Saudi Journal of Ophthalmology (2012) 26, 401–407

Oculoplastic Imaging Update

Neuroimaging in ophthalmology
James D. Kim, MD, MS b; Nafiseh Hashemi, MD a; Rachel Gelman, BA c; Andrew G. Lee, MD a,b,c,d,e,⇑

Abstract

In the past three decades, there have been countless advances in imaging modalities that have revolutionized evaluation, manage-
ment, and treatment of neuro-ophthalmic disorders. Non-invasive approaches for early detection and monitoring of treatments
have decreased morbidity and mortality. Understanding of basic methods of imaging techniques and choice of imaging modalities
in cases encountered in neuro-ophthalmology clinic is critical for proper evaluation of patients. Two main imaging modalities that
are often used are computed tomography (CT) and magnetic resonance imaging (MRI). However, variations of these modalities
and appropriate location of imaging must be considered in each clinical scenario. In this article, we review and summarize the best
neuroimaging studies for specific neuro-ophthalmic indications and the diagnostic radiographic findings for important clinical
entities.

Keywords: Neuroophthalmology, Imaging, Magnetic resonance imaging, Computed tomography

Ó 2012 Saudi Ophthalmological Society, King Saud University. All rights reserved.
http://dx.doi.org/10.1016/j.sjopt.2012.07.001

Introduction Computed tomography

Advances in neuroimaging have revolutionized the evalua- The computed tomography (CT) scan obtains image by
tion, management, and treatment of neuro-ophthalmic disor- conventional X-ray technology. The CT X-ray source moves
ders. Despite the ever-increasing resolution ability of modern around the patient and the X-ray detectors located on the
neuroimaging technology, it remains critical that both the opposite side of the X-ray source measure the amount of
ordering eye physician and the interpreting radiologist com- attenuation. Data points analyzed by a computer and attenu-
municate about the relevant topographical and localizing ation values, in Hounsfield units, are assigned to each pixel,
anatomy, the clinical and radiographic differential diagnosis, which are then compared to the attenuation value of water
and the most likely, single best unifying diagnosis (i.e., ‘‘clin- (zero) and reconstructed into an array of pixels forming images
ical correlation required’’). In this paper, we review and that we see on the computer screen. By convention, denser
summarize the best neuroimaging studies for specific neu- materials, such as bone, are displayed bright white, while less
ro-ophthalmic indications and the diagnostic radiographic dense material, such as air, is displayed darker. Materials with
findings for important clinical entities. densities between these values are displayed in a gray scale

Available online 21 July 2012

a
Department of Ophthalmology, The Methodist Hospital, Houston, TX, USA
b
Department of Ophthalmology (AGL: Clinical Professor), The University of Texas Medical Branch, Galveston, TX, USA
c
Baylor College of Medicine, Houston, TX (AGL: Adjunct Professor of Ophthalmology), USA
d
Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medical College, New York, NY, USA
e
Department of Ophthalmology (AGL: Adjunct Professor), The University of Iowa Hospitals and Clinics, Iowa City, IA, USA

⇑ Corresponding author at: Department of Ophthalmology,The Methodist Hospital, 6560 Fannin Street, Scurlock 450, Houston, TX 77030, USA.
Tel.: +1 713 441 8843; fax: +1 713 793 1636.
e-mail address: AGLee@tmhs.org (A.G. Lee).

Peer review under responsibility Access this article online:

of Saudi Ophthalmological Society, www.saudiophthaljournal.com
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402 J.D. Kim et al.

gradient. Iodinated contrast material can be used to improve iodinated contrast material of CT, is the contrast material.
the sensitivity and specificity of CT scan interpretation in many As in CT, however, the administration of gadolinium contrast
situations. However, in some situations, contrast material material increases the sensitivity and specificity of imaging
does not add any benefit (e.g., thyroid eye disease), dimin- for neuro-ophthalmology and, in general, contrast material
ishes the ability to detect the lesion of interest (e.g., acute should be given for most clinical indications.
hemorrhage), or might be contraindicated (e.g., iodine With this background information in mind, we will now dis-
allergy). cuss some specific clinical indications of interest to the oph-
thalmologist for which neuroimaging might be necessary.

Magnetic resonance imaging Unilateral or bilateral optic neuropathy

In contrast to CT scan, which uses conventional X-ray tech- In a patient with an unexplained unilateral or bilateral op-
nology, the imaging technique in magnetic resonance imag- tic neuropathy (e.g., optic atrophy), a pre- and post-contrast
ing (MRI) relies on the interaction of hydrogen atoms, mostly magnetic resonance imaging (MRI) of the head and orbit
water, with the intense magnetic field generated by the MRI might disclose a compressive, inflammatory, or infiltrative eti-
scanner. Thus, as opposed to CT, there is no radiation expo- ology. As noted above, fat has a very high signal intensity on
sure with MRI. Certain atoms become polarized when sub- the conventional T1-weighted MRI and suppression of the
jected to a strong magnetic field, creating a net magnetic fat signal (i.e., fat suppression or fat saturation) is highly
vector that is longitudinal to the direction of the magnetic recommended for showing intraorbital lesions, especially
field. Atoms that are misaligned to the magnetic field can any enhancing optic nerve (e.g., optic neuritis) or optic nerve
be forced to align when they absorb a characteristic fre- sheath (e.g., sheath meningioma) lesions. Imaging along the
quency (Larmor frequency) that is directly proportional to intraorbital (i.e., MRI of orbit) and intracranial (i.e., MRI of
the strength of the magnetic field that is subjected. This en- brain) course of the optic nerve is essential to exclude an eti-
ergy is called excitation and it is re-emitted over time as the ology in the setting of an unexplained optic neuropathy.
excited atoms move from the higher to the lower energy
state. This process and energy release is known as relaxation.
The basic MRI sequences are T1 and T2 modes. Detailed Optic neuritis
discussion of the complex physics and the technical parame-
ters of these methods are beyond the scope of this article, Acute demyelinating optic neuritis (ON) is a common
but a short and simple description of T1 and T2 might be consideration of acute to subacute painful (pain with eye
of value to the ophthalmologist. On a T2 weighted scan, movement) unilateral vision loss in young adults. Our recom-
water and fluid containing tissues are bright and fat-contain- mended imaging modality to exclude demyelinating disease
ing tissues are dark, and on T1-weighted images, the fluid is in ON is MRI with pre- and post-contrast fat suppression of
dark and the fat is bright. Thus, the T2-weighted imaging is the orbits to look for enhancement of the optic nerve
useful in detecting pathologic tissues that tend to develop (Fig. 1) and T2-weighted brain imaging for periventricular
edema and fluid that can be distinguished from normal tis- demyelinating lesions (including sagittal views of the corpus
sue. However, the ‘‘brightness’’ of normal structures on T1- callosum). As noted above, cerebrospinal fluid (CSF) shows
and T2-weighted imaging can make it more difficult to detect very high signal intensity on T2-weighted MRI and Fluid
pathology. In a specialized T2-weighted sequence, fluid Attenuation Inversion Recovery (FLAIR) sequences can sup-
attenuated inversion recovery (FLAIR), the free water signal press the normal CSF bright signal on T2 and allow easier
(e.g., in cerebrospinal fluid) can be attenuated and made detection of demyelinating white matter lesions in ON.1,2 In
dark, while water in edematous and pathologic tissue will re- the Optic Neuritis Treatment Trial (ONTT) patients with ON
main bright. This is particularly useful in demyelinating dis- without demyelinating lesions in the brain have a 22% risk
ease such as multiple sclerosis, which we discuss later in of multiple sclerosis (MS) versus a 78% risk of MS after
this article. Likewise, in T1-weighted imaging, the normal 15 years with multiple white matter lesions.3 Thus, the MRI
fat signal is bright and can obscure both pathologic bright is prognostic (but not definitive) for the prediction of future
T1 signal and also gadolinium contrast enhancement of MS in patients with ON.
pathology in the fat-filled orbit. Thus, T1 post-contrast stud-
ies with fat suppression sequence of the orbits might be nec- Bitemporal hemianopsia
essary to visualize orbital pathology (e.g., optic nerve sheath
meningioma, intraorbital optic neuritis). In addition to fat- Bitemporal hemianopsia most commonly occurs as a result
suppressed T1 and T2 FLAIR, additional special sequences of lesions of the optic chiasm. Although compressive lesions
might be of interest to the ophthalmologist such as diffusion are typical causes for a bitemporal hemianopsia, uncom-
weighted imaging (DWI) and apparent diffusion coefficient monly, demyelinating (i.e., chiasmal neuritis) and inflamma-
(ADC). Diffusion weighted MRI measures aberrancies in tory (e.g., sarcoid) lesions can occur and might demonstrate
expected Brownian motion of free water. A frequent applica- enlargement or enhancement in the chiasm on neuroimag-
tion for DWI/ADC is in acute ischemic strokes where in- ing. Common tumors causing compression of the optic chi-
creased restriction of water diffusion can differentiate acute asm include pituitary adenoma, craniopharyngioma,
ischemic cytotoxic edema from vasogenic edema. DWI/ meningioma, or dysgerminoma in adults and optic pathway
ADC imaging can show abnormalities within minutes of the glioma in children. In addition, internal carotid artery aneu-
onset of stroke symptoms (even before structural CT and rysm can also present with sellar symptoms and signs. MRI
conventional MRI show abnormalities) and may remain for of the sella with and without contrast can help to differentiate
up to two weeks. In MRI, gadolinium, as opposed to the between these pathologies4 (Fig. 2). In the acute setting, CT
Neuroimaging in ophthalmology 403

Figure 1. Axial (A) and coronal (B) views of T1 sequence post contrast fat suppression magnetic resonance imaging demonstrating post contrast
enhancement of the left optic nerve (arrows).

conjunction with apparent diffusion coefficient technique

(ADC), can demonstrate restricted diffusion consistent with
ischemia. In the acute setting DWI and ADC MRI sequences
can discriminate reversible vasogenic edema (bright signal
on T2 and FLAIR, but no restricted diffusion on DWI/ADC),
as seen in posterior reversible encephalopathy syndrome
(PRES), from less reversible cytotoxic edema in ischemic
stroke (bright signal on T2 and FLAIR with restricted diffusion
on DWI/ADC). In vasogenic edema the diffusion of water
molecules is increased, so the ADC is elevated and the DWI
shows iso- or hypo-intense signal. In contrast, in cytotoxic
edema the movement of water from the extracellular to the
intracellular compartment produces restricted diffusion, so
the ADC is decreased and the DWI appears hyperintense5–
10
(Fig. 3). The clinical importance for the ophthalmologist
is that DWI/ADC imaging of homonymous hemianopsia or
Figure 2. MRI of the sella in coronal image of post contrast T1 sequence cortical blindness in patients with PRES may be prognostic
shows pituitary macroadenoma compressing chiasm from below (arrow). for recovery (i.e., the deficit is reversible), whereas ischemic
infarction with restricted DWI/ADC might not recover.
scan of the sella might be useful for hemorrhage (e.g., pitui-
tary apoplexy) and CT might also be useful for demonstrating
calcification in a suprasellar lesion or hyperostosis of bone in Cranial nerve palsy
meningioma.
Ocular motor cranial neuropathies (e.g., third, fourth, or
sixth nerve palsy) typically are best imaged with cranial pre-
Homonymous hemianopsia (or cortical blindness) and post-contrast MRI following the course of the involved
nerve(s). Newer MRI sequences, such as CISS (constructive
Any type of intracranial lesion of the retrochiasmal visual interference in steady-state) and FIESTA (fast imaging
pathways (i.e., lesions of the optic tract, the lateral geniculate employing steady-state acquisition), have been deployed to
nucleus, the optic radiations, and the occipital cortex) can better demonstrate the cranial nerves and might be particu-
cause a homonymous hemianopia. The preferred imaging larly useful for smaller intrinsic lesions of the nerve (e.g., ocu-
study for homonymous hemianopsia is a cranial MRI with lomotor nerve schwannoma).11 The sixth cranial nerve runs
and without contrast with attention to the contralateral retro- along the clivus to either side of the midline and CT scan,
chiasmal pathway. Patients who present acutely (e.g., possi- in conjunction with cranial MRI, might show any lesion involv-
ble stroke) or who have high suspicion for intracranial ing bone or sinus disease better (Fig. 4).
hemorrhage (e.g., hemorrhagic stroke, pituitary apoplexy, Although typically MRI is the superior imaging strategy for
ruptured aneurysm or arteriovenous malformation) might un- ocular motor cranial neuropathy, when a patient presents
dergo an initial head CT scan without contrast. In general, with an acute third nerve palsy (especially with pupil involve-
however, even if the initial CT is negative, a follow up MRI ment) the most emergent diagnosis is a posterior communi-
is recommended for acute or chronic ischemic lesions pro- cating artery aneurysm. Patients may present with ptosis,
ducing a homonymous hemianopsia. Diffusion weighted anisocoria, diplopia and headache. Severe headache (e.g.,
imaging (DWI) is a special MR imaging technique that is very ‘‘worst headache of my life’’), nausea, and/or vomiting might
helpful to differentiate the various phases of cerebral infarc- indicate a ruptured aneurysm with subarachnoid hemor-
tion (e.g., hyperacute, acute, subacute or chronic) and, in rhage. In this setting, the initial imaging modality of choice
404 J.D. Kim et al.

Figure 3. (A) Hyperintensity in DWI due to acute infarct in the left MCA distribution caused right homonymous hemianopsia (arrow). (B) Hypointensity in
ADC due to acute infarct of left MCA distribution (arrow).

seen in disorders affecting the cervicomedullary junction14

(e.g., Arnold-Chiari malformation15, skull base tumors, spi-
nocerebellar degenerations16 and toxic metabolic syn-
dromes).17 Convergence retraction nystagmus may be seen
in the setting of the dorsal midbrain syndrome.18 Oculopala-
tal myoclonus is a pendular vertical nystagmus associated
with compromised pathway between the inferior olive, den-
tate nucleus of the cerebellum, and red nucleus due to olivary
hypertrophy following stroke, multiple sclerosis, or head trau-
ma.19,20 Thus, in general, pre- and post-contrast cranial MRI is
the imaging study of choice for unexplained nystagmus.

Proptosis

Figure 4. MRI of brain (sagittal, T1, post contrast) shows a clival Proptosis is a condition where the globe abnormally pro-
chondroma (arrow) in a 29 year-old patient with a left 6th nerve palsy. trudes anteriorly. The most common cause of unilateral or
bilateral proptosis in adults is thyroid ophthalmopathy.
Computed tomography (CT) and MRI of the orbit, without
is typically an emergency non-contrast CT of the head to look contrast, are both neuroimaging studies that can be used to
for subarachnoid hemorrhage followed by a contrast com- make the diagnosis of thyroid eye disease (TED) (Fig. 5). Con-
puted tomography angiogram (CTA) for aneurysm. In many trast is typically not necessary however because of the intrin-
institutions, CTA offers faster and better results than MRA sic contrast provided by fat in the orbit. In addition, for CT
for detection of aneurysm, but the ordering clinician should orbit iodinated contrast material might potentiate iodine-in-
discuss the pros and cons of each study with their institutional duced thyrotoxicosis. CT is also superior to MRI for evaluat-
neuroradiologist in advance to design the best imaging strat- ing sinus disease and for bone especially before and after
egy for third nerve palsy. orbital decompression in TED. Thus, our recommendation
for TED is CT rather than MRI of the orbit. Other causes for
Nystagmus proptosis include: orbital cellulitis, orbital inflammatory dis-
ease (e.g., idiopathic, Wegener granulomatosis, systemic lu-
Nystagmus is a rhythmic oscillating movement of the pus erythematosus) and neoplasm (e.g., meningioma,
eyes.12 Brainstem imaging, typically with cranial MRI, is the glioma, hemangioma21, lymphangioma22, metastasis, or lym-
best initial study for any unexplained nystagmus. Although phoma23). In children unilateral proptosis is commonly due to
most forms of nystagmus require brainstem imaging, a few orbital cellulitis24 and subperiosteal abcess6, and in bilateral
types of nystagmus localize to other specific locations. For cases neuroblastoma25 and leukemia26 are the most likely
example, see-saw nystagmus may be seen in lesions that in- causes. CT scan of the orbit is recommended for the initial
volve the midbrain or parasellar region (e.g., pituitary tumor evaluation of acute onset proptosis (Fig. 6A). CT is faster than
or craniopharyngioma)13 and spasmus nutans in children an MRI and can be useful for defining orbital cellulitis, orbital
might be associated with an optic pathway glioma. Down- abscess, idiopathic orbital inflammation, thyroid orbitopathy
beat nystagmus and periodic alternating nystagmus may be with compressive optic neuropathy or vision threatening
Neuroimaging in ophthalmology 405

Figure 5. A 30 year old female with thyroid eye disease status post left orbital wall decompression. The T1 weighted MRI sequence of coronal (A) and
axial (B) views show markedly enlarged extraocular muscles.

Figure 6. A 20 year old male with allergic fungal sinusitis with severe expansion of the ethmoid sinus pressing on the medial rectus and pushing the
orbital content anteriorly. The CT scan (A) shows great details of the bony structure, while the T1sequence MRI with fat suppression (B) shows the great
details of the soft tissue in orbit and sinus.

proptosis, and post-surgical or spontaneous retrobulbar

hemorrhage.27 For more chronic lesions, orbital fat-sup-
pressed post-contrast MRI (Fig. 6B) may be required to ob-
tain more detailed imaging of the lesion of interest.

Horner’s syndrome

A Horner syndrome (HS) is characterized clinically by ipsi-

lateral ptosis and miosis with anisocoria greater in the dark.
HS can be divided into three types, depending on where
the disruption lies along the oculosympathetic pathway: cen-
tral, preganglionic and postganglionic.28
Central causes of HS are typically recognized based on
the accompanying neurologic signs and symptoms that indi-
cate involvement of the hypothalamus, brainstem or cervico-
thoracic spinal cord (e.g., ataxia, diplopia, hemisensory or
hemimotor loss). Most commonly, central HS is of vascular
etiology leading to lateral medullary syndrome, but other
causes include tumors, trauma, demyelination, and arterio- Figure 7. A 46 year old white male presenting with left ptosis and
anisocoria from left Horner’s syndrome. Patient had left carotid artery
venous malformations. MRI of the head and neck to the sec-
dissection. T1 weighted sequence with contrast in axial view shows classic
ond thoracic vertebra (T2) with and without gadolinium is ‘‘crescent sign’’ (arrow) in distal portion of the left internal carotid artery.
probably the single best mode of imaging for HS. In the
acute setting, a painful HS is commonly caused by internal
carotid artery (ICA) dissection (Fig. 7). A T1-weighted MRI to MR angiography (MRA) of the neck, might be diagnostic.
of the neck with contrast and fat suppression, in addition The diagnostic MRI sign is a crescent of hyperintense signal
406 J.D. Kim et al.

Table 1. Neuro-ophthalmologic indications and recommended imaging study. (modified from Lee et al27 with permission).
Clinical indication Preferred imaging study Contrast material Comment
Bilateral optic disc swelling Magnetic resonance imaging (MRI) Yes Consider concomitant contrast MRV to
head with magnetic resonance exclude venous sinus thrombosis,
venogram (MRV) Computed especially in atypical cases of
tomography (CT) scan might be first pseudotumor cerebri who are thin,
line study in emergent setting. male, or elderly.
Transient monocular visual loss Magnetic resonance angiogram Depends on clinical Carotid Doppler study might be first
(amaurosis fugax) due to ischemia (MRA) or computed tomography situation line and may still require follow up
angiogram (CTA) of neck for carotid catheter angiography.
stenosis or dissection.
Demyelinating optic neuritis MRI head and orbit Yes (enhancing lesions Fluid attenuated inversion recovery
suggest acute disease) (FLAIR) to look for demyelinating white
matter lesions. MRI has prognostic
significance for development of
multiple sclerosis.
Inflammatory, infiltrative, or MRI head and orbit Yes Fat suppression to exclude intraorbital
compressive optic neuropathy optic nerve enhancement CT is
superior in traumatic optic neuropathy
for canal fractures.
Bitemporal hemianopsia MRI head (attention to chiasm and Yes Consider CT of sella if an emergent
sella) scan is needed (e.g. pituitary or
chiasmal apoplexy) or if imaging for
calcification (e.g., meningioma or
craniopharyngioma or aneurysm).
Homonymous hemianopsia MRI head Yes Retrochiasmal pathway. Diffusion
weighted imaging (DWI) may be useful
if acute ischemic infarct or Posterior
reversible encephalopathy syndrome
(PRES). If structural imaging negative
and organic loss consider functional
imaging like positron emission
tomography (PET)
Cortical visual loss or visual MRI head Yes Retrochiasmal pathway. Consider DWI
association cortex (e.g., cerebral in ischemic infarct. If structural imaging
achromatopsia, alexia, negative and organic loss consider
prosopagnosia, simultagnosia, functional imaging (e.g., PET, Single
optic ataxia, Balint’s syndrome) photon emission computed
tomography (SPECT), or MRI
spectroscopy (MRS)).
Third, fourth, sixth nerve palsy or MRI head with attention to the skull Yes Rim calcification in aneurysm,
cavernous sinus syndrome. base. Isolated vasculopathic cranial calcification in tumors, and
neuropathies may not require initial hyperostosis may be better seen on
imaging. CT.
Nystagmus MRI brainstem Yes Localize nystagmus.
Horner syndrome: preganglionic MRI head and neck to second thoracic Yes Rule out lateral medullary infarct,
vertebra (T2) in chest with neck MRA brachial plexus injury, apical lung
neoplasm, carotid dissection, etc.
Horner syndrome: post-ganglionic MRI head and neck to level of Yes Rule out carotid dissection. Isolated
superior cervical ganglion (C4 level) post-ganglionic lesions are often
with MRA neck benign.
Thyroid eye disease CT or MRI of orbit Iodinated contrast may Bone anatomy is better seen on a CT
interfere with scan especially if orbital
evaluation and decompression is being considered.
treatment of systemic
thyroid disease.
Orbital cellulitis and orbital disease CT orbit and sinuses Depends on clinical MRI and/or CT with CTA may be useful
secondary to sinus disease situation adjunct to a CT alone; especially if
possible concomitant cavernous sinus
thrombosis is present.
Orbital tumor (e.g., proptosis or CT or MRI of orbit Yes Include head imaging if lesion could
enophthalmos, gaze-evoked visual extend intracranially. MRI with contrast
loss) is superior at determining intracranial
extent of primary optic nerve tumors
(e.g., optic nerve glioma or sheath
meningioma). CT scan may be superior
if looking for hyperostosis or
calcification.

intensity on T1 surrounding the typically hypointense normal over conventional MRI and MRA of the neck, and at some
carotid artery flow void. CT and CTA of the neck might also institutions, may be the initial evaluation of choice in acute
be diagnostic for a carotid dissection, has some advantages HS.
Neuroimaging in ophthalmology 407

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