CT Scans of the Head:

A Neurologist’s Perspective

Lara Cooke
January 15, 2009
 Objectives

• At the end of this session, residents should be able

to:
• Identify key anatomic structures on CT
• Apply an approach to reading a CT of the head
• List reasons to image a patient with headache
• Identify CT signs of raised ICP, early ischemia
• Describe the clinical presentation of dural sinus
thrombosis
• Distinguish between intracranial hemorrhages
General Principles of the CT

• CT is basically a specialized X-Ray

• We talk about “density” or “attenuation”
• The image is a measure of absorption of X-
rays through different angles through a
given tissue and then transformed
mathematically
What is hyperdense vs hypodense
on CT?
• Bone (dense calcium) (1000 HU)
• Metal
• Acute (but not hyperacute) blood (56-76 HU)
• Thrombosis
• Grey matter>white matter (30, 20 HU)
• CSF (0 HU)
• Fat (-30-100 HU)
• Air (-1000)
 General Principles:
• Are there any fractures?
• Use bone windows
• Look around the orbits, skull base, zygoma

• Remember to look at the sinuses (frontal,

maxillary, ethmoid, sphenoid, mastoid air cells)
• Should be black & full of air--look for hyperdense fluid
levels, thickening of mucosa, cysts….especially when
the patient complains of headache
Bones

Fracture
Sinuses

Maxillary
Sphenoid

Frontal

Ethmoid
 General Principles

• Look at the dura

• Is there anything ‘extra’ between the brain and
the skull?
• Hygroma
• Blood
• Tumor
• Air
 Things between skull & brain
that shouldn’t be there
Hygroma

Subdural Meningioma
hematoma

Epidural hematoma
Pneumocephaly
 General Principles

• Look at the brain:

• Grey-white differentiation
• Basal ganglia
• Internal capsule
• Corona radiata
• Is there blood? Is there edema? Is there CSF
due to encephalomalacia/cysts? Is there a mass?
 GW Differentiation
Anatomic Structures
Anterior horn of
caudate lateral ventricle
lentiform

Internal
Insular ribbon capsule
Sylvian fissure (post.
limb)
thalamus Pineal gland
3 ventricle
rd
 General Principles
• Look at the spaces
• Ventricles:
• Can you see all the ventricles?
• Is there hydrocephalus?
• Cisterns
• Are the normal spaces around the brainstem still visible?
• Dural Sinuses
• Can you see them?
• Are they thicker or brighter than usual?
 Case

• 43 yo woman with headache x 3 weeks

• Presents to hospital with double vision
• Low grade fever
• On examination, weakness of EOM of left
eye, mild proptosis, red eye
What do you see?

Sphenoid
sinusitis
 CT is good at showing…
• Bony abnormalities
• Acute blood
• Large masses (and small enhancing masses if
contrast is given)
• Calcified intracranial abnormalities
• Edema
• Large intracranial aneurysms (now we have CTA
which is very good at this!!!)
• stroke
 CT might miss…
• Subacute subdural (isodense to brain)
• Isodense tumors/infections with little mass effect/edema associated
• Small aneurysms
• Vasculitis
• Vascular malformations
• Dural sinus thrombosis
• Lesions in the posterior fossa
• Demyelination/white matter disease
• Stroke
• Meningeal processes
• Diffuse axonal injury
 Yield of CT for headache

• CT is generally low yield if a thorough

neurologic exam is normal (including
LOC/mentation)
• CT is higher yield with focal findings,
decreased LOC
• In typical migraine with normal exam, yield
is 0.18%
Normal CT

Maxillary sinus
air-fluid
level

Brainstem
-medulla
Normal CT

Superior ophthalmic vein

Sphenoid sinus
Temporal lobe
Mastoid air cells
4th ventricle
Cerebellum
Normal CT

Internal carotid
artery
Basilar artery
Pons
Temporal horn of right
lateral ventricle
Normal CT

Left MCA
Suprasellar cistern
Cerebral aqueduct
Normal CT

Cerebral peduncle
Interpedulcular cistern
 Normal CT Anterior horn
of left lateral
ventricle
Caudate
Lentiform
Posterior limb
of internal
capsule
Insular ribbon
Thalamus
Sylvian fissure 3rd ventricle
Normal CT
 Normal CT

Falx cerebrei

Superior sagittal sinus

Normal or Not Normal?
Normal or not normal?
Normal or Not Normal?
Normal or Not Normal?
Raised Intracranial Pressure: What
to look for
• Loss of basal cisterns
• Loss of suprasellar cistern (unilateral or
bilateral)
• Loss of sulcal/gyral pattern
• Loss of grey-white differentiation
• Enlarged “trapped ventricles”
• Slit-like ventricles
Valproic Acid Overdose
Valproic Acid Overdose
Posterior Fossa
Posterior Fossa Day 3
When not to do an LP
 Raised ICP
• Do not do an LP if:
• you suspect raised ICP
• You see a mass or structural lesion with mass effect
(e.g. hematoma)
• You see mass effect (displaced structures like the falx,
uncus, ventricles)
• You cannot see the basal cisterns
• You see hydrocephalus
• You have not done a CT, there are neuro
findings/altered LOC and you work in a tertiary care
centre where this test is readily available
When should you image a
headache patient?
When should you order CT for
headache?
• Any unexplained neurologic signs
• Altered LOC
• New headache type in an older patient
• Change in pattern of previous headache
• Progressive headache
• Thunderclap headache
• Refractory headache
Headache Red Flags…CT please!
• Abnormal neuro exam
• Headache worst on waking in a.m.
• Headache waking patient from sleep
• Progressive headache
• Worse with valsalva
• Worse supine than upright
• Abrupt onset headache
• Other condition predisposing to CNS disease
(immune suppressed, cancer, clotting disorder,
anticoagulants, recent trauma, etc)
35 yo man, assaulted with pipe

Subarachnoid Obliteration of
hemorrhage ant horn of R
lateral ventricle
Epidural
hematoma
Intracerebral
hemorrhage
assault

Midline shift
66 yo man with subacute onset
of language difficulty

Hypodense mass
Edema
Midline shift
wet

Ring enhancing
47 yo man with RA and vertigo

Cerebellar
hemorrhage
 Case

• 39 yo man with polycystic kidney disease

• CT head was done for headache
• Normal neuro exam
 What do you see?

Small hyperdense
lesion
 Case

• 18 yo girl with a history of ITP

• Presents with bizarre behaviour, difficulty
walking and headache
• On exam appears ‘indifferent’ to her ‘state’
• Moves both sides well with encouragement
• Left side ‘lags’ behind when she gets off
bed
CT

Enlarged cortical
veins
MRV & MRI
 Dural Sinus Thrombosis

• May present with chronic progressive

headache
• May present with thunderclap headache
• May or may not have abnormal neurosigns
 Predisposing Factors
• OCP +/-smoking
• Pregnancy/post-partum
• Clotting disorder (APA, ACA, Pr C, ATIII, S
deficiencies, Factor V Leiden, cancer, IBD,
nephrotic syndrome)
• Dehydration
• Local occlusion by trauma/tumor
• Infection (meningitis, mastoiditis, sinusitis, dental
abscess)
What you might see on CT
• Nothing at all
• Hyperdense/misshapen/thickened dural sinus or
cortical vein
• Hyperdense/empty delta (empty on enhanced CT)
(do not hang your hat on this to r/o DST)
• Venous infarct (wedge shaped, grey-white
junction, associated hemorrhage, deeper white
matter, non-arterial territory
• May be bilateral
• Diffuse edema/raised ICP
 DST

• Often missed
• 25% don’t have predisposing factors
• Ask yourself if this is a possibility
whenever you want to scan a patient for
headache
• Remember the redflags
• Remember to look at the fundi
 Case II

• 89 yo woman with progressive confusion

and intermittent spells lasting 10-20 min of
word-finding difficulties
• Headache for two weeks--moderate, dull,
holocephalic
• 1) additional history you would like?
• 2) do you want to do a CT?
Acute on chronic
SDH
 Key Points:

• Older people are at risk due to atrophy +

tearing of bridging veins
• Ask about anticoagulants
• Ask about recent minor trauma
• Scan older people who have new headache
• Scan people with ‘TIAs’
Small SDH
Acute on chronic
SDH
 Case

• 29 yo male involved in a bar-fight this

evening
• Punched in the head - brief LOC then went
home with his girlfriend
• Brought in 2 hours later with progressive
decrease in LOC
• On exam, comatose, right pupil sluggish
• Do you want to do a scan?
 Management?

Epidural hematoma
 Acute on chronic
SDH

Epidural hematoma
Midline shift
Epidural hematoma
 Case

• 55 yo man fell off of a stool and struck head

on concrete floor
• Had had some EtOH
• Wife brought him in because he had some
slurred speech and inappropriate behaviour
• Headache
• On exam, smells like EtOH. Slurred speech.
Behaviour inappropriate. Nil focal.
• What do you want to do?
Subarachnoid
hemorrhage
Blood follows the pattern of
gyri/sulci

Subarachnoid
hemorrhage
 “Pentagon Sign”

Subarachnoid
hemorrhage
Pentagon sign + hydrocephalus

Temporal horn of
lateral ventricle
 Case

• 40 y.o. man with new onset mild

incoordination of the Left hand &
behavioural change
• What do you want to know?
• What do you want to do?
 Loss of lentiform
nucleus

Hypodense region
& loss of G-W in M1
Early Ischemic Changes: Clues
to Stroke
• ASPECTS
• Out of 10
• M1, M2, M3, M4, M5,
M6
• Caudate
• Lentiform nucleus
• Internal capsule
• Insular ribbon
• Also, look at MCA
ASPECT Score
• M1,2,3, IC, L, C
 ASPECTS

• M4-6
 Looking for stroke

• Time is brain
• Stroke more than 12 hours old begins to
look quite hypodense (dark) in the affected
arterial territory
• Acutely, there ARE subtle signs--which
may alter likelihood of getting TPa and risk
of hemorrhage
 Subtle findings

• Look at:
• Grey-white differentiation
• Presence/loss of sulcal/gyral pattern
• Compare side to side - stroke is usually
unilateral--so you have a built-in comparator
• Look for hyper dense, asymmetric, vessels
• Look for loss of signal in deep structures (basal
ganglia, thalami, internal capsule)
• Know the basics of vascular anatomy
80 yo man with dysphasia x 3hrs

Loss of G-W
Differentiation
In M1, M2, M3
Loss of insular
ribbon
Same scan, superiorly

Loss of GW
differentiation
in M4, M5, M6
12 hrs later
 Case

• 68 yo man with DMII, htn.

• Woke up with left-sided weakness, leg
more than hand.
 What do you see?

Hypodense
Region - ACA
 Case

• 43 yo waiter
• Binge drinking
• Awoke at 4 am feeling nauseated/headache
• Awoke at noon unable to get out of bed
• Discovered by his mother & brought to
hospital
Holiday Heart
Monday morning
 Case

• 28 yo woman, 2 days post partum

• Headache, left-sided, nausea, vomiting,
photophobia, phonophobia, worsening with
routine activity.
• What else do you want to know?
What do you want to do?
What do you see?
 Case

• Pt 3 weeks post-partum develps severe

headache and left leg paresthesias
• Throbbing pain, photophobia, phonophobia,
nausea, x 4 days
• Worse with valsalva & lying down
Post-Partum Patient
 Case

• 43 yo man works at packing plant

• Developed acute onset of headache and left-
sided weakness
• One exam, normal power on left, but
complete sensory loss to all modalities and
mild neglect
• PMHx; htn, DM
• Ran out of BP meds 2 months earlier
Left sensory loss & neglect

Thalamic ICH
Acute vertigo, N/V, then coma in
80 yo hypertensive man

Cerebellar
hemorrhage
Hypertensive Hemorrhages

• Basal ganglia (putamen>caudate)

• Thalamus
• Pons
• Cerebellum
• Centrum semiovale
• Intraventricular (from basal ganglia)
 Case

• 68 yo RHD woman found wandering at

work, speaking incoherently.
• PMHx: Htn, gout
• Discontinued BP meds one month ago
Aphasia
 Case

• 70 yo woman developed severe headache &

confusion
• On examination, has receptive aphasia &
mild expressive problems
• Right visual field abnormality
(homonymous hemianopia)
Headache & Confusion
 Case

• 65 yo man with gradual onset of left-sided

weakness, now has decreased LOC.
?
 Case

• 49 yo woman with known breast cancer

• Presents with complaints of problems
seeing
• Has L visual field defect
 ?

Multiple hyperdense
foci

Edema
 Case

• 65 yo man with colon Ca

• Presents with word finding difficulties and
headache.
• Onset was acute.
?
 Take-Home Messages
- don’t LP if you think ICP might be up
- Remember to look at more than
parenchyma: Bones, dura, sinuses, cisterns,
ventricles, and dural sinuses
- Look for normal anatomy: grey-white
margin, basal ganglia, insula, internal
capsule
- Chronic blood is not bright--may be
isodense, and therefore subtle
Messages about Headache
• If there are focal findings, decreased LOC
or red flag features: SCAN
• Ask yourself if this could be a dural sinus
thrombosis
• Do LP query SAH, encephalitis, meningitis
• Do not LP if you’re not sure about the CT
• Do not LP without a CT in a tertiary care
centre (caveat--some clinical judgement
here)
 Messages about Stroke

• Compare side to side

• Changes may be present under 3 hours
• Image your TIA patients (sometimes they
have something else--eg. SDH)
• A normal CT means better prognosis
• Early subtle signs mean more damaged
tissue, greater risk of hemorrhage
• Time is brain
Tests that sometimes don’t
happen, but should….
• If you think there may be a neuro problem, be sure
to always do these parts of the CNS exam--
otherwise you may miss the boat:
• Look at the discs (don’t be shy about dilating)
• Check fields
• Look at nasolabial folds & forehead
• Look for drift
• Check toes
• Check for sensory extinction
• Walk your patient
I don’t know what the heck this
is…