Emergency Radiology Course – Brain, Not Bleed

In this lecture, Andrew covers emergency CT brain interpretation with a particular focus on cytotoxic edema
and vasogenic edema, and the pathologies that cause them.

4 Review Questions

Question 1:
Which of the following is the earliest visible CT finding of likely ischemic stroke?
gyriform enhancement of cortex
hyperdense artery sign
hypoattenuation of white matter
loss of grey white matter differentiation
regional swelling

Question 2:
Which is NOT a region used as part of the Alberta stroke program early CT score (ASPECTS) for middle
cerebral artery stroke?
caudate
insular cortex
internal capsule
putamen/lentiform nucleus
thalamus

Question 3:
Axial CT image in an 80-year-old female
with fluctuating GCS. In which vascular
territory is an infarct seen?

anterior cerebral artery (ACA)

anterior inferior cerebellar artery (AICA)
middle cerebral artery (MCA)
posterior cerebral artery (PCA)
superior cerebellar artery (SCA)
Question 4:
Which is NOT TRUE of vasogenic cerebral edema?
can develop around cerebral contusions
often induced by high grade tumors, metastases and abscesses
produces heightened grey-white differentiation
represents swelling of the cell bodies
results from processes that breakdown the blood brain barrier

Explanations:

Question 1:
The hyperdense artery sign refers to focal increased density of an intracranial artery on CT (typically MCA) and
is direct visualization of thromboembolic material within the lumen. It is thus the earliest visible sign
of infarction seen immediately at the time of embolism.
The hyperdensity of the arterial content is due to the thrombus having previously formed and contracted,
usually within the heart or carotid bulb, prior to embolizing and occluding the artery.

Question 2:
The thalamus is not supplied by the MCA and therefore does not form part of the ASPECTS assessment in early
MCA stroke. The remaining 4 answer options are included as regions along with 6 MCA cortical territory
regions

Question 3:
There is hypoattenuation within the left superior portion of the cerebellum (directly inferomedial to the
tentorium on this image) with the low density stopping at the midline. This is a superior cerebellar artery (SCA)
territory infarct.

Question 4:
Cerebral edema owing to swelling of the cell bodies after cellular death is known as cytoxic edema and is not
vasogenic.
Vasogenic edema represents extra-cellular fluid that has leaked out of capillaries due to breakdown of the blood
brain barrier and is often seen with tumors, metastases, abscesses and may develop around contusions. The fluid
leaks into the white-matter and produces heightened grey-white differentiation.
Related Articles

Cytotoxic edema (main article)

 ischemic stroke
o mechanical thrombectomy
 HSV encephalitis
 hypoxic-ischemic injury
Vasogenic edema (main article)
 brain tumors
 cerebral metastases
 cerebral abscess