Normal looking abnormal brain:

Review areas in routine practice.

ECR 2019

C-2347
Learning objectives

1. To understand the anatomy of the review areas where pathological findings are commonly missed.

2. To illustrate the subtle radiological findings commonly misinterpreted by junior doctors and residents.

3. To discuss the appropriate steps in systematic evaluation of CT and MR images of brain to avoid these common
misinterpretations.
 Background
Radiologists are prone to make perceptual or cognitive errors and/or miss the findings in certain areas in the head encountered at routine
CT and MR imaging of brain. Probability of missing findings is much more when the findings are subtle, especially for an untrained eye!

Bahrami et al (1), defined these areas as "blind spots" (Table 1).

Findings and procedure details - 200 CT scans and 100 MR
scans of brain over a period of
~4 years in a tertiary centre and found out the most commonly
missed pathologies by the
reporting junior radiologists and residents in decreasing order
• Traumatic
of frequencies (Subtle subarachnoid hemorrhage, subacute subdural hemorrhage, non-
were
hemorrhagic contusion, diffuse axonal injury and fractures particularly at the base of the
skull, nasal bones, and orbital blow out)
• Ischemic ( hyper acute MCA infarct, watershed infarcts, infarcts in brainstem and
cerebellum particularly in plain CT, diffuse hypoxic / ischemic injury , cerebral venous
thrombosis , cervical spinal cord infarct visualised in brain MRI)
• Vascular (small aneurysm, particularly contra lateral aneurysm in bilateral/ multiple
aneurysms, vertebral/ carotid artery dissection, acute internal carotid artery thrombosis)
• Neoplastic (glomus jugulare tumor, clival/ convexity meningioma , small
vestibular schwannoma, trigeminal schwannoma, small tectal plate lipoma).
• Infective/Inflammatory (meningitis, skull base osteomyelitis, small
granulomas particularly extra-cranial neurocysticercosis).
TRAUMATIC PATHOLOGIES
Diagnosis: Acute subarachnoid and intraventricular hemorrhage

Missed finding /error: Subtle left parietal subarachnoid hemorrhage and

intraventricular hemorrhage were missed by reporting junior radiologist.

Learning point: Appropriate windowing can assist in the identification of subtle

acute SAH.
25 Year old male with history of road traffic accident 5 hours back
 25 years old male with history of road traffic accident

Axial bone window CT image of head shows subtle left nasal bone fracture (blue arrow in A) and thin
linear lucent line in the right supra orbital margin extending along the orbital roof suggestive of fracture
(red arrows in B). Subtle superficial soft tissue swelling seen over right orbit (yellow arrow in C).
Axial bone window CT image demonstrates comminuted fracture of left carotid
canal (red arrow in A) and mildly displaced fracture of lateral wall of right
carotid canal(green arrow in A). Also there are longitudinal fractures of
bilateral temporal bones with hemomastoid. Follow up non-contrast CT brain
(performed after 3 days) demonstrates multiple varying sized hypo dense
areas in bilateral cerebral hemispheres suggestive of infarcts.
 ISCHEMIC PATHOLOGY

Axial MR images of brain showing subtle hyperintensity in the left insular cortex
on DWI image (A) with corresponding hypointensity on ADC image (B) suggesting
diffusion restriction and suggestive of hyper acute left MCA territory infarct.FLAIR
(C) demonstrates no abnormality in left insular cortex (Normal looking !).
48 year old male with sudden onset of right sided weakness and sensory loss
32 year old female with history of sudden onset of vertigo since 6 hours. Her
brain CT scan was negative.

medulla showing small hyperintense focus in the right lateral portion of

medulla on DWI (red arrow) and T2w (yellow arrow) images-s/o lateral
medullary infarct (ADC image not shown).DWI image of brain demonstrates
small acute infarct ( blue arrow)demonstrates small acute infarct in the para-
sagittal portion of right frontal lobe (This finding was missed by resident).
sudden collapse at work place
 h/o headache

FLAIR and T2W images of brain demonstrate loss of flow void in right transverse sinus
(yellow arrows in A and B). GRE image of brain demonstrating blooming lines in right
transverse sinus (red arrow in C). TOF MRV image demonstrate loss of flow related
enhancement (green arrow in D). Features suggestive of dural venous thrombosis.
NEOPLASMS
75 years old female with history of left sided tinnitus
35 year female with history of left facial pain and numbness since 2 months
inflammatory/infective pathologies
o/c/o left ear surgery - 6 months
42 Year female patient with history of pain in the bilateral orbital region with
no vision loss
left sided numbness a/w mild headache
31 y/ m - c/o 1 day history of memory loss
Conclusion

● Crucial step in avoiding errors is to systematically review the blind spots using
● comprehensive check list. Knowledge of anatomical features of these blind
spots, use
● of appropriate window width while evaluating CT images and use of
appropriate imaging
● sequence while evaluating MR images are important for avoiding false
negative results.
thank you