CT BRAIN - BASICS

Frankfurt plane

HOUNSFIELD UNITS
Numeric information in each pixel of ct image Related to composition & nature of tissue Represent the density of tissue Also called as CT NUMBER

air fat Pure water Csf White matter Gray matter blood Bone/cacification

--- 1000 ---70 0 +8 +30 +45 +70 +1000

CT /MRI
CT PICTURE
I.
WHITE MATTER IS DARKER THAN GREY MATTER SINCE LIPID CONTAINING MATERIAL IS RADIOLUCENT CSF IS BLACK

MR PICTURE
GREY MATTER
T1WI
DARK T2WI BRIGHT

WHITE MATTR

BRIGHT

DARK

CSF

I.

GREY TO DARK

WHITE

Step wise approach

1. 2. 3. 4. 5. 6. 7. Ventricles/ cisterns Cortex Deep gray matter Focal lesions Bone Extracranial soft tissue Para nasal sinuses

LV
FRONTAL HORN
OCCIPITAL HORN

3V
FORAMEN OF MONRO

4V

TEMBORAL HORN AQUEDUCT OF SYLVIUS

COMMON SECTIONS
AXIAL SECTIONS
POSTERIOR FOSSA CUTS
-ABOVE THE FORAMEN MAGNUM LEVEL -LEVEL OF THE FOURTH VENTRICLE -ABOVE THE FOURTH VENTRICULAR LEVEL - TENTORIAL

CORONAL SECTIONS
-FRONTAL HORN LEVEL -THIRD VENTRICULAR LEVEL -MID VENTRICULAR LEVEL

SAGITTAL SECTIONS
-MID SAGITTAL LEVEL

-PARASAGITTAL LEVEL THROUGH THE LATERAL VENTRICULAR BODY

SUPRATENTORIAL CUTS -THIRD VENTRICULAR

LEVEL -LOW VENTRICULAR LEVEL -ABOVE THE VENTRICULAR LEVEL

-OCCIPITAL HORN LEVEL -LATERAL ORBITAL LEVEL

ABOVE THE LEVEL OF FORAMEN MAGNUM

VA MEDULLA TONSIL
INT OCC PROT

4V CM

LEVEL OF FOURTH VENTRICLE

Optic nerve
TEM HORN

CPCISTERN PONS 4V

MCP

LEVEL ABOVE FOURTH VENTRICLE

OLF SULCUS SYLV FISSURE

SUPRA SELLAR CISTERN

AMB CIST MB

4V
vermis

THIRD VENTRICULAR LEVEL

LOW VENTRICULAR

Above ventricle level

Cerebral Arterial Territory

MCA-most of lateral hemisphere, Basal
ganglia, insula, ACA-Inferomedial basal ganglia,ventromedial frontal lobes, anterior 2/3rd medial cerebral hemispheres, 1 cm supero medial brain convexity PCA-Thalami, midbrain, posterior 1/3of medial hemisphere, occipital lobe, postero medial temporal lobe

 Anterior Choroidal artery branch of ICA supply part of the hippocampus, the posterior limb of the internal capsule Medial lenticulostriate arteries Branches of the A1-segment of the anterior cerebral artery. They supply the anterior inferior parts of the basal nuclei and the anterior limb of the internal capsule. Lateral lenticulostriate arteries Branches of the horizontal M1-segment of the middle cerebral artery. They supply the superior part of the head and the body of the caudate nucleus, lentiform nucleus and the posterior limb of the internal capsule

MCA

ACA

PCA

 AICA- inferolateral part of pons, middle cerebellar peduncle, floccular region, anterior petrosal surface of cerebellar hemisphere PICA-posteroinferior surface of cerebellar hemisphere , ipsilateral part of inferior vermis, Superior cerebellar artery-superior aspect of cerebellar hemisphere (tentorial surface), ipsilateral superior vermis, largest part of deep white matter including dentate nucleus, pons

Water shed infarct

CEREBRAL ISCHEMIA

Cerebral ischemia
Significantly diminished blood supply to all parts(global ischemia) or selected areas(regional or focal ischemia) of the brain Focal ischemia- cerebral infarction Global ischemia-hypoxic ischemic encephalopathy(HIE),hypotensive cerebral infarction

 Exclude hemorrhage

Goal of imaging

Identify the presence of an underlying structural lesion such as tumour , vascular malformation ,subdual hematoma that can mimic stroke Identify stenosis or occlusion of major extra- and intracranial arteries Differentiate between irreversibly affected brain tissue and reversibly impaired tissue (dead tissue versus tissue at risk)

Infarct vs pneumbra
In the central core of the infarct, the severity of hypoperfusion results in irreversible cellular damage .
Around this core, there is a region of decreased flow in which either:

The critical flow threshold for cell death has not reached Or the duration of ischemia has been insufficient to cause irreversible damage.

Hyper acute infarct(<12 hours) Acute infarct(12 - 48 hours) Subacute infarct(2 - 14 days) Chronic infarct(>2 weeks) Old infarct(>2 months)

CT-Hyperacute infarct
Hyperdense MCA sign-acute intraluminal
thrombus Attenuation of lentiform nulei fissure

Dot sign-occluded MCA branch in sylvian Insular ribbon sign grey white interface
loss along the lateral insula

Dense mca sign

 loss of insular ribbon

M C A DOT SIGN

ATTENUATION OF LENTICULAR NUCLEUS

CT- Acute infarct

Low density basal ganglia Sulcal effacement Wedge shaphed parenchymal hypo density area that involves both grey and white matter Increasing mass effect Hemorrhagic transformation may occur -15 to 45% ( basal ganglia and cortex common site) in 24 to 48 hours

 PLAIN CT Wedge-shaped area of decreased attenuation involving gray/white matter in typical vascular distribution Mass effect initially increases, then begins to diminish by 7-10 days Hgic transformation occurs in 15-20% of MCA occlusions, usually by 48-72 hrs CECT Enhancement patterns typically patchy May appear as early as 2-3 days , persisting up to 8-10 weeks "2-2-2" rule = enhancement begins at 2 days, peaks at 2 weeks, disappears by 2 months

CT sub acute infarct

CT-chronic infarct
Plain ct
Focal, well-delineated low-attenuation areas in affected vascular distribution sulci become prominent; ipsilateral ventricle enlarges Dystrophic Ca++ may occur in infarcted brain but is very rare CECT: No enhancement

INFARCT / TUMOUR
CLINICAL HISTROY DISTRIBUTION SHAPES GRAY / WHITE INVOLVEMENT ADVANCED IMAGING

VENOUS INFARCT
HISTROY BEYOND VASCULAR DISTRIBUTION HAEMORRHAGIC INFARCT THORMBUS IN VENOUS SINUSES SYMMETRICAL LOW ATTENUATION IN DEEP GRAY MATTER - DEEP CEREBRAL VEIN THORMBUS

EDEMA/ INFARCT
INFARCT TYPICAL VASCULAR DISTRIBUTION GRAY MATTER INVOLVEMENT EDEMA NOT CONFINED TO VASCULAR DISTRIBUTION MOSTLY INVOLVES WHITE MATTER

PCA INFARCT

MCA INFARCT
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ACA INFARCT

WATERSHED INFARCT

Old infarct

Hgic infarct