often resulting in neonatal
seizure but with near normal Apgar scores. Following a profound asphyxia, those infants typically have low Apgar scores
necessitating resuscitation at delivery and usually sustain bilateral deep gray matter injury including ventrolateral thalami,
posterior putamina, hippocampi, corticospinal tracts, and perirolandic gyri (Barkovich, 1992; Huang and Castillo, 2008;
Triulzi et al., 2006).
MR imaging can provide important information about the
site, extent, severity, and etiology of cerebral injury, as well as
prognostic factors (Rutherford et al., 2006). However, conventional (e.g., T1- and T2-weighted) MRI generally lacks sensitivity in the acute phase, as the abnormalities may not become
apparent until several days after onset of injury on these types
of images. DWI may also appear unremarkable in early stages
of HIE and frequently underestimates the final extent of injury
depending on the time of imaging after acute insult (Barkovich
et al., 1999; Barkovich et al., 2006). 1H MRS, particularly by the
elevation of lactate (Lac), has been used to provide the most
sensitive and useful diagnosis in acute hypoxic-ischemia injury
as early as the first day of life (Barkovich et al., 1999; Barkovich
et al., 2001). However, corresponding to the physiologic response and very similar to DWI, MRS also shows temporal
evolution and topological variation of metabolite concentrations (Barkovich et al., 2006).
108
MRI of the Brain
1-day-old, HIE
T1
T2
Cho
DWI
ADC
Cr
NAA
PPM 4.0
3.0
2.0
Lac
1.0
(b)
3-day-old, normal MRI
(a)
Figure 11 MRI and MRS in HIE. (a) Top panel shows MRI of a 1-day-old infant with severe hypoxic ischemic encephalopathy. Diffuse T1 hypointense
and T2 hyperintense signal abnormality is identified in the white matter, internal capsules, and some cortical regions, as well as deep gray
structures, with DWI hyperintensity in the white matter, corpus callosum, and internal capsules reflecting cytotoxic edema. The bottom panel
(for comparison) shows normal MRI findings from a 3-day-old patient. (b) MRS (TR/TE 1500/135 ms) performed on the 1-day-old newborn with
HIE with a voxel placed in the right basal ganglia shows an inverted Lac peak.
In the case of severe HIE, both the deep gray matter and
cerebral hemispheres may be affected. Figure 11(a) shows
diffusely decreased T1 and increased T2 signal throughout the
white matter, internal capsules, and some cortical regions, in
addition to edematous deep gray structures in a 1-day-old
infant. Diffusion-weighted images depict areas of hyperintensity including the white matter, corpus callosum, and internal
capsules reflecting cytotoxic edema. MRS with a voxel placed in
the right basal ganglia shows an inverted Lac doublet at 1.33.
In this case, it is consistent with a state of anaerobic metabolism as a consequence of hypoxemia (Figure 11(b)).
Another case of a term neonate presenting with seizures
and profound neurological abnormality is shown in Figure 12.
Conventional MRI and DWI are unremarkable, although mild
ADC hypointensity is seen in the deep gray nuclei. MRS shows
elevation of Lac in the basal ganglia and occipital lobe, supporting the diagnosis of severe HIE. SWI also demonstrates sharply
delineated hypointensity throughout the intracranial venous
structures, suggesting a profoundly deoxygenated blood content typically seen in brain death. This child was sustained
by mechanical support and the imaging findings predicted a
poor prognosis.
Seven neonates with encephalopathy following a complicated delivery during the first 24 h of life were evaluated with
conventional MRI, DWI, and single-voxel MRS in a retrospective case study (Barkovich et al., 2001). Conventional imaging
was largely normal, although some cases showed T2 prolongation, indicating mild edema, in the basal ganglia or cortex.
DWI findings were also not dramatically abnormal, but in a
few cases showed reduced diffusion in the PLIC and/or lateral
thalami. This subtle abnormality was better assessed by measuring ADC values rather than visual inspection of DWI: a
1520% of decrease in ADC was found throughout the brain
compared to healthy controls. In contrast, 1H MRS showed
more prominent abnormalities, with elevation of Lac/NAA
ratios and reduction of NAA. Furthermore, follow-up imaging
studies suggested that acute MRI and DWI underestimated the
topological extent of injury (Barkovich et al., 2001).
DWI
ADC
Cho
I: 14.2
NM
1.5
SWI
NAA
I: 12.7
Cr
I: 10.4
1.0
Cr2
I: 7.75
*Lac
0.5
0.0
ppm
4
Figure 12 A term neonate presenting with seizures and abnormal

neurological exam at 1 day of life. DWI is unremarkable, but
mild hypointensity is suggested on ADC map in the deep gray matter
(block arrow). SWI shows distinct hypointensity throughout the
intracranial venous structures. MRS (TR/TE 1500/270 ms) from a voxel
in the left basal ganglia shows an elevation of Lac at 1.33 ppm (*Lac).
3.07.5.3
Injury
Intracranial Hemorrhage and Traumatic Brain
Acute intracranial hemorrhage (ICH) may be effectively

detected by head CT. MRI is also very sensitive for the detection
of ICH; the FLAIR sequence is particularly useful in depicting
subarachnoid hemorrhage for a longer window of time compared to CT, and SWI or other hemosiderin sensitive GRE
sequences are very sensitive for detecting parenchymal hemorrhage. MRI furthermore provides a detailed means of dating
the age of a parenchymal hematoma since the appearance of
intracranial hemorrhage depends on different MR contrast by
MRI of the Brain

T1- or T2-weighting, and varies with the age of the hematoma
(Bradley, 1993). The hemoglobin products evolve with time
through several forms including oxyhemoglobin, deoxyhemoglobin, intracellular, and extracellular methemoglobin, and
finally, get broken down to ferritin and hemosiderin, which are
sequestered by macrophages and scavenger cells in the chronic
stage. T1-shortening occurs in methemoglobin as a result of
paramagnetic dipoledipole interactions, whereas the magnetic
susceptibility effect is responsible for T2-shortening observed
with deoxyhemoglobin, methemoglobin, and hemosiderin
blood products (Bradley, 1993). T2-shortening or susceptibility
effects are accentuated by increasing the strength of magnetic
field used.
Five stages of hemorrhage are described on conventional
MRI:
1. hyperacute (intracellular oxyhemoglobin, long T1 and T2)
2. acute (intracellular deoxyhemoglobin, long T1, short T2)
3. early subacute (intracellular methemoglobin, short T1,
short T2)
4. late subacute (extracellular methemoglobin, short T1, long
T2)
5. chronic (ferritin and hemosiderin, short T2)
In the setting of trauma, MRI has been demonstrated to be
more useful than CT in detecting abnormalities related to
diffuse axonal shearing injury (DAI) since only about 20% of
DAI present with punctate foci of acute hemorrhage detectable
on CT, and the extent of injury is grossly underestimated by CT
(Gentry et al., 1988; Gentry et al., 1989). This type of injury
results from acute acceleration and deceleration, with rotation
forces and shear strains developing between tissues possessing
different rigidity and composition. Most frequently, the DAI
lesions occur in the lobar white matter at the corticomedullary
junction (67%), corpus callosum (particularly the splenium;
2147%), and in more severe circumstances, dorsolateral
brainstem (Gentry et al., 1988). Those lesions with macroscopic hemorrhage may either be inconspicuous or show up
as small areas of hyperdensity on head CT, often in marked
discordance with the clinical status of a comatous or obtunded
patient. MRI in these cases can often reveal multifocal lesions
with signal abnormality on different sequences including
FLAIR, DWI, and SWI (suggesting the presence of vasogenic
edema, cytotoxic edema, and hemorrhage), which may reflect
different stages or characteristics of shearing injury (Hergan
et al., 2002; Parizel et al., 1998). An example is illustrated
in Figure 13 in an 18-year-old female who was involved in a
motor vehicle accident.
As mentioned in the previous section, MRI is at least
as sensitive as CT in detecting hemorrhagic stroke (Chalela
et al., 2007). The use of SWI is particularly helpful in detecting
tiny foci of parenchymal hemorrhagic lesions even in the
chronic stages. Aside from traumatic brain injury, SWI is very
sensitive in depicting multiple punctate foci of hemosiderin
scattered throughout the brain parenchyma that can occur in a
number of pathologic conditions (Tong et al., 2008). For
example, this can be seen in hypertensive vasculopathy, with
distribution following anatomic locations that are prone
to hypertensive hemorrhage such as basal ganglia, thalami,
pons, and cerebellum. A pattern of multiple lesions distributed
more peripherally in an elderly, normotensive individual
FLAIR
T2*
109
DWI
Figure 13 Severe traumatic brain injury (TBI) in an 18-year-old

female following motor vehicle collision with a telephone pole. FLAIR, T*,
2
and DWI images are shown in three different axial slices: top row at the
level of the midbrain; middle at the level of the basal ganglia; and
bottom row at the level of superior cortex. FLAIR images show multiple
foci of edema in the right dorsal midbrain (arrow), left medial temporal
lobe (curved arrow), bilateral deep gray (block arrows), splenium of the
corpus callosum (curved block arrow), as well as the superior frontal
lobes bilaterally (*). The frontal lobe lesions show hypointensity on T*2
weighted gradient echo sequence indicating hemorrhagic contusions that
are also evident on CT (not shown). Restricted diffusion with DWI
hyperintensity is evident in the right dorsal brainstem, left temporal
lobe, bilateral deep gray and bilateral frontal white matter, and
more extensively in the genu as well as splenium of the corpus
callosum.
suffering from dementia would be highly suggestive of amyloid angiopathy. Multiple scattered foci of lesions, often varying in size, can be seen in individuals with multiple cerebral
cavernous malformations. A similar pattern in an individual
with a history of previous total brain radiation in early childhood may indicate radiation-induced telangiectasia.
In addition to the detection of hemorrhagic lesions, SWI
can be very useful in depicting venous anatomy, as well
as mineralized lesions with either calcification or iron deposition. SWI takes advantage of intrinsic contrast of the deoxyhemoglobin in the veins, so that small, normal cerebral venous
structures are exquisitely depicted. Developmental venous
anomaly (DVA) is the most frequently encountered vascular
malformation in the brain, and can be readily identified on
SWI with a characteristic caput medusa appearance including
a linear transmedullary draining vein. DVA increases in occurrence in association with rare disorders such as SturgeWeber
syndrome, hereditary hemorrhagic telangiectasia, and facial
hemangioma. Finally, qualitative and quantitative SWI has
been used in evaluation of iron deposition in neurodegenerative disorders such as Parkinsons disease, Huntingtons
disease, and multiple sclerosis.
110
MRI of the Brain
3.07.5.4
Brain Tumors
MRI is indispensable for the diagnosis and characterization

of brain tumors. Anatomic imaging provides important
information for surgical planning, and by combining with
multimodality advanced imaging techniques, physiologic,
hemodynamic, and functional assessment also becomes possible such by the use of PWI, 1H MRS, and blood oxygenation
level-dependent functional MRI (fMRI). These advanced techniques enhance ones understanding of tumor biology, and
allow increased precision in diagnosis as well as better target
definition and assessment of treatment response.
There is a growing interest among neurosurgeons to incorporate the information provided by diffusion tractography,
fMRI, and intraoperative MRI in clinical practice to maximize
safety and assist decisions rendered before, during, and after
surgery (Young et al., 2010). DTI provides microstructural
information and can be helpful in defining axonal tract involvement, whether by tumor infiltration or displacement, and
predicting the functional deficits in order to accurately plan
surgical approach and extent of resection. Task-based fMRI also
helps delineate the eloquent cortex that may be involved in
language, motor, or somatosensory function in relation to the
tumor.
1
H MRS allows assessment of changes in a number of
metabolites in brain tumors, with elevated Cho (3.20 ppm)
levels reflecting increased cellular density, proliferative index,
and membrane turnover, often correlating with a more aggressive neoplasm (Shimizu et al., 2000; Tamiya et al., 2000).
Figure 14 shows an example of multislice magnetic resonance
spectroscopic imaging (MRSI) of glioblastoma multiforme
(GBM). Markedly elevated Cho levels and diminished NAA,
with increased Cho/Cr ratio compared to the contralateral
normal brain tissue are features consistent with a nonnecrotic,
malignant neoplasm. MRSI has the advantage of displaying
heterogeneity within the large tumor. Note that in Figure 14,
only the posterior aspect of this high-grade tumor seen on
FLAIR
Cho
FLAIR has elevated Cho on metabolic maps. This can be useful in directing target for biopsy as well as treatment. While
MRS by itself usually does not contribute to the diagnosis of
tumor type, it often may provide important adjunct information, and may be useful in discriminating neoplasms from
nonneoplastic lesions related to infection, inflammation, or
demyelination (Hourani et al., 2008).
Decreased ADC values are correlated with increased cellularity of tumors, and can often be seen in small round blue cell
tumors including lymphoma and primitive neural ectodermal
tumor, as well as in higher grade of astrocytomas. Areas of
restricted diffusion were found to be a consistent feature
(90% of cases) of primary CNS lymphoma in a study of 20
patients prior to treatment, and could be useful in offering the
initial diagnosis as well as prognosis (Zacharia et al., 2008).
In the case of high-grade gliomas, the utility of ADC measurements becomes less certain; ADC values could be used to
distinguish tumors from normal brain tissues, but there was
substantial overlap in values and they were not significantly
different between the tumor and adjacent edema (Castillo
et al., 2001). In a larger study of 51 patients diagnosed with
primary brain gliomas, on the other hand, ADC values or ADC
ratios were deemed helpful in preoperative grading (Arvinda
et al., 2009). More importantly, in several studies, ADC has
been found to be a useful biomarker in the evaluation of
treatment response in brain tumors (Moffat et al., 2005;
Provenzale et al., 2006).
In primary brain glial tumors such as astrocytomas, increased relative cerebral blood volume (rCBV) derived from
MR perfusion has been correlated with progressively higher
grading of the tumor (Arvinda et al., 2009; Rollin et al.,
2006). At the time of initial diagnosis, rCBV values were
found to be greater in high-grade than in low-grade glial tumors (3.87 1.94 vs. 1.30 0.42), and were also consistently
elevated in recurrent tumors (Rollin et al., 2006). Low-grade
gliomas had lower rCBV values than high-grade tumors even
Right
Cho
Cr
NAA
NAA
Lac
Left
PPM 4.0
3.0
2.0
1.0
Figure 14 MRSI of GBM. FLAIR image shows an infiltrative hyperintense mass in the right temporal lobe. The posterior aspect of this mass
shows marked hyperintensity on the Cho metabolic map. A spectrum (TR/TE 2000/280 ms) obtained from this region demonstrates elevated Cho
levels and diminished NAA compared to the contralateral normal brain. Riedy and Barker; ASNR Washington, DC; 2003, image courtesy of Peter
B. Barker, DPhil.
MRI of the Brain
when they showed contrast enhancement (a feature more

common in high grade tumors; Rollin et al., 2006). In analyzing perfusion data from a retrospective study of 51 patients
with cerebral gliomas, a threshold rCBV value of 2.91 discriminated high-grade tumors with sensitivity, specificity, positive
predictive value, and negative predictive value of 94.7%,
93.8%, 90.0%, and 96.8%, respectively. The ranges were
0.293.14 for low-grade and 2.8212.86 for high-grade tumors
(Arvinda et al., 2009). Finally, rCBV was also found to be useful
in monitoring therapeutic response (Cha, 2004; Provenzale
et al., 2006; Rollin et al., 2006; Scarabino et al., 2009).
Primary CNS lymphoma and GBM are both aggressive,
malignant brain tumors and can share many similar features
on MRI. Both affect older individuals, grow by infiltration,
demonstrate contrast enhancement, and preferentially involve
the white matter including the corpus callosum. However,
GBM tends to have a necrotic center, whereas primary CNS
lymphoma in an immunocompetent host typically shows solid
enhancement. Accurate presurgical diagnosis is important
since treatment is different, with lymphomas being virtually
always unresectable yet responsive to chemoradiation.
By multiparametric analysis of ADC values, MRS metabolic
ratios, and rCBV, primary CNS lymphoma can be distinguished from high-grade primary gliomas and from metastatic
lesions (Chawla et al., 2010; Hartmann et al., 2003; Toh et al.,
2006). In general, lymphomas show decreased ADC values,
and on MRS they tend to demonstrate prominent lipids and
Lac, in addition to elevated Cho (Chawla et al., 2010; Toh
et al., 2006; Zacharia et al., 2008). The maximum mean
rCBV ratio in lymphoma is significantly lower than that of
the GBM (1.29 0.18 vs. 4.99 2.1; Hartmann et al., 2003).
An example (Figure 15) of CNS lymphoma is shown in a
71-year-old male who presented with multifocal FLAIR hyperintense lesions in the right frontal lobe as well as the splenium
of the corpus callosum, accompanied by heterogeneous
FLAIR
111
contrast enhancement. Restricted diffusion is identified in

these lesions, indicating hypercellularity that is often seen in
lymphoma. Cerebral blood volume is not particularly elevated
in these lesions, but this may be confounded by steroids administration in this patient. Proton MRS from a voxel placed in
the splenium of corpus callosum shows elevated Cho, decreased NAA, as well as a prominent Lac doublet. A biopsy
from the right frontal lobe lesion confirmed large B cell
lymphoma.
Amide proton transfer (APT) imaging (Wen et al., 2010) is
an emerging technique that utilizes the endogenous contrast
provided by the protein and peptide contents in the lesion
(Figure 16), which, as suggested by preliminary data, may
correlate with the degree of tumor cellularity and grade.
Although still in the early stages of development, this information again complements morphological data, and
in the future may be useful in predicting tumor behavior,
and serve as a surrogate marker in monitoring response to
therapy.
3.07.6
Conclusion
The introduction of MRI and MRS into neuroradiology

has opened new possibilities for studies of brain anatomy,
function, and metabolism in living humans, both in health
and disease. As documented in this chapter on current examples of clinical applications, multimodal MRI protocols are
becoming routine in clinical neuroimaging. The use of highfield imaging approaches for mapping brain function and
their integration into multimodal neuroimaging protocols
will help better understand brain damage in patients with a
wide range of pathologies, such as tumors, stroke, trauma,
coma, and infectious, inflammatory, and demyelinating disorders (Moseley and Liu, 2008). Furthermore, this integrated
T1 + C
DWI
ADC
Cho
I : 20.7
CBV
4
Cr
I : 15.4
NAA
I : 17.1
Cr2
I : 18.8
-2
4
Figure 15 Seventy-one-year-old male with newly diagnosed primary CNS lymphoma. FLAIR image shows hyperintense lesions in the right frontal lobe
and the splenium of the corpus callosum, which show heterogeneous contrast enhancement (T1 C). DWI hyperintensity with corresponding ADC
hypointensity is identified in these lesions indicating restricted diffusion, but CBV does not appear elevated. MRS (TR/TE 2000/140 ms) with a voxel
placed in the splenium of corpus callosum shows elevated Cho, decreased NAA, as well as a prominent inverted Lac doublet.
112
MRI of the Brain
T2
T1
T1+C
APT
5%
5%
Figure 16 APT imaging of GBM. T2-weighted image demonstrates a
large hyperintense tumor in the left frontal lobe with an area of cyst
formation (black arrow). T1-weighted image shows that the entire tumor
is hypointense. Gadolinium-enhanced T1-weighted image (T1 C)
demonstrates an enhancing tumor core (red arrow) with nonenhancing
necrotic areas. APT image shows that both the gadolinium-enhancing
tumor core (red arrow) and the cystic cavity (black arrow) have high APT
signal intensities, while the necrotic regions (pink arrow) and edema
areas (orange arrow) have low APT signal intensities. Reproduced from
Wen Z, Hu S, Huang F, et al. (2010) MR imaging of high-grade brain
tumors using endogenous protein and peptide-based contrast.
Neuroimage 51(2): 616622, with permission from Elsevier.
information will facilitate the development of the most timely

and effective interventions.
Acknowledgment
The authors are thankful to Peter Barker for his comments on
the manuscript.
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3.

MRI of the Brain

Comprehensive Biomedical Physics

Diffusion-weighted MRI A noninvasive technique able

MRI of the Brain

Magnetic resonance imaging (MRI) is a noninvasive technique

3.07.2 MR-Based Modalities for Assessing

these constituents can dominate the image. The basic MRI

MRI of the Brain

Figure 3 A quantitative susceptibility map reconstructed from a 3D

Figure 4 Depiction of human cerebrovasculature, color-coded, from a

High-field MRI also offers opportunity for more detailed

Improved contrast and resolution at ultra-high magnetic

MRI of the Brain

affecting signal stability, such as subtle head motion, brain

MRI in Normal Brain Development

Both conventional MRI and advanced MRI techniques are

MRI of the Brain

that can extract differences over the whole brain (support

MRI in Normal Brain Aging

As average longevity continues to increase, the number of

MRI of the Brain

Figure 6 Axial images of a 19-gestational-week fetal (top row), 0-year

MRI in studies of aging is to identify biomarkers that can

Figure 7 A typical outer cortical surface with the mean cortical

over 40% of the participants aged 60 and above. Thus, it was

MRI of the Brain

in men, while in the hippocampus and the parietal lobes,

MRI of the Brain in Pathologic Conditions

A stroke, or cerebrovascular accident, is the rapid loss of brain

MRI of the Brain

cerebral artery and posterior cerebral artery territories likely

Hypoxic Ischemic Injury in Neonates

DWI provides a highly sensitive evaluation of acute stroke in

MRI of the Brain

Figure 10 Sixty-eight-year-old female presenting with left-sided

Management of HIE is mainly supportive care and prevention

should most effectively be targeted to prevent the onset of

MRI of the Brain

3-day-old, normal MRI

Figure 12 A term neonate presenting with seizures and abnormal

Intracranial Hemorrhage and Traumatic Brain

Acute intracranial hemorrhage (ICH) may be effectively

MRI of the Brain

Figure 13 Severe traumatic brain injury (TBI) in an 18-year-old

MRI of the Brain

MRI is indispensable for the diagnosis and characterization

MRI of the Brain

when they showed contrast enhancement (a feature more

contrast enhancement. Restricted diffusion is identified in

The introduction of MRI and MRS into neuroradiology

MRI of the Brain

information will facilitate the development of the most timely

after perinatal asphyxia: Preliminary report. American Journal of Neuroradiology

MRI of the Brain

Fiebach JB, Schellinger PD, Jansen O, et al. (2002) CT and diffusion-weighted MR

MRI of the Brain

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