Window Width

• The window width (WW) as the name suggests is the measure of the range of CT
numbers that an image contains.
• A wider window width (2000 HU), therefore, will display a wider range of CT
numbers. Consequently, the transition of dark to light structures will occur over a
larger transition area to that of a narrow window width (<1000 HU).
• Accordingly, it is important to note, that a significantly wide window displaying all
the CT numbers will result in different attenuations between soft tissues to become
obscured.
Wide window
• Defined as 400-2000 HU best used in areas of acute differing attenuation values, a
good example is lungs or cortical tissue, where air and vessels will sit side by side. 
Narrow window
• Defined as 50-350 HU are excellent when examining areas of similar attenuation,
for example, soft tissue.
 Parts of CT Scan
Control Console
Computer
Gantry
Couch/Table
Control Console
Extradural hematoma (EDH), also known as an epidural hematoma, is a
collection of blood that forms between the inner surface of the skull and outer
layer of the dura, which is called the endosteal layer. They are usually associated
with a history of head trauma and frequently associated with skull fracture. The
source of bleeding is usually arterial, most commonly from a torn middle
meningeal artery.
EDHs are typically biconvex in shape and can cause a mass effect with
herniation. They are usually limited by cranial sutures, but not by venous sinuses.
Both CT and MRI are suitable to evaluate EDHs. When the blood clot is
evacuated promptly (or treated conservatively when small), the prognosis of
EDHs is generally good.
Pathology
• The source of bleeding is typically from a torn meningeal artery, usually the
middle meningeal artery (75%). An associated skull fracture is present in ~75%
of cases . Pain (often severe headache) is caused by the stripping of dura from
the bone by the expanding hemorrhage. The posterior fossa is a rare location for
traumatic injury, in general, including EDH .
• Occasionally, an EDH can form due to venous blood, typically a torn sinus with
an associated fracture: see venous extradural hemorrhage.
Radiographic features
• The morphology of extradural hematomas is best understood by reviewing their
relationship to the bone and dura. 
• An extradural hematoma is actually a subperiosteal hematoma located on the
inside of the skull, between the inner table of the skull and parietal layer of the
dura mater (which is the periosteum).
• As a result, EDHs are usually limited in their extent by the cranial sutures, as
the periosteum crosses through the suture continuous with the outer periosteal
layer.
• This is therefore helpful in distinguishing EDHs from subdural hematomas,
which are not limited by sutures.
CT findings
• In almost all cases, extradural hematomas are seen on CT scans of the brain.
They are typically bi-convex (or lentiform) in shape, and most frequently
beneath the squamous part of the temporal bone. EDHs are hyperdense,
somewhat heterogeneous, and sharply demarcated. Depending on their size,
secondary features of mass effect (e.g. midline shift, subfalcine herniation, uncal
herniation) may be present.
• When acute bleeding is occurring at the time of CT scanning the non-clotted
fresh blood is typically less hyperdense, and a swirl sign may be evident
The swirl sign refers to the non-contrast CT appearance of acute extravasation of
blood into a hematoma, for example an intracerebral hemorrhage, extradural
hematoma or subdural hematoma. It represents un-clotted fresh blood which is of
lower attenuation than the clotted blood which surrounds it
Subdural hemorrhage (SDH) (Subdural hematoma)
It is a collection of blood accumulating in the subdural space, the potential space
between the dura and arachnoid mater of the meninges around the brain.
SDH can happen in any age group, is mainly due to head trauma and CT scans are
usually sufficient to make the diagnosis.
Prognosis varies widely depending on the size and chronicity of the hemorrhage. 
Clinical presentation
• Acute subdural hemorrhages usually present in the setting of head trauma. This
is especially the case in young patients, where they commonly co-exist with
cerebral contusions.
• Most patients (65-80%) present with a severely depressed conscious state and
pupillary abnormalities are seen in ~40% (range 30-50%) of cases.
• Occasionally spontaneous acute subdural hematomas are seen with an
underlying bleeding disorder (e.g. anticoagulation medication,
thrombocytopenia) or structural abnormality (e.g. dural arteriovenous fistula).
• Clinical presentation of subacute/chronic subdural in the elderly is often vague
and is one of the classic causes of pseudodementia. A history of head trauma is
often absent or very minor.
Radiographic features
• Overall 85% of subdural hematomas are unilateral in adults. However, 75-
85% are bilateral in infants. 
• Common sites for subdural hematomas are frontoparietal convexities and
the middle cranial fossa.
• Isolated interhemispheric/parafalcine subdural hematomas are seen more
frequently in children and are common in cases of non-accidental trauma.
CT Findings
• Hyperacute
• In most instances, patients are not imaged in the hyperacute phase (first hour or
so), but on occasion when this is performed they appear relatively isodense to the
adjacent cortex, with a swirled appearance due to a mixture of the clot, serum
and ongoing unclotted blood .
• There is often a degree of underlying cerebral swelling (especially in young
patients where head trauma is often more severe) which accentuates the mass-
effect created by the collection .
Acute
• The classic appearance of an acute subdural hematoma is a crescent-shaped
homogeneously hyperdense extra-axial collection that spreads diffusely over the
affected hemisphere.  As the clot starts to retract the density increases typically
to >50-60 HU and is thus hyperdense relative to the cortex .
• Up to 40% of SDHs have mixed hyper- or hypodense areas that reflect unclotted
blood, serum extruded during clot retraction, or CSF within the subdural
hematoma due to an arachnoid laceration.
• Rarely, acute SDHs may be nearly isodense with the adjacent cerebral cortex.
This occurs with anticoagulation, coagulopathies, or severe anemia when the
hemoglobin concentration drops to 8 to 10 g/dL. Patients with deficient
coagulation can also demonstrate a hematocrit fluid-fluid level as the blood does
not form a clot and red cells have time to drift dependently.
In patients with underlying low hemoglobin and platelet conditions such as sickle
cell anemia, acute subdural hemorrhage may be hypodense even in the acute
phase.
Subacute
• As the clot ages and protein degradation occurs, the density starts to drop. At
some point between 3 and 21 days (typically 10-14 days), the density will drop
to ~ 35-40 HU and become isodense to the adjacent cortex, making
identification potentially tricky, especially if subdural collections are bilateral
.The key to identification is visualizing a number of indirect signs, including:
• CSF-filled sulci do not reach the skull but rather fade out into the subdural
space.
• Mass-effect including sulcal effacement (distortion) and midline shift.
• Apparent thickening of the cortex.
Chronic
• It lasts at least for 3 weeks old.
• The subdural collection becomes hypodense and can reach ~0 HU and be
isodense to CSF, and mimic a subdural hygroma(fluid filled sac formed due to
repeated trauma).
• A crescentic shape may change to a biconvex one.
• Rarely, the periphery of the SDH may calcify, see calcified chronic subdural
hematoma for an in-depth discussion regarding the CT appearance of this entity.
Acute on chronic
• Acute on chronic subdural hematomas refers to a second episode of acute
hemorrhage into a pre-existing chronic subdural hematoma.
• It typically appears as a hypodense collection with a hematocrit level (located
posteriorly). A similar appearance can be seen in patients with clotting disorders
or on anticoagulants
Subdural Hematoma
Subarachnoid hemorrhage (SAH) 
It is a type of extra-axial intracranial hemorrhage and denotes the presence of
blood within the subarachnoid space.(Extra-axial hemorrhage, bleeding that
occurs within the skull but outside of the brain tissue. )
Pathology
• Three distinct patterns of subarachnoid hemorrhage have been described each
with its own etiology and treatment/prognostic implications:-
• Suprasellar cistern with diffuse peripheral extension
• Perimesencephalic and basal cisterns
• Isolated cerebral convexity
Etiology
Causes include :
• Trauma
• Spontaneous
• ruptured berry aneurysm: 85% 
• perimesencephalic hemorrhage: 10%
• arteriovenous malformation
• cerebral amyloid angiopathy 
• ruptured mycotic aneurysm
• reversible cerebral vasoconstriction syndrome
• dural arteriovenous fistula
• spinal arteriovenous malformation
• venous infarction
• sympathomimetic drugs (eg. cocaine)
• cerebral vasculitis
• anticoagulation therapy
CT Findings
• The sensitivity of CT to the presence of subarachnoid blood is strongly
influenced by both the amount of blood and the time since the hemorrhage.
• The diagnosis is suspected when a hyperdense material is seen filling the
subarachnoid space. Most commonly this is apparent around the circle of Willis,
on account of the majority of berry aneurysms occurring in this region (~65%).
• Small amount of blood can sometimes be appreciated pooling in the
interpeduncular fossa, appearing as a small hyperdense triangle, or within the
occipital horns of the lateral ventricles .
• Subarachnoid hemorrhages are grouped into four categories according to the
amount of blood on unenhanced CT by the Fisher scale. This scale has been
updated to the modified Fisher scale, which more accurately correlates the risk
of vasospasm
• The modified Fisher scale is a method for radiological grading subarachnoid
hemorrhage (SAH) secondary to intracranial aneurysm rupture, assessed on the
first non-contrast CT.
• Classification
• Grade 0
• no subarachnoid hemorrhage (SAH)
• no intraventricular hemorrhage (IVH)
• incidence of symptomatic vasospasm: 0%
• Grade 1
• focal or diffuse, thin SAH
• no IVH
• the incidence of symptomatic vasospasm: 24%
• Grade 2
• thin focal or diffuse SAH
• IVH present
• the incidence of symptomatic vasospasm: 33%
• Grade 3
• thick focal or diffuse SAH
• no IVH
• the incidence of symptomatic vasospasm: 33%
• Grade 4
• thick focal or diffuse SAH
• IVH present
• the incidence of symptomatic vasospasm: 40%
Intracerebral hemorrhage, or intraparenchymal cerebral hemorrhage:-
It is a subset of an intracranial hemorrhage and encompasses a number of entities
that have in common the acute accumulation of blood within the parenchyma of
the brain.
• They are most often broadly divided according to whether they are spontaneous
(primary) or due to an underlying lesion (secondary), and then further divided
according to etiology and/or location. 
• Primary hemorrhages
• Lobar hemorrhages secondary to cerebral amyloid angiopathy ( it is a condition in which
proteins called amyloid build up on the walls of the arteries in the brain)
• Hypertensive hemorrhages
• Secondary hemorrhages (some other lesion complicated by hemorrhage)
• Vascular malformation
• Cerebral venous thrombosis
• Tumor (primary or secondary)
CT Findings:-
Large hyperdense haemorrhage with spot sign(non traumatic)
The spot sign is a CTA is an acute intracerebral hemorrhage and representing the
focal accumulation/pooling/extravasation of contrast containing blood within the
hematomas.
It is an important feature to identify during the evaluation of acute intracerebral
hemorrhage as it significantly increases the likelihood of hematoma growth. 
• The spot sign is seen on CTA images as a small focal region of contrast
enhancement within the hematoma.
• It should not be present on pre-contrast images although a region of lower
attenuation may be seen at its location representing non-clotted blood.
White matter
• White matter refers to areas of the central nervous system (CNS) that are
mainly made up of myelinated axons, also called tracts.
• White matter is composed of bundles, which connect various grey matter areas
(the locations of nerve cell bodies) of the brain to each other, and carry nerve
impulses between neurons. Myelin acts as an insulator, which allows electrical
signals to jump, rather than coursing through the axon, increasing the speed of
transmission of all nerve signals.
There are three different kinds of tracts (bundles of axons) that connect one part of
the brain to another within the white matter:
• Projection fibres extend vertically between higher and lower brain areas and
spinal cord centers, and carry information between the cerebrum and the rest of
the body. Other projection tracts carry signals upward to the cerebral cortex.
Superior to the brainstem, such tracts form a broad, dense sheet called the
internal capsule between the thalamus and basal nuclei, then radiate in a
diverging, fanlike array to specific areas of the cortex.
The projection fibres connect the cerebral cortex to the subcortical centers (such
as the corpus striatum, thalamus, brainstem) and spinal cord. These fibers are of
two types:
• Corticofugal fibers go away from the cortex (cortical efferents) to centers in the
other parts of the CNS.
• Corticopetal fibers come to the cerebral cortex from the other centers in the
CNS.
The most important bundles of projection fibers are: internal capsule and fornix.
Internal capsule
• The internal capsule is a compact bundle of projection fibres between the
thalamus and caudate nucleus medially and the lentiform nucleus laterally.
• These fibres fan out rostrally to form the corona radiata and condense caudally
to continue as the crus cerebri of the midbrain. The ascending
(corticopetal/sensory) and descending (corticofugal/motor) fibres of internal
capsule chiefly interconnect the cerebral cortex with the brainstem and spinal
cord.
• These fibres are mainly responsible for the sensory and motor innervation of the
opposite half of the body.
Because of high concentration of motor and sensory nerve fibres within the
internal capsule, even a small lesion may produce a widespread paralytic effects
and sensory loss in the opposite half of the body.
Parts of the internal capsule
• The internal capsule is divided into following five parts
• Anterior limb, lies between the head of caudate nucleus medially and the
anterior part of the lentiform nucleus laterally.
• Posterior limb, lies between the thalamus medially and the posterior part of the
lentiform nucleus laterally.
• Genu, is the bend between the anterior and posterior limbs with concavity of the
bend facing laterally.
• Retrolentiform part, lies behind the lentiform nucleus.
• Sublentiform part, lies below the lentiform nucleus.
Arterial supply of the internal capsule
• The arterial supply of the internal capsule is of great clinical significance, due to
high incidence of vascular lesions of internal capsule (called capsular lesions).
• Various arteries supplying the internal capsule are:
• Medial and lateral striate branches of the middle cerebral artery. One of the
lateral striate branches is larger and more frequently ruptured. It is often
termed Charcot's artery of cerebral hemorrhage. It enters through the anterior
perforated substance and supplies the posterior limb of the internal capsule.
• Striate branches of anterior cerebral artery. One of these branches is larger
and takes a recurrent course.
It is termed as recurrent artery of Huebner. It arises just proximal to the anterior
communicating artery, runs superior to the optic chiasma and penetrates the
anterior perforated substance to supply the genu and anterior limb of the internal
capsule.
• Central branches of the anterior choroidal artery supply the sublentiform part.
• Some direct branches from the internal carotid artery supply the genu.
• Central branches of the posterior communicating artery.
• Posterolateral central branches of the posterior cerebral artery supply the
retrolentiform and sublentiform parts of the internal capsule.
Clinical Correlation
• Damage to the internal capsule, due to hemorrhage or infarction leads to loss of
sensations and spastic paralysis of the opposite half of the body (contralateral
hemiplegia).
The hemorrhage commonly occurs due to rupture of artery of cerebral
hemorrhage, which supplies the posterior limb of the internal capsule. The
spastic paralysis of the opposite half of the body occurs due to the involvement of
the pyramidal and extrapyramidal fibers for the upper limb, trunk and lower limb.
Rupture of Charcot's artery of cerebral haemorrhage is the most common cause of
the hemiplegia.
• Involvement of recurrent artery of Huebner (due to thrombosis/rupture)
results in paralysis of the face and upper limb on the opposite side (because of the
involvement of corticonuclear fibres in genu and adjacent pyramidal fibres in the
posterior limb for the upper limb).
• Lesions of the posterior one-third of the posterior limb, and sublentiform and
retrolentiform parts of the internal capsule lead to visual (hemianopia) and
auditory (loss of hearing) defects. These lesions usually occur due to thrombosis
of the anterior choroidal artery, a branch of internal carotid artery.
• Commissural tracts cross from one cerebral hemisphere to the other through
bridges called commissures. The great majority of commissural tracts pass
through the large corpus callosum. A few tracts pass through the much smaller
anterior and posterior commissures. Commissural tracts enable the left and right
sides of the cerebrum to communicate with each other.
• The association fibers interconnect the different regions of the cerebral cortex
in the same hemisphere (intrahemi-spheric fibres). Long association fibers
connect different lobes of a hemisphere to each other, whereas short association
fibers connect different gyri within a single lobe. Among their roles, association
tracts link perceptual and memory centers of the brain.
There are two types of Association fibers:-
Short association fibers (arcuate or ‘U’ fibers) which interconnect the adjacent
gyri by hooking around the sulcus, hence they are also called arcuate fibers.
Long association fibers travel for long distances and interconnect the widely
separated gyri, viz. gyri of different lobes. The long association fibers are grouped
into bundles.
Long association fibres are as follows:
• Uncinate fasciculus which connects the motor speech area and orbital cortex of
frontal lobe with the cortex of temporal pole by hooking around the stem of
lateral sulcus. It is narrow in the middle and fanned out at both ends.
• Cingulum (also called limbic association bundle): It is thick bundle of fibres
occupying the cingulate and parahippocampal gyri. It extends from the parater-
minal gyrus to the uncus forming almost a circle like a girdle (cingulum =
girdle) hence its name.
• Superior longitudinal bundle: It is the longest association bundle which
connects the frontal lobe to the occipital and temporal lobes.
Inferior longitudinal bundle: It connects the visual association area of occipital
lobe to the temporal lobe.
Fronto-occipital bundle: It commences in the frontal pole, runs backwards to
radiate into the occipital and temporal lobes. The fronto-occipital bundle pursues
a similar course to that of superior longitudinal fasciculus. However, it lies deep
to the superior longitudinal bundle and is separated from it by the fibres of
the corona radiata.
 Corpus callosum
The corpus callosum (plural: corpora callosa) is the largest of the commissural
fibers, linking the cerebral cortex of the left and right cerebral hemispheres. It is
the largest white matter tract in the brain.
Gross anatomy
• The corpus callosum is approximately 10 cm in length and is C-shaped (like
most supratentorial structures) in a gentle upwardly convex arch. It is thicker
posteriorly.
It is divided into four parts (from anterior to posterior):
• Rostrum
• Genu
• Trunk/body
• Splenium
Fiber tracts
• Although the corpus callosum can be seen as a single large fiber bundle
connecting the two hemispheres, a number of individual fiber tracts can be
identified. These include:
• Genu: forceps minor connects medial and lateral surfaces of the frontal lobes
• Rostrum: connecting the orbital surfaces of the frontal lobes
• Trunk (body): pass through the corona radiata to the surfaces of the
hemispheres
• trunk and splenium: tapetum; extends along the lateral surface of the occipital
and temporal horns of the lateral ventricle
• Splenium: forceps major; connect the occipital lobes
Arterial supply
• The corpus callosum (CC) has a rich blood supply, relatively constant and is
uncommonly involved by infarcts. The majority of the CC is supplied by the
pericallosal arteries (the small branches and accompanying veins forming the
pericallosal moustache) and the posterior pericallosal arteries, branches from the
anterior and posterior cerebral respectively. In 80% of patients, additional
supply comes from the anterior communicating artery, via either the subcallosal
artery or median callosal artery.
• Subcallosal artery (50% of patients) is essentially a large version of a
hypothalamic branch, which in addition to supplying part of the hypothalamus
also supplies the medial portions of the rostrum and genu
• Median callosal artery (30% of patients) can be thought of as a more extended
version of the subcallosal artery, in that it travels along the same course, supplies
the same structures but additionally reaches the body of the corpus callosum
• Posterior pericallosal artery (also known as the splenial artery) supplies a
variable portion of the splenium.

Function:- The main function of the corpus callosum is the communication

between the two hemispheres; the different parts of the corpus callosum connect
similar areas of each hemisphere.
Blood Supply of Brain
The central nervous system requires constant oxygenation and nourishment. The
brain has a particularly high oxygen demand at rest it represents one fifth of the
body’s total oxygen consumption. It is also very sensitive to oxygen deprivation,
with ischemic cell death resulting within minutes.
• There are two paired arteries which are responsible for the blood supply to the
brain; the vertebral arteries, and the internal carotid arteries. These arteries arise
in the neck, and ascend to the cranium.
• Within the cranial vault, the terminal branches of these arteries form an
anastomotic circle, called the Circle of Willis. From this circle, branches arise
which supply the majority of the cerebrum.
• Other parts of the CNS, such as the pons and spinal cord, are supplied by smaller
branches from the vertebral arteries.
 ICA
• The internal carotid arteries (ICA) originate at the bifurcation of the left and right
common carotid arteries, at the level of the fourth cervical vertebrae (C4).
• They move superiorly within the carotid sheath, and enter the brain via the carotid
canal of the temporal bone. They do not supply any branches to the face or neck.
• Once in the cranial cavity, the ICA pass anteriorly through the cavernous sinus.
Distal to the cavernous sinus, each ICA gives rise to:
• Ophthalmic artery – supplies the structures of the orbit.
• Posterior communicating artery – acts as an anastomotic ‘connecting vessel’ in the
Circle of Willis (see ‘Circle of Willis’ below).
• Anterior choroidal artery – supplies structures in the brain important for motor
control and vision.
• Anterior cerebral artery – supplies part of the cerebrum.
• The ICA then continue as the middle cerebral artery, which supplies the lateral
portions of the cerebrum.
 Vertebral Artery
• Right and left vertebral arteries arise from the subclavian arteries, medial to the
anterior scalene muscle. They then ascend the posterior aspect of the neck,
through holes in the transverse processes of the cervical vertebrae, known
as foramen transversarium.
• The vertebral arteries enter the cranial cavity via the foramen magnum. Within
the cranial vault, some branches are given off:
• Meningeal branch – supplies the falx cerebelli, a sheet of dura mater.
• Anterior and posterior spinal arteries – supplies the spinal cord, spanning its
entire length.
• Posterior inferior cerebellar artery – supplies the cerebellum.
• After this, the two vertebral arteries converge to form the basilar artery. Several
branches from the basilar artery originate here, and go onto supply the
cerebellum and pons. The basilar artery terminates by bifurcating into the
posterior cerebral arteries.
 Arterial Circle of Willis
• The terminal branches of the vertebral and internal carotid arteries all
anastomose to form a circular blood vessel, called the Circle of Willis.
• There are three main (paired) constituents of the Circle of Willis:
• Anterior cerebral arteries – terminal branches of the internal carotid arteries.
• Internal carotid arteries – located immediately proximal to the origin of the
middle cerebral arteries.
• Posterior cerebral arteries – terminal branches of the basilar artery
• To complete the circle, two ‘connecting vessels’ are also present:
• Anterior communicating artery – connects the two anterior cerebral arteries.
• Posterior communicating artery – branch of the internal carotid, this artery
connects the ICA to the posterior cerebral artery.