Basic Approach To Brain CT

Dr. Sayed Munir Pasha

Specialist Radiologist
LLH Hospital, Abu Dhabi
OBJECTIVES
• Describe the CT technology.
• Explain the Cross sectional anatomy of the brain.
• Explain the Common important pathologies.
 HISTORY
• Computed tomography (CT) scan machines uses ionizing
radiation- X-rays, a powerful form of electromagnetic
energy.
• Sir Godfrey hounsfield-1972
• Nobel prize in 1979 with Allan Cormack
• Sixth generation of scanners.
• Latest 728 slice multidetector CT.
PRINCIPLE
• Internal structure of an object can be
reconstructed from multiple projections of the
object.
• Uses x rays applied in sequence of slices
across the organ.
• Images reconstructed from x-ray absorption
data.
• Xray beam moves around the patient in a
circular path

Beam of light projected in two direction's,

detecting two different shadows
Region and Planes
• Transaxial and extend from the foramen magnum to vertex.
• Coronal
• Sagittal

• Slice thickness is between 5 and 10 mm for a routine Head CT.

CT termonology
• Hypodense—Hypointense
• Isodense—Isointense
• Hyperdense—Hyperintense
 DESCRIPTION Approx. HU DENSITY

Calcium > 1000 Hyperdense

Acute blood 60-80 Hyperdense

Grey matter 38 (32-42) Hyperdense

White matter 30 (22-32) Hyperdense

CSF 0-10 ISODENSE

Fat -30 to - 100 Hypodense

Air - 1000 Hypodense

Hounsfield units represent logarithmic scale of CT density.

Pure water has an HU value of ‘0’.
Conventional CT scanners -1024 to 3071—4096
Current CT scans measure from – 1204 to + 3407.
CT Windowing
• Brain Window— 80 / 35
• Bone Window— 1600 / 600
• Subdural hematoma window— 400 / 35
ANATOMY
• Cranial cross-sectional anatomy is very important to know prior to
analyzing a head CT.
• Once the normal structures are identified, abnormalities can be
detected and a diagnosis may be possible.
• Symmetry is an important concept in anatomy and is almost always
present in a normal head CT unless the patient is incorrectly
positioned with the head cocked at an angle.
ANATOMY
1 Sphenoid sinus
2 Medulla oblongata
3 cerebellum
ANATOMY
4 Fourth ventricle
5 Middle cerebellar peduncle
6 Sigmoid sinus
7 Petrous temporal bone and mastoid
air cells
8 Cerebellopontine angle
9 Pons
10 Pituitary fossa
ANATOMY
11 Cerebellar vermis
12 Basilar artery
13 Prepontine cistern
14 Dorsum sellae
15 Temporal horn of lateral ventricle
ANATOMY
16 Ambient cistern
17 Interpeduncular cistern
18 Cerebral peduncle
19 Sylvian fissure
ANATOMY
20 Supra vermian cistern
21 Frontal horn of lateral ventricle
21 Third ventricle
ANATOMY
22 Head of caudate nucleus
23 Insular cortex
24 External capsule
25 Lentiform nucleus
26 Thalamus
ANATOMY
27 Interhemispheric fissure
28 Anterior limb of internal capsule
29 Genu of internal capsule
30 Posterior limb of internal capsule
31 Trigone of lateral ventricle and
calcified choroid plexus
32 Occipital horn of lateral ventricle
ANATOMY
33 Body of lateral ventricle
34 Corona radiata
ANATOMY
• 35 Centrum semiovale
ANATOMY
36 Pre-central gyrus
37 Central sulcus
38 Post-central gyrus
ANATOMY
• 39 ¼ Superior sagittal sinus.
TRAUMA
• Approximately 45% of injuries result from transportation accidents,
26% from falls, and 17% from assaults. Other causes, such as sports
injuries, comprise the remainder of cases.
• Two-thirds of the patients are less than 30 years of age, and
• Men are twice as likely as are women to be injured.
Skull Fractures
The bone windows must be examined carefully.
Divided into
• Linear
• Depresssed
 Most clinically significant if the paranasal sinus or
skull base is involved.
Fractures must be distinguished from sutures and
venous channels
Subarachnoid Hemorrhage
• The ruptured vessel bleeds into the space between the pia and
arachnoid matter.
• When traumatic, subarachnoid hemorrhage occurs most commonly
over the cerebral convexities or adjacent to otherwise injured brain
(adjacent to a cerebral contusion)
• In the absence of significant trauma, the most common cause of
subarachnoid hemorrhage is the rupture of a cerebral aneurysm.
• On CT, subarachnoid hemorrhage appears as focal high density in sulci
and fissures or linear hyperdensity in the cerebral sulci.
• Unenhanced scan and a CT angiogram. Extensive subarachnoid
haemorrhage secondary to a ruptured MCA aneurysm (arrowheads).
27Yrs/Male came to ER with severe headache, vomiting,
loss of consciousness.
Acute Subdural Hematoma
• The blood collects in the space between the arachnoid matter and
the dura matter.
• Characteristics of hematoma :
• Crescent shaped
• Hyperdense, may contain hypodense foci due to serum, CSF or active
bleeding
• Does cross dural reflections at suture sites
• High density, crescent / semilunar / concavo-convex shaped
hematoma (arrowheads) overlying the right cerebral hemisphere.
shift of the normally midline septum pellucidum due to the mass
effect also seen (arrow).
• The hypodense region (arrow)
within the high density
hematoma (arrowheads) may
indicate active bleeding
Subacute Subdural Hematoma
• May be difficult to visualize as becomes isodense to normal gray
matter.
• Suspicion raise when shift of midline structures without an obvious
mass.
• Contrast study can help in difficult
• Compressed lateral ventricle
• Effaced sulci
• White matter "buckling“
• Thick cortical "mantle
Chronic Subdural Hematoma
• Low density as the hemorrhage is further reabsorbed.
• Usually uniformly low density but may be loculated.
• Rebleeding often occurs and causes mixed density and fluid levels.
Crescent shaped chronic subdural This chronic subdural hematoma
collection same density as CSF (arrowheads) shows
the septations and loculations that
often occur over time.
Epidural/ Extradural Hematoma
• An epidural hematoma is usually associated with a skull fracture.
• Often occurs when an impact fractures the calvarium. The fractured
bone lacerates a dural artery or a venous sinus. The blood from the
ruptured vessel collects between the skull and dura.
CT Appearance

• Hyperdense biconvex
• Usually uniformly high density but may contain hypodense foci due to
active bleeding.
• Extradural
• Usually does not cross suture lines where the dura tightly adheres to
the adjacent skull.
• Biconvex epidural hematoma
(arrowheads), deep to the
parietal skull fracture (arrow).
Diffuse Axonal Injury
• “Shear injury“.
• Fifty percent of all primary intra-axial injuries are diffuse axonal
injuries.
• Acceleration, deceleration and rotational forces cause portions of the
brain with different densities to move relative to each other resulting
in the deformation and tearing of axons.
• An ill-defined areas of high density or hemorrhage in characteristic
locations.
Hemorrhage in the corpus callosum (arrow). Hemorrhage of the posterior limb of the
internal capsule (arrow) and hemorrhage
of the thalamus (arrowhead).
 Cerebral Contusion

• Most common primary intra-axial injury.

• Often occurs when the. brain impacts an
osseous ridge or a dural fold. The foci of
punctate hemorrhage or edema are located
along gyral crests
• On CT cerebral contusion appears as an ill-
defined hypodense area mixed with foci of
hemorrhage. After 24-48 hrs, hemorrhagic
transformation or coalescence of petechial
hemorrhages into a rounded hematoma is
common.
 Intraventricular Hemorrhage
• Traumatic intraventricular hemorrhage is
associated with diffuse axonal injury, deep gray
matter injury, and brainstem contusion. An
isolated intraventricular hemorrhage may be
due to rupture of subependymal veins.
Stroke
• Stroke is a clinical term for sudden, focal neurological deficit
• Hemorrhagic
• Ischemic.
• Hemorrhagic strokes account for 16% of all strokes.
• An ischemic stroke is caused by blockage of blood flow in a major
cerebral blood vessel, usually due to a blood clot.
Hemorrhagic Stroke
• Hemorrhagic strokes account for 16% of all strokes.
• Intracerebral hemorrhage is the most common, accounting for 10%
of all strokes.
• Subarachnoid hemorrhage, due to rupture of a cerebral aneurysm,
accounts for 6%
The most common causes:
• Hypertensive hemorrhage.
• amyloid angiopathy,
• Ruptured vascular malformation,
• Coagulopathy,
• Hemorrhage into a tumor
• Venous infarction.
• Drug abuse (ICH in cocaine users include
rapid increases in blood pessure,aneurysmal
rupture and vasculitis).

Hemorrhage in the cerebellum

Hypertensive Hemorrhage
• Often appears as a high-density hemorrhage in the region of
• Basal ganglia
• Thalamus
• Pons / midbrain
• cerebellum

• Blood may extend into the ventricular system. Intraventricular

extension of the hematoma is associated with a poor prognosis
Thalamic hemorrhage (arrow) Hypertensive hemorrhage in High density blood fills the
extending into the basal ganglia. cisterns (arrowheads) .
the left lateral ventricle
(arrowheads).
• Coagulopathy related hemorrhage is heterogeneous due to
incompletely clotted blood.
• AVM bleed may show adjacent calcifications
Ischemic stroke
• Dense middle cerebral artery or a dense
basilar artery
• Basilar Thrombosis
• Lentiform Nucleus Obscuration
• Diffuse Hypodensity and Sulcal Effacement
Hypodensity in the left
hemisphere (arrows) involving
the caudate
nucleus and lentiform nuclei
(globus pallidus and putamen).
Loss of insular ribbon sign, subtle Large areas of hypodensity in right
hypodensity and effacement of sulci middle cerebral artery vascular
territories.
CT of Subacute Infarction
• The CT of a subactue infarction has the
following findings in 1 -3 days:
- Increasing mass effect
- Wedge shaped low density
- Hemorrhagic transformation
Infections—Meningitis
• Imaging in suspected meningitis patients has no role except
• to look for complications
• assess safety of lumbar puncture
• Imaging is not usually performed to diagnose meningitis because
imaging studies are frequently normal despite the presence of the
disease.
Common complications of meningitis:

• Hydrocephalus
• Ventriculitis / Ependymitis
• Subdural effusion
• Subdural empyema
• Cerebritis / Abscess
• Vasospasm / arterial infarcts
• Venous thrombosis / venous infarcts
•
Hydrocephalus
 Ventriculitis / Ependymitis

• In this post contrast CT scan, note the

ring enhancing
brain abscess (arrowheads) and
enhancement of the
ependymal lining of the left lateral
ventricle (arrow).
Intracranial Tumors
• Intracranial tumors generally present with a focal neurological deficit,
seizure, or headache.
• They may present as well defined circumscribed masses on contrast
studies or as irregular masses with necrosis and haemorrhage.
Glioblastoma Multiforme

ll-defined low density in the right frontal post contrast administration in the same
region. patient reveals patchy
enhancement, a portion of which is crossing
the corpus callosum (arrow).
Meningioma

• Most common extra-axial

neoplasm of the brain.
• Middle-aged women are most
frequently affected.
• Twenty percent of meningiomas
calcify.
• On CT, meningiomas are usually
isointense to gray matter Axial, post contrast CT
therefore contrast is administered. demonstrating broad based
enhancing extra-axial mass.
Summary
• Cranial CT has assumed a significant role in the practice of emergency
medicine for the evaluation of intracranial emergencies, both
traumatic and non-traumatic.

• Cranial CT interpretation is a skill, like ECG interpretation, that can be

learned through education, practice, and repetition.
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