A. Head CT Module

Noncontrast Head CT:
A Systematic Approach
Introduction Search Pattern Blood/Mass Hydrocephalus Stroke Aneurysm Trauma/Sinus Orbits/Neck Cases HELP
Pretest
If you would like to take the pre-test and have not done so, please do so now.
When you have completed it, click the forward arrow to continue.
Welcome to neuroradiology!
Neuroradiology is not only one of the largest subspecialties of radiology, it will form a
large percentage of the studies you read on call.
Among the most bread and butter neuroradiology studies is the head CT, the focus of
this module. You should strive to become a master of the head CT, a process that will
require years of experience and study*. Today we’ll jump start that process.
*Recommended reading:
Beginner: Emergency CT Scans of the Head: A Practical Atlas. By Cwinn and Grahovac.
Advanced: The Requisites Neuroradiology. By Yousem and Grossman.
Relax and Learn

If you are anything like the creators of this program, at this point you are probably
thinking the following:
Oh crap! Why didn’t I pay more attention during neuroanatomy in med school…
This is going to be bad...Why can’t I go back to bone…I was sick of post op follow-ups,
but at least I know what bones are supposed to look like. {silent prayer}.
Relax. Take a few deep breaths. It’s going to be fine. By taking a systematic approach,
both to interpreting individual studies and learning about noncontrast head CT as a
whole, you’ll be crushing cases in no time. Let’s find out how…
Learning Objectives
• Primary:
• Utilize a systematic search pattern when interpreting noncontrast head CT
• “By being systematic you will miss fewer important findings – not that experienced hands
don’t miss findings; they just miss fewer findings. Learn [an] ordered approach and then
stick with it case after case. You will look like a pro.”
- Goodman, Felson’s Principles of Chest Roentgenology
• A reliable search pattern is especially critical on call where fatigue, interruptions and other
distractions will make the gestalt method (i.e. just looking around) even less effective.
Learning Objectives
• Secondary:
• Identify normal anatomy on a non-contrast head CT
• Learning the numerous normal variants will come in time
• Recognize common, emergent pathology on a non-contrast head CT

Program Navigation
• The ‘HELP’ button is located in the top right corner of the screen.
• Click it at any time to return to this screen.
• At present the text is yellow, indicating you are in the help section.
• The forward and back buttons are in the bottom right corner of the screen.
Program Navigation
• The tabs along the top of the screen denote the major sections of the course.
• Clicking a tab will take you to the beginning of that section.
• When you are in a section, the name turns yellow.
Program Navigation
• The course uses both single images and
image series which you can scroll through.
• Generally scrolling will be available when

we are discussing the search pattern. As you
read the search pattern follow along by
scrolling through the images!
• When scrolling is available the

buttons will appear.
• Try scrolling each direction.

Program Navigation



Program Navigation



Program Navigation



Program Navigation



Program Navigation



Program Navigation



Program Navigation
• If text appears highlighted click on it to

highlight the image
• Try it out: lateral ventricles
• Click the name again to remove the

highlight.
• If a question appears highlighted, click to

reveal the answer (but not before you think
of the answer!)
• Got it?
• Nice work.
Program Navigation
• Lastly, this is a programmed learning module, meaning instead of just sitting
back and learning passively you will be asked to:
• Answer fill in the blank questions
• Identify structures
• Match descriptions to findings, etc.
• Active involvement will help you retain more and have more fun (hopefully).
• When presented with a question, DO NOT immediately reveal the answer. Take
your time, consider how you would answer and THEN reveal the answer.
• Okay, enough with that, let’s get started.

Effectively Interpreting a CT
CT exams contain thousands of pieces of information, how to make sense of it all?
1) Know normal anatomy
• You can’t recognize abnormal if you don’t know normal
2) Find all of the abnormalities

• How can you put the puzzle together if you don’t have all the pieces?
3) Place the abnormalities in the correct anatomic location to develop a DDX
4) Narrow the DDX using other available information:

• Imaging characteristics
• Prior studies
• Labs
• History
• Age
• Etc
Review
To review, the four strategies to mastering CT are:
1) Click
Knowfor answer
normal .
anatomy.
2) Click
Find for
ALLanswer .
the findings (abnormalities).
Locate
3) Click forthe abnormality
answer . to guide your DDX.
4) Click for answer

Use history, . age, imaging characteristics, etc to narrow the DDX.
patient
A Word About Technique

• Before we get started it is useful to understand a few basics regarding the images you will look at
• First, this module focuses on NONCONTRAST head CT, why?

• Most head CTs are noncontrast, especially out of the ED
• Most head CTs you read during your first neuro rotation will be noncontrast
• Common indications include
• Trauma
• Intracranial hemorrhage (ICH)
• Stroke
• Seizure
• Headache
• Altered mental status
• Etc
• Additionally, the search pattern you learn for noncontrast head CT can easily be adapted to contrast head CT
Window Width and Window Level

• Say you’re going stargazing. You can’t see the stars on a
sunny afternoon, right? It’s not because they’re not there…
it’s because there’s too much light in the sky, so the stars
don’t stand out. You see stars better at night for two reasons:
• First, there is less light in the sky, so the weaker light
of the stars is perceptible.
• Second, your vision adjusts, heightening your ability to
detect subtle changes in brightness.
• Similarly, depending on what you are looking for on a CT

different settings help you see better.
• Window width (WW, →) is similar to contrast, or the ability

to detect subtle changes in light
• Window Level (WL, →) is similar to brightness, or the

WW: 80 amount of light in the sky
WL: 35
12/31
• Most software packages allow WW and WL to be adjusted
by holding down the right mouse button and moving the
mouse up/down or right/left.
Windows
WW: WW: WW:

80 350 4000
WL: WL: WL:
35 50 1000
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• In addition to adjusting WW/WL using the right mouse button, there are also present WW/WL combinations
optimized for viewing certain structures. These combinations are simply called windows.
• Compare the images above, in brain, soft tissue and bone windows from left to right. Notice how the WW/WL
changes from image to image.
• For now, don’t worry too much about the actual numbers. Focus on the concept: adjusting WW/WL
allows for optimal visualization of different structures.
Now, let’s move on to algorithms.

Algorithms
WW: WW:
80 4000
WL: WL:
35 1000
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• When you open a head CT you will see two sets of cross sectional images (approximately like those above).
•These represent the same data processed by two different algorithms. An algorithm is a method for processing the
data acquired by a CT scanner. Different algorithms are optimized for viewing different tissues.
• Brain algorithm (left) – appear smoother and use thicker sections (5 mm), default is brain windows.
• Used for examining the brain and soft tissues (orbits, neck, scalp, etc)
• Bone algorithm (right) - emphasize fine details and use thinner sections (2.5 mm), default is bone windows.
• Used for examining the bones and sinuses
Brain Algorithm Bone Algorithm
WW: WW:
80 80
WL: WL:
35 35
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• But wait, if the bone algorithm images are better for looking at fine details, why not use them all the time?
• Well, look what happens if you take the bone algorithm images and change to brain windows (say that 10 times
fast). Notice how the bone algorithm image makes the brain look incredibly grainy! That’s an artifact caused by the
bone algorithm which is optimized for very dense structures like bones and over processes data from less dense
structures like soft tissues.
Brain Algorithm Bone Algorithm
WW:
WW: 4000
4000 WL:
WL: 1000
1000 12/31
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• Conversely, if you use brain algorithm to look at the bones you will not see fine details because the brain algorithm
under processes data from very dense structures (i.e. makes it look too smooth).
• This is illustrated by the lambdoid sutures (circle), which look comparatively blurry on the brain algorithm.
• Okay, now that you understand a little about where the images come from let’s move on to the search pattern.
Review
• The image at left is in ___________
click
brain windows
click algorithm.
using ______________
brain
edges
click/ fine details
• Bone algorithm emphasizes _________________
grainy
but makes the brain look very _____________.
click
increases
increase / decreases? the difference
• A narrow window width ___________________
between structures of different densities.
• Well done!
• Let’s move on to the search pattern.

WW:
80
WL:
35
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The Search Pattern

• Throughout the search pattern you will notice there is a lot of comparing one side of the brain/head to the other.
• Fortunately the brain/head is symmetric
• Many abnormalities effect only one side leaving us a nice internal control
• Remember, when in doubt compare to the other side!*
*If you’re still in doubt compare to a prior study. As Dr. Gross says “old films are better than brains”.
The Search Pattern

To ensure you are fully mentally engaged, ask yourself questions as you interpret an exam. The search pattern is
formatted as a series of questions to facilitate this process:
1. Is there any intracranial blood or mass effect?

2. Is there hydrocephalus?
3. Is there a stroke?
4. Is there an aneurysm?
5. Is there evidence of trauma or sinus disease?
6. Are the visualized orbits and upper neck normal?
Just 6 questions, but since we’ve clumped things together (you’ll see why in a bit) there are actually 9 things to
remember, still that’s not too bad, right? Still having trouble? Fine here’s a mnemonic:
Boston Blood
Men Mass effect
Have Hydrocephalus
Strong Stroke
Accents Aneurysm
That Trauma
Sound Sinuses
Overly Orbits
Nasal Neck
The Search Pattern

Let’s review: when interpreting a head CT you should ask yourself the following questions:
(click for the mnemonic if you need it)
1.
ClickIshere
there
forany intracranial blood, mass, or mass effect?
answer
2.
ClickIshere
there
forhydrocephalus?
answer
3.
ClickIshere
there
foraanswer
stroke?
4.
ClickIshere
there
foran aneurysm?
answer
5.
ClickIshere
there
forevidence
answer of trauma or sinus disease?
6.
ClickAre
herethe
forvisualized
answer orbits and upper neck normal?
Boston Men Have Strong Accents That Sound Overly Nasal.
Blood Mass effect Hydro Stroke Aneurysm Trauma Sinus Orbits Neck.
Great work!
The remainder of the module goes through the search pattern in depth. At times the amount of detail may seem
overwhelming. Do not be discouraged. The goal is NOT for you to memorize an exact order to look at every
bone, gyrus, etc. The goal is to remember the questions above and HOW to look for each. As you gain experience
you will develop an exact order that works for you.
Is there any blood or mass effect?

• Why clump blood and mass effect together?
1. When looking for blood it is also easy to look for mass effect because you’re
looking in the same places.
2. Blood frequently causes mass effect and masses may bleed.
Blood
• Why look for acute blood?

• Acute intracranial blood is bad and its presence or absence impacts patient care:
• Acute stroke + blood = no thrombolytics
• Large bleed + mass effect = surgical evacuation
• So seeing blood means you can help save lives, and that’s what we’re here for, right?
• But what does acute blood look like?

• Compare the normal (left) and abnormal (right) images above and you can probably
BRIGHT
guess that acute blood looks click for answer
Review
• Because this is so important, make sure you can answer this question before we go on:
What does acute blood look like on a head CT?
BRIGHT (hyperdense to brain)
• So what does subacute or chronic blood

look like you ask?
• Over a 2 week period the density of blood

steadily decreases becoming isodense (→)
and eventually hypodense (→). Many
patient’s have blood of varying ages, like the
example on the right.
• Why does the density change?

• Hemoglobin (Hb) content determines blood density
• Acute extravascular blood = high Hb = high density
• Hb is degraded over time causing the density to slowly decrease
Types of Intracranial Hemorrhage

• Extra-axial = outside brain parenchyma
• Click below for examples:
• Epidural Hematoma
• Subdural Hematoma
• Isodense subdural hematoma
• Subarachnoid Hemorrhage
• Intra-axial = inside brain parenchyma

• Hemorrhagic stroke
• Hemorrhagic contusion
• Intraventricular = inside ventricles

• Technically extra-axial, but referred to separately
• Click below for example
• Intraventricular hemorrhage
• If this seems like a lot to learn, don’t worry, reading and

daily practice will make it easy. For now the take home
message: acute blood is BRIGHT.
Epidural Hematoma
• Epidural hematoma (EDH) = blood between the skull and the dura.
• Biconvex or lens shaped (‘lentiform’)
• Causes mass effect including sulcal effacement and/or shift of midline structures which we’ll discuss shortly.
• Are usually temporal or along the ‘convexities’ (i.e. the upper curved or ‘convex’ parts of the parietal/frontal lobes).
• May be arterial or venous bleeds.
• Frequently post traumatic and classically associated with skull fractures (not always present in reality)
• Do NOT cross suture lines (because the dura attaches at the sutures), CAN cross midline
Subdural Hematoma
• Subdural hematoma (SDH) = blood between the dura and the arachnoid.
• Typically have a concave or ‘crescentic’ shape
• Can cause underlying mass effect
• Often along the frontal or frontoparietal convexity.
• Subtle SDH can be seen along the falx or the tentorium, so pay attention to these areas
• Usually result of venous bleeding.
• Frequently post traumatic, but NOT associated with fractures.
• CAN cross suture lines, but NOT midline (dural reflections along falx prevent)
Isodense Subdural Hematoma

Effaced sulci Open sulci
Gyral surface
Skull
• Isodense subdural hematoma = a particularly tricky version of the subdural hematoma

• Blood is isodense to brain, making detection more difficult
• Usually acute blood is hyperdense and subacute blood isodense, but an isodense SDH may actually be acute
• Why?
• Anemia and/or anticoagulants may reduce the density of acute blood making it appear isodense
• Clues to an isodense subdural hematoma:
• Asymmetric sulci
• Failure of sulci/gyri to reach the inner aspect of the skull
Subarachnoid Hemorrhage
• Subarachnoid hemorrhage (SAH) = blood in the subarachnoid space

• Follows the surface of the brain.
• Linear areas of bright blood in the sulci.
• Fill cisterns
• Can layer along the convexity (like EDH or SDH)
• Linear areas in sulci indicate it is SAH (at least partly)
• Frequently post traumatic or due to aneurysm rupture.
• If history is unknown the clinicians may want an angiogram to evaluate for aneurysm.
Hemorrhagic Stroke
• Hemorrhagic stroke = generic term for parenchymal hematoma not due to trauma
• Frequently result from rupture of small perforating vessels in the basal ganglia or thalami, most commonly due to
hypertension or amyloid angiopathy.
• Frequently cause mass effect
Hemorrhagic Contusion
• Hemorrhagic contusion = Parenchymal hematoma due to brain smacking against the skull during trauma
• Most common where brain meets skull
• Inferior / anterior frontal lobes (like the above example)
• Inferior / anterior temporal lobes
• Often small with little mass effect, but can be quite large
Intraventricular Hemorrhage
• Intraventricular hemorrhage (IVH) = blood in ventricles

• Blood is denser (heavier) than CSF  blood layers in the dependent portions of the vents
• Patient’s usually imaged lying on their back  occipital horns, posterior 3rd and posterior 4th are dependent
• Look in these locations for intraventricular blood
• IVH rarely the primary site of bleeding, usually spread of SAH or extension of parenchymal bleed
Blood
• Again
• Acute blood is? • As we discussed earlier, brain algorithm images arrive in
• BRIGHT ‘brain windows’.
• Subacute blood is? • Often times blood is easy to see with these settings.
• Isodense • In some locations it can be difficult, for example when bright
• Chronic blood (>2 wks) is? blood is next to the bright skull.
• Hypodense • Solution?
• ‘blood’ windows, as shown below
• And you thought this would be hard!
Blood
windows
Subdural hematoma
seen only on blood
windows
Blood Windows
• Everyone has different preferences • Okay, now you know what blood looks like and have a
•Main point is to WIDEN windows (>175) tool to help you look for it, what about mass effect?
• More pixels are shades of gray
• Fewer pixels are pure black/white
• Most helpful for blood near the skull
Blood
windows
WW: 80 WW:
WL: 35 300
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Mass Effect
• Blood, masses, foreign bodies, edema, etc take up space and
may push the brain out of the way. We call this “mass effect.”
• Mass effect is bad!
• Skull and spinal canal are closed spaces = little extra room
• Mass effect + little extra room = herniation +/or compression

• Herniation: movement of brain to the wrong place
• Compression: come on, you passed kindergarten, right?
• Result = compromise of vessels (infarcts) or nerves (palsies)
• BAD, BAD, BAD (and not in the MJ “bad = good” way)
• For example, in the above image the right parenchymal hematoma causes mass effect on the right ventricle
which is significantly compressed (aka effaced) compared to the contralateral side.
Types of Mass Effect

• Click below for examples of each on CT:
• Subfalcine herniation
• Uncal herniation
• Transtentorial herniation
• Tonsillar herniation
• External herniation 7
• Sulcal effacement
• Ventricular distortion 2
• Effaced basal cisterns
• This image nicely summarizes many types of mass

effect including:
1. Descending transtentorial herniation
2. Sulcal effacement
3. Subfalcine herniation
4. External herniation www.thefullwiki.org
5. Ascending transtentorial herniation
6. Tonsilar herniation
7. Ventricular distortion
Subfalcine Herniation
Normal Subfalcine Herniation
midline
• Subfalcine herniation = herniation “under the falx”, aka ‘shift of midline structures’
• Most common type of herniation
• Features:
• Septum pellucidum (interventricular septum) off midline
• 3rd vent off midline (not shown)
• Thalami or other paramedian structures pushed towards/over midline
Uncal Herniation
Normal Uncal Herniation
midline
• Uncus = part of the anteromedial temporal lobes

• Uncal herniation = your dad’s brother has a stick up his…just kidding
• Uncal herniation = movement of the uncus towards (or across) the midline
• Frequently displaces the brainstem contralaterally, widening the ipsilateral ambient cistern
• Can compress the 3rd cranial nerve causing an ipsilateral “blown pupil” or 3rd nerve palsy
• In severe cases large vessels like the MCA can also be compressed
Transtentorial Herniation
www.thefullwiki.org
• Remember the tentorium, the connective tissue separating cerebellum from the occipital lobe?
• Transtentorial herniation = brain herniating upwards or downwards past its anterior free margin
• If its due to the cerebellum moving up = ascending transtentorial herniation (#5 above)
• If its due to the supratentorial structures moving down = descending transtentorial herniation (#1)
• Both are very bad  brainstem and occipital lobe infarcts may follow
• Can be difficult to appreciate on CT, for now just remember the concept
Tonsillar Herniation
Normal Tonsillar Herniation
• Remember the cerebellar tonsils?

• Tonsillar herniation = downward displacement around the spinal cord in the foramen magnum
• Look for soft tissue filling the spinal canal
• May be congenital (Chari malformation) or due to mass effect in the posterior fossa
External Herniation
Normal location of calvarium (surgically removed)
Externally herniated
brain
• External herniation (aka extracranial herniation) = brain outside normal location of skull
• May or may not remain within the meninges (still within the dura in above example)
Sulcal Effacement
Effaced sulci
Normal open sulci
• Effacement = obliteration
• Sulcal effacement = compression of sulci so they are obliterated or no longer open
• Can be caused by mass effect from:
• An intra-axial source pressing outward against skull (tumor, infarct, etc)
• An extra-axial source pressing inward (tumor, blood, etc)
Ventricular Distortion
Effaced right lateral ventricle
• When a ventricle gets compressed or ‘effaced’

• If severe, may obstruct CSF flow, leading to non-communicating hydrocephalus (more on that later)
• Frequently associated with shift of midline structures
• Which was also called what? (Subfalcine herniation)
Effaced Basal Cisterns

Normal Effaced Basal Cisterns
Cisterns No cisterns
visible visible
• ‘Basal cisterns’ commonly used to refer to the suprasellar and other skull base cisterns
• Should be open (‘patent’) and symmetric
• Can be compressed due to mass effect from the frontal lobes, temporal lobes, basal ganglia, sella (pituitary), etc
• Bad because most of the large arteries are in this region
• Arterial compression = ______?______ (ischemia/infarction)
Finding Blood and Mass Effect

• Now that you know what you’re looking for, let’s start looking
• Start in ‘brain windows’. Which algorithm should you use?
• Brain algorithm
• Scroll through the series at left to follow along as we discuss

the search pattern. And remember, if you don’t know where a
structure is, click on it to highlight the image.
• First, examine the spinal canal around the spinal cord in the
foramen magnum:
• Any BLOOD?
• Check that the cord sits in the middle of the canal. Any
soft tissue mass around the cord?
• Are the cerebellar tonsils in their normal position above
the foramen magnum?
• Scroll upward following the CSF space into the 4th ventricle.
• Any BLOOD?
• Is it asymmetric or off midline?
WW: 80
WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
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WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
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WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
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WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
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WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
WW: 80
WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
WW: 80
WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
WW: 80
WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
WW: 80
WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
WW: 80
WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
WW: 80
WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
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WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
WW: 80
WL: 35
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• Brain algorithm

foramen magnum:
• Any BLOOD?
the foramen magnum?
• Any BLOOD?
WW: 80
WL: 35
10/31

•Continue upward to the quadrigeminal plate cistern.
• It should look like a symmetric smile.
• Is the smile bright? (BLOOD!)
• Is it crooked or too thin?
• What was it called when the cerebellum pushes

upward through the tentorium?
• Ascending transtentorial herniation!
WW: 80
WL: 35
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WW: 80
WL: 35
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• Now move anteriorly to the suprasellar cistern, which looks
like a five or six pointed star, depending on the level.
• The anterior set of “arms” are the Sylvian cisterns.

• Any BLOOD?
• Are they symmetric and open?
• The posterior “arms” are the ambient cisterns.

• Any BLOOD?
• The anterior point of the star is the interhemispheric fissure

which contains the (falx cerebri).
• Any BLOOD?
• Is it midline and open?
• The final small point of the star is only seen in the upper
part of the cistern and is the interpeduncular fossa (between
the cerebral peduncles). This fossa extends posteriorly in the
midline.
WW: 80
WL: 35
• Any BLOOD?
11/31 • Is it midline and open?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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WL: 35
• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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WL: 35
• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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WL: 35
• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
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WL: 35
• Any BLOOD?


• Any BLOOD?

• Any BLOOD?

• Any BLOOD?
midline.
WW: 80
WL: 35
• Any BLOOD?

• So we’re done with the suprasellar cistern, right? Not
quite.
• The lateral borders of the suprasellar cistern are

formed by the uncal portions of the temporal lobes.
• When these herniate toward the midline, we call

that?
• This can cause compression of the ________ leading

to ____________ .
• Third cranial nerve leading to a ‘blown pupil’
WW: 80
WL: 35
7/31

• Let’s review. What are the two important cisterns to look at?
• Suprasellar (the star)
A • Quadrigeminal plate (the smile)
• Name the parts of the suprasellar cistern labeled in the top

B figure. (Click the label in the figure to reveal the name below)
• A: Interhemispheric fissure
• B: Sylvian cistern
C • C: Ambient cistern (aka paramesencephalic cistern)
• Match the types of mass effect below with their label in the
bottom figure (click the labels to reveal the names below)
1. Descending transtentorial herniation
3. Subfalcine herniation
4. External herniation
5. Ascending transtentorial herniation
6. Tonsillar herniation
• EXCELLENT!
• Let’s continue.
www.thefullwiki.org

• Let’s continue our search.
• Following the interhemispheric fissure from it’s base

upward between the frontal lobes to the vertex. Note the
midline position of the falx.
• Any BLOOD?
• Are the frontal lobes symmetrically positioned with
the interhemispheric fissure in the midline?
• Shift of a frontal lobe across midline is called?
• Once you’ve checked the anterior midline, scroll back

downwards examining the posterior interhemispheric fissure
to its base at the tentorium. Carefully compare the two sides
of the tentorium.
• Any BLOOD?
• Are the parietal and occipital lobes symmetrically
positioned with the interhemispheric fissure midline?
WW: 80
WL: 35
5/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
6/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
7/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
8/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
9/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
10/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
11/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
12/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
13/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
14/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
14/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
15/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
16/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
17/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
18/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
19/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
20/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
21/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
22/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
23/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
24/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
25/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
26/31


• Any BLOOD?

of the tentorium.
• Any BLOOD?
WW: 80
WL: 35
27/31

• OK, we’re looking in the back of the head, that’s a great
place to start looking at the ventricles for blood.
• Start with the occipital horns of the lateral ventricles.

• Why does blood collect here?
• They are dependent
• Scroll downward to the temporal horns.
• Finish off the lateral ventricles by scrolling upward through

the body and frontal horns.
• Any BLOOD?
• Any effacement?
• It’s worth noting that the choroid plexus can calcify, so

not all bright material in the lateral (and even third)
ventricles is blood. After you’ve seen a few studies it’s
usually pretty easy to tell the difference.
WW: 80
WL: 35
7/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
7/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
8/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
9/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
10/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
11/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
11/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
12/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
13/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
14/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
14/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
15/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
15/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
16/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
16/31



• Any BLOOD?
• Any effacement?

WW: 80
WL: 35
17/31

• Move posteriorly to check the third ventricle.
• Any BLOOD?
• Is it midline?
• If not there may be subfalcine herniation
• Continue posteriorly to the fourth ventricle

• But we already looked at this!
• It never hurts to look twice
• Continue to follow the CSF outward to the extra-axial spaces

between the skull and brain parenchyma.
• Compare the extra-axial spaces around each

cerebellar hemisphere.
• Any BLOOD?
• Are the cerebellar folia (leaves or folds) symmetric?
• Any effacement?
WW: 80
WL: 35
4/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
5/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
6/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
6/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
7/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
7/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
8/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
9/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
10/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
11/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
11/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
12/31

• Any BLOOD?
• Is it midline?



• Any BLOOD?
• Any effacement?
WW: 80
WL: 35
13/31

• Move upward to the vertex, comparing the occipital and
parietal extra-axial spaces for symmetry.
• Scroll downward from the vertex comparing the frontal

extra-axial spaces.
• Any BLOOD?
• Are the cerebral sulci effaced?
• The upper, curved parts of the frontal lobes and parietal

‘convexities’
click
lobes are often called the _____________. Extra-axial blood is
commonly seen along these areas.
• Do you remember what kinds?
• Epidural hematoma (EDH)

• Subdural hematoma (SDH)
• Subarachnoid hemorrhage (SAH)
•Lastly compare the temporal extra-axial spaces, including the

sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?
6/31 • Are the sulci effaced?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?


extra-axial spaces.
• Any BLOOD?

‘convexities’
click


sylvian fissures.
WW: 80
WL: 35
• Any BLOOD?

• You’ve successfully searched for extra-axial blood and mass
effect.
• Now lets look for intra-axial blood or mass effect.
• Again, start at the bottom of the brain and compare the

cerebellar hemispheres looking for blood or asymmetry.
• Follow the brainstem upwards to the occipital lobes.
• Continue upward through the parietal lobes to the vertex.
• Move forward and compare the frontal lobes to their base.
• Compare the deep gray nuclei including the basal ganglia

and thalami.
• Finish by comparing the temporal lobes.
WW: 80
WL: 35
3/31

effect.


and thalami.
WW: 80
WL: 35
4/31

effect.


and thalami.
WW: 80
WL: 35
5/31

effect.


and thalami.
WW: 80
WL: 35
6/31

effect.


and thalami.
WW: 80
WL: 35
7/31

effect.


and thalami.
WW: 80
WL: 35
8/31

effect.


and thalami.
WW: 80
WL: 35
9/31

effect.


and thalami.
WW: 80
WL: 35
10/31

effect.


and thalami.
WW: 80
WL: 35
11/31

effect.
caudate • Again, start at the bottom of the brain and compare the

globus
pallidus • Move forward and compare the frontal lobes to their base.
putamen
and thalami.
WW: 80
WL: 35
11/31

effect.


and thalami.
WW: 80
WL: 35
12/31

effect.


and thalami.
WW: 80
WL: 35
13/31

effect.


and thalami.
WW: 80
WL: 35
14/31

effect.


and thalami.
WW: 80
WL: 35
14/31

effect.


and thalami.
WW: 80
WL: 35
15/31

effect.


and thalami.
WW: 80
WL: 35
16/31

effect.


and thalami.
WW: 80
WL: 35
17/31

effect.


and thalami.
WW: 80
WL: 35
18/31

effect.


and thalami.
WW: 80
WL: 35
19/31

effect.


and thalami.
WW: 80
WL: 35
20/31

effect.


and thalami.
WW: 80
WL: 35
21/31

effect.


and thalami.
WW: 80
WL: 35
22/31

effect.


and thalami.
WW: 80
WL: 35
23/31

effect.


and thalami.
WW: 80
WL: 35
24/31

effect.


and thalami.
WW: 80
WL: 35
25/31

effect.


and thalami.
WW: 80
WL: 35
26/31

effect.


and thalami.
WW: 80
WL: 35
27/31

• That seems like a long list to look through, but you’ll be
amazed how quickly you can do it.
• Let’s switch to blood windows and run through again. It may

seem redundant, but it’s that important!
• Use the series on the left to go through the list below. If you
have trouble remembering which structures are which go
back to those slides and review.
• Extra-axial: Spinal canal  4th ventricle  quadrigeminal

plate cistern  suprasellar cistern  anterior
intrahemispheric fissure to vertex  posterior
interhemispheric fissure to tentorium  occipital horns 
temporal horns  body and anterior horns of lateral vents 
3rd vent  4th vent  extra-axial spaces around the
cerebellum, occipital lobes, parietal lobes, frontal lobes,
temporal lobes and sylvian fissures.
• Intra-axial: cerebellar hemispheres  brainstem  occipital

lobes  parietal lobes  frontal lobes  deep gray nuclei 
temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!




temporal lobes.
• Great work!
Review
• That was a lot! Pat yourself on the back for working your way through.
Click
Subdural hematoma crosses sutures while ___________________
• __________________ Click hematoma does not.
epidural
Click hemorrhage fills cisterns and looks like linear brightness in the sulci
Subarachnoid
• ________________________
• Chronic blood is __________________

Click / darker compared to acute and subacute blood.
less dense
Click
• Herniation is bad because it can _________
compress vessels causing _______
Click
ischemia
Click
• Ventricular distortion is often associated with ____________
subfalcine herniation
Click windows
• After looking for intracranial blood using brain windows it is useful to look again using _________________.
blood
• Great work!
Examples:
Review the following examples by clicking on each:
• Intracranial hemorrhage:
• Extra-axial
• Epidural Hematoma
• Subdural Hematoma
• Isodense Subdural Hematoma
• Subarachnoid Hemorrhage
• Intra-axial
• Hemorrhagic stroke
• Hemorrhagic contusion
• Intraventricular
• Intraventricular hemorrhage
• Mass effect
• Transtentorial herniation
• Tonsillar herniation
• Extra-cranial herniation
• Sulcal effacement
• Ventricular effacement
• Effaced basal cisterns
Epidural Hematoma
• Causes mass effect including sulcal effacement and/or shift of midline structures
• Are usually temporal or along the ‘convexities’.
Subdural Hematoma
Isodense Subdural Hematoma

Effaced sulci Open sulci
Gyral surface
Skull
• Isodense subdural hematoma = a particularly tricky version of the subdural hematoma

• Blood is isodense to brain, making detection more difficult
• Usually acute blood is hyperdense and subacute blood isodense, but an isodense SDH may actually be acute
• Why?
• Anemia and/or anticoagulants may reduce the density of acute blood making it appear isodense
• Clues to an isodense subdural hematoma:
• Asymmetric sulci
• Failure of sulci/gyri to reach the inner aspect of the skull

• Fill cisterns
Hemorrhagic Stroke
• Hemorrhagic stroke = generic term for parenchymal hematoma not due to trauma
• Frequently result from rupture of small perforating vessels in the basal ganglia or thalami, most commonly due to
hypertension or amyloid angiopathy.
• Frequently cause mass effect
Intraventricular Hemorrhage
• Intraventricular hemorrhage (IVH) = blood in ventricles

• Blood is denser (heavier) than CSF  blood layers in the dependent portions of the vents
• Patient’s usually imaged lying on their back  occipital horns, posterior 3rd and posterior 4th are dependent
• Look in these locations for intraventricular blood
• IVH rarely the primary site of bleeding, usually spread of SAH or extension of parenchymal bleed
Subfalcine Herniation
Normal Subfalcine Herniation
midline
• Subfalcine herniation = herniation “under the falx”, aka ‘shift of midline structures’
• Most common type of herniation
• Features:
• Septum pellucidum (interventricular septum) off midline
• 3rd vent off midline (not shown)
• Thalami or other paramedian structures pushed towards/over midline
Uncal Herniation
Normal Uncal Herniation
midline
• Uncus = part of the anteromedial temporal lobes

• Uncal herniation = your dad’s brother has a stick up his…just kidding
• Uncal herniation = movement of the uncus towards (or across) the midline
• Frequently displaces the brainstem contralaterally, widening the ipsilateral ambient cistern
• Can compress the 3rd cranial nerve causing an ipsilateral “blown pupil” or 3rd nerve palsy
• In severe cases large vessels like the MCA can also be compressed
Transtentorial Herniation
www.thefullwiki.org
• Remember the tentorium, the connective tissue separating cerebellum from the occipital lobe?
• Transtentorial herniation = brain herniating upwards or downwards past its anterior free margin
• If its due to the cerebellum moving up = ascending transtentorial herniation (#5 above)
• If its due to the supratentorial structures moving down = descending transtentorial herniation (#1)
• Both are very bad  brainstem and occipital lobe infarcts may follow
• Can be difficult to appreciate on CT, for now just remember the concept
Tonsillar Herniation
Normal Tonsillar Herniation
• Remember the cerebellar tonsils?

• Tonsillar herniation = downward displacement around the spinal cord in the foramen magnum
• Look for soft tissue filling the spinal canal
• May be congenital (Chari malformation) or due to mass effect in the posterior fossa
External Herniation
Normal location of calvarium (surgically removed)
Externally herniated
brain
• External herniation (aka extracranial herniation) = brain outside normal location of skull
• May or may not remain within the meninges (still within the dura in above example)
Sulcal Effacement
Effaced sulci
Normal open sulci
• Effacement = obliteration
• Sulcal effacement = compression of sulci so they are obliterated or no longer open
• Can be caused by mass effect from:
• An intra-axial source pressing outward against skull (tumor, infarct, etc)
• An extra-axial source pressing inward (tumor, blood, etc)
Ventricular Distortion
Effaced right lateral ventricle
• When a ventricle gets compressed or ‘effaced’

• If severe, may obstruct CSF flow, leading to non-communicating hydrocephalus (more on that later)
• Frequently associated with shift of midline structures
• Which was also called what? (Subfalcine herniation)
Effaced Basal Cisterns

Normal Effaced Basal Cisterns
Cisterns No cisterns
visible visible
• ‘Basal cisterns’ commonly used to refer to the suprasellar and other skull base cisterns
• Should be open (‘patent’) and symmetric
• Can be compressed due to mass effect from the frontal lobes, temporal lobes, basal ganglia, sella (pituitary), etc
• Bad because most of the large arteries are in this region
• Arterial compression = ______?______ (ischemia/infarction)
Is there hydrocephalus?
• Phew, that last section was a slog. Fortunately this section is much easier.
• We’ll start with the basics:
• What is hydrocephalus?
• Hydrocephalus is dilation of the ventricular system due to increased CSF pressure.
• Why do we care?
• Two reasons:
1. The resultant increased intracranial pressure predisposes to herniation and its complications as previously
discussed.
2. Hydrocephalus is (almost) always caused by a pathologic process impeding CSF flow or resorption, in other
words, hydrocephalus is a sign of additional pathology.
What does hydrocephalus look like?

• Hydrocephalus is present when the ventricles are
enlarged out of proportion to the overall brain volume.
• When the brain is normal sized the ventricles should be

fairly small (top image).
• When the brain shrinks, as in age related generalized

brain volume loss, the ventricles enlarge to fill the void, so
called ‘ex vacuo dilatation’ (bottom image).
• How can you tell there is volume loss? Simply look at
the sulci, if they are prominent there has been
volume loss.
• Note: you will hear people throw around the phrase “age
appropriate volume loss”. In time you’ll develop a sense of
how big the brain should be at a given age, for now just
keep it simple.
What does hydrocephalus look like?
• Now compare the above brains. On the left we have out diffuse volume loss example. Now look on the right. See
how the ventricles are large but the sulci are relatively small (effaced, actually), that’s hydrocephalus.
Types of Hydrocephalus
• Communicating
• Non-communicating
Communicating Hydrocephalus
Equally dilated
lateral,
3rd and
4th ventricles
• All part of the ventricular system are dilated

• CSF able to flow (communicate) from the ventricular system into the extra-axial space
• Usually due to reduced resorption of CSF:
• Meningeal metastases, venous sinus thrombosis, etc
Non-Communicating Hydrocephalus
• Only a portion of the ventricular system is dilated

• The pattern of dilation indicates where the obstruction is located, like in the above example:
• The lateral and 3rd ventricles are dilated, but the 4th ventricle is not dilated
• Therefore the obstruction must be between the 3rd and 4th ventricles
• What connects the 3rd and 4th ventricles?
• The cerebral aqueduct
• The aqueduct is frequently obstructed by blood clots after SAH, however, the clots are often too small to see
Looking for hydrocephalus

• Start in brain windows.
• Examine the overall brain volume

• Are the sulci prominent?
• Do you think there is any volume loss?
• This will take a little practice, but you’ll get the hang
of it pretty quickly
• Compare the lateral ventricles:

• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
• The temporal horns are the first to dilate and should
be slits in the normal young adult brain
• Each part should be symmetric and proportional to
overall volume
• If there is asymmetry is it due to mass effect
WW: 80 compressing one side, dilation of the other side, or
WL: 35
3/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
4/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
5/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
6/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
7/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
7/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
8/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
9/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
10/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
11/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
11/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
12/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
13/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
14/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
15/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
15/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
16/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
16/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
17/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
18/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
19/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
20/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
21/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
22/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
23/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
24/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
25/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
26/31
both?



• Temporal horns
• Occipital horns
• Body
• Frontal horns
• Helpful hints:
overall volume
WL: 35
27/31
both?

• Continue to the third ventricle, is it enlarged?
• Again, in a normal young adult brain the third vent
should be relatively slit like
• By the way, do you remember what connects the
lateral and third ventricles?
• The foramina of Monro
• Follow the course of the cerebral aqueduct to the

fourth ventricle, is it enlarged?
• Enlarged lateral and 3rd vents + normal 4th vent =
non-communicating
click
_________________ hydrocephalus
WW: 80
WL: 35
3/31


non-communicating
click
WW: 80
WL: 35
4/31


non-communicating
click
WW: 80
WL: 35
5/31


non-communicating
click
WW: 80
WL: 35
6/31


non-communicating
click
WW: 80
WL: 35
7/31


non-communicating
click
WW: 80
WL: 35
7/31


non-communicating
click
WW: 80
WL: 35
8/31


non-communicating
click
WW: 80
WL: 35
9/31


non-communicating
click
WW: 80
WL: 35
10/31


non-communicating
click
WW: 80
WL: 35
10/31


non-communicating
click
WW: 80
WL: 35
11/31


non-communicating
click
WW: 80
WL: 35
11/31


non-communicating
click
WW: 80
WL: 35
12/31
Review
brain volume
click
• To look for hydrocephalus you first assess overall __________________
cerebral
click sulci
• You do this by looking at the prominence of the _________________
temporal
click horns
• The first portion of the ventricular system to dilate in hydrocephalus = __________________
click
• If the lateral, third and fourth ventricles are all dilated we are dealing with ____________________
communicating hydrocephalus
• After a subarachnoid hemorrhage, non-communicating hydrocephalus may occur due to thrombus obstructing the
__________
cerebral
click aqueduct
• Well done!
Examples
Click each to review
• Diffuse brain volume loss
• Communicating hydrocephalus
• Non-communicating hydrocephalus
Diffuse Brain Volume Loss
• Sulci are prominent throughout all portions of the brain

• ‘Ex vacuo dilatation’ of ventricles to fill the void
• Commonly age related
• If sulci are only prominent over portions of the brain, not the entire brain may be related to
pathologies such as Alzhiemer’s, Pick’s, etc
Communicating Hydrocephalus
Equally dilated
lateral,
3rd and
4th ventricles
• All part of the ventricular system are dilated

• CSF able to flow (communicate) from the ventricular system into the extra-axial space
• Usually due to reduced resorption of CSF:
• Meningeal metastases, venous sinus thrombosis, etc
Non-Communicating Hydrocephalus
• Only a portion of the ventricular system is dilated

• The pattern of dilation indicates where the obstruction is located, like in the above example:
• The lateral and 3rd ventricles are dilated, but the 4th ventricle is not dilated
• Therefore the obstruction must be between the 3rd and 4th ventricles
• What connects the 3rd and 4th ventricles?
• The cerebral aqueduct
• The aqueduct is frequently obstructed by blood clots after SAH, however, the clots are often too small to see
Is there a stroke?
• So far we’ve covered the first two questions you should ask yourself when interpreting a head CT:
blood/mass
click effect
• Is there __________________________ ?
hydrocephalus
• Is there ___________________________?
click (hydrocephalus)
• The next question you should ask yourself is:

• Is there a stroke?
• As you know, the clinical signs and symptoms of stroke are nonspecific and include:
•______,
click
AMS,________________,
weakness/paralysis, ________,
numbness,______,
ataxia, __________
visual defects, etc.
• Given this lack of specificity, imaging is the key to the timely diagnosis of stroke. Know how to
recognize stroke and you’ll know how to have a huge positive impact on a patient’s life!
Types of Stroke
• Reaching back to med school, you may remember that stroke can be divided into two broad types:
• _________
ischemic and___________
click and hemorrhagic
• Differentiating the two on imaging is critical as __________

ischemic
click strokes may be treated with thrombolytics while
___________
hemorrhagic
click strokes may be made worse by thrombolytics and may require surgical evacuation.
• The following pages will discuss the appearance of ischemic and hemorrhagic strokes as well as a few related
pathologies.
Ischemic Strokes
• Primary findings of ischemic strokes are:
• Loss of the gray-white differentiation (common)
• Click for example
• The hyperdense vessel sign (rare)
• A secondary finding is mass effect

Ischemic Strokes
Loss of the gray-white
differentiation with more
uniform low attenuation


Normal sharp demarcation

between the brighter gray matter
and the darker white matter
Ischemic Strokes
Sulcal effacement (mass effect)


Normal sulci
Ischemic Strokes

Note:
• The hyperdense vessel sign is NON-SPECIFIC.
• ALWAYS correlate with the patient’s symptoms to improve

interpretation accuracy.
Why does it look this way?

• Blood vessel occlusion by ________________
click or emboli causes most ischemic strokes. In a minority of cases the actual clot
thrombi
hyperdense vessel sign.
can be seen in the vessel, the _____________________
click
• Blockage leads to cellular hypoxia. The cell cannot make ATP, the normal osmotic gradient is destroyed, and the
cell becomes ___________.
edematous
click darker/less dense/lower attenuation
On CT, edematous tissue becomes ____________________________________
click .
• Normally the gray

____ matter appears more dense or lighter than the ______
click click matter. When gray matter ischemia
white
loss click
of the gray-white differentiation
occurs, the resultant cytotoxic edema leads to __________________________________.
• To reiterate, ischemia causes Na/K ATPase dysfunction leading to derangement of the normal osmotic gradient. As
a result water moves into the ischemic cells. This is called cytotoxic edema and looks dark (hypodense) on CT.
When the gray matter becomes hypodense the gray-white differentiation is lost.
• Lastly, it is important to remember that hyperacute ischemia (i.e. first 6 hours) may be silent on CT and is better
evaluated on MR.
Related Entities
• Below are several entities related to ischemic strokes,
click each for an example:
• Lacunar Infarcts
• Chronic small vessel ischemic disease
• Sequela of prior infarcts
• Venous ischemic infarct
Lacunar Infarcts
• Lacunar infarcts = small infarcts due to obstruction of small perforating vessels

• Usually in the basal ganglia or thalami
• Generally cause little mass effect, may get ‘ex vacuo dilatation’ of nearby ventricles (as seen above)
• Unless you have a prior study showing the same lesion these are ‘age indeterminate’
Chronic Small Vessel Ischemia
Note: images are in

stroke windows
(explained shortly) to
accentuate the
findings.
• Chronic small vessel ischemia = chronic microangiopathy = lots of tiny infarcts from tiny vessel occlusions
• Usually in the cerebral white matter
• Look like patchy areas of low density
• Very common in older patient’s
• Like lacunar infarcts, unless you have a prior exam these are technically ‘age indeterminate’
but many people call them chronic anyway
Sequela of Prior Infarcts

Shift of midline structures towards the
area of low attenuation, also
suggesting volume loss
Encephalomalacia
from prior infarct
‘Ex vacuo’ dilation of the lateral ventricle,

a sign of adjacent volume loss
• What if you see an area with loss of the gray white differentiation, but no mass effect or even volume loss?
• Especially if the area doesn’t correlate with current symptoms?
• Probably a prior infarct, confirm by comparing to prior studies
Venous Ischemic Infarct
• Venous infarct = venous occlusion leading to vascular congestion and ischemia

• May be ischemic with loss of the gray-white differentiation or hemorrhagic with hematoma
• Can demonstrate the hyperdense vessel sign (in this case the internal cerebral veins)
• Causes mass effect similar to other infarcts
• Think of venous infarct when there is ischemia in a non-arterial distribution (i.e. bilateral symmetric, etc)
• Most common in pregnant women, oral contraceptive users, other hypercoaguable states
Hemorrhagic Strokes
• The primary finding of hemorrhagic stroke is:
• hematoma
click
Parenchymal _________
• Secondary Findings include:

• Vasogenic edema
• Mass effect
• Note: strokes may start as ischemic and then

bleed, a process called hemorrhagic transformation
Hemorrhagic Strokes
• The primary finding of hemorrhagic stroke is:
• hematoma
click

• Vasogenic edema
• Mass effect

Large right
frontotemporal
parenchymal
hematoma
Hemorrhagic Strokes
• The primary finding of hemorrhagic stroke is: Vasogenic
• hematoma
click
Parenchymal _________ edema

• Vasogenic edema
• Mass effect

- Note how vasogenic edema causes low attenuation in the gray matter with finger like
projections extending into the subcortical white matter.
- While vasogenic edema may accompany a hemorrhagic infarct it may be seen with other
pathology, such as tumors
- Suggest a contrast enhanced exam to exclude tumor when vasogenic edema is present
- Don’t confuse edema for infarct!
- With edema the gray-white differentiation is intact!
Hemorrhagic Strokes
• The primary finding of hemorrhagic stroke is: Initial presentation Days later
• hematoma
click

• Vasogenic edema
• Mass effect

Right parietotemporal Scattered new high

ischemic infarct attenuation foci
consistent with
hemorrhage
Hemorrhagic Strokes
• Hemorrhagic strokes frequently result from rupture of small perforating parenchymal vessels, most commonly
due to hypertension or amyloid angiopathy. Less common causes include neoplasms and vascular malformations.
• Blood vessel rupture damages the blood brain barrier, allowing plasma proteins into the parenchyma resulting in
vasogenic
click
__________ edema, surrounding low attenuation with ‘fingers’ extending into the subcortical white matter.
• Together, intra-axial (i.e. parenchymal) blood and vasogenic edema lead to __________.
mass effect Remember to check for
click
herniation!
Related Entities
• Below are entities related to hemorrhagic strokes,
click each for an example:
• Venous hemorrhagic infarcts
Venous Hemorrhagic Infarcts
Thrombosed
straight and
superior sagittal
• Venous hemorrhagic infarct = hemorrhage due to venous obstruction sinuses
• Usually caused by venous thrombosis, look for the hyperdense vein or sinus!
• Think of this when you see intraparenchymal hemorrhage in a pregnant women, young woman on OCPs, patient
with history of other hypercoagable state and no other history to explain bleeding (i.e. no trauma, etc).
Finding Strokes
WW: 80
WL: 35 WW: 14
12/31 WL: 31
12/31
• Now you have a basic idea of what strokes look like. So how to make sure you don’t miss one?
• First, you need to change to stroke windows with narrow window width (WW/WL around 20/30), greatly
emphasizing the gray-white differentiation (GWD).
Finding Strokes • Start in the cerebellum.

• Compare the hemispheres side to side, is the
GWD intact?
• Artifact in the posterior cranial fossa can make
evaluation of the cerebellum difficulty, but do the
best you can!
• Follow the brainstem upwards to the occipital lobes

• Looking for abnormal dark spots (hypodensities)
• Brainstem = mostly white matter, so no GWD
WW: 14
WL: 31
3/31

GWD intact?
best you can!

WW: 14
WL: 31
4/31

GWD intact?
best you can!

WW: 14
WL: 31
5/31

GWD intact?
best you can!

WW: 14
WL: 31
6/31

GWD intact?
best you can!

WW: 14
WL: 31
7/31

GWD intact?
best you can!

WW: 14
WL: 31
8/31

GWD intact?
best you can!

WW: 14
WL: 31
9/31

GWD intact?
best you can!

WW: 14
WL: 31
10/31

GWD intact?
best you can!

WW: 14
WL: 31
11/31

GWD intact?
best you can!

WW: 14
WL: 31
12/31

GWD intact?
best you can!

WW: 14
WL: 31
13/31

GWD intact?
best you can!

WW: 14
WL: 31
14/31

GWD intact?
best you can!

WW: 14
WL: 31
15/31

GWD intact?
best you can!

WW: 14
WL: 31
16/31

GWD intact?
best you can!

WW: 14
WL: 31
17/31

GWD intact?
best you can!

WW: 14
WL: 31
18/31

GWD intact?
best you can!

WW: 14
WL: 31
19/31

GWD intact?
best you can!

WW: 14
WL: 31
20/31
Finding Strokes
• Continue upwards comparing the occipital lobes, then
the parietal lobes. GWD okay?
• From the vertex move downwards comparing the

frontal lobes all the way to their inferior margins.
• Move posteriorly and compare the insular cortex, basal

ganglia and thalami. These important structures are
sensitive to oxygen deprivation and often the first to
show signs of ischemia!
• Do you remember the parts of the basal ganglia?

click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________
• Lastly, check the temporal lobes.
• Great, part one of the stroke evaluation is done!

WW: 14
WL: 31
3/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
4/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
5/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
6/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
7/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
8/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
9/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
10/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
11/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
11/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
11/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
12/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
13/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
14/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
14/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
15/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
16/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
17/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
18/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
19/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
20/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
21/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
22/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
23/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
24/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
25/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
26/31
Finding Strokes



click
caudate
• _______
click
putamen
• ________
click pallidus
globus
• _________

WW: 14
WL: 31
27/31
Finding Strokes • Now, switch back to brain or blood windows and

complete the same checklist, looking for intra-axial
blood/hematoma and foci of low attenuation.
• “But I already looked for parenchymal blood in the

‘blood’ section.” True, in many ways this part of the
search pattern is redundant. If you feel confident in your
prior check for parenchymal blood you’re good to go.
For now go over it once more for practice.
• Cerebellum  brainstem  occipital lobes  parietal

lobes  frontal lobes  insula, basal ganglia and
thalami  temporal lobes
click
• Traumatic injuries such as __________
contusions also present
with intra-axial blood/hematoma. The above checklist
will help you find those too!
WW: 80
WL: 35
3/31



click
WW: 80
WL: 35
4/31



click
WW: 80
WL: 35
5/31



click
WW: 80
WL: 35
6/31



click
WW: 80
WL: 35
7/31



click
WW: 80
WL: 35
8/31



click
WW: 80
WL: 35
9/31



click
WW: 80
WL: 35
10/31



click
WW: 80
WL: 35
11/31



click
WW: 80
WL: 35
12/31



click
WW: 80
WL: 35
13/31



click
WW: 80
WL: 35
14/31



click
WW: 80
WL: 35
15/31



click
WW: 80
WL: 35
16/31



click
WW: 80
WL: 35
17/31



click
WW: 80
WL: 35
18/31



click
WW: 80
WL: 35
19/31



click
WW: 80
WL: 35
20/31



click
WW: 80
WL: 35
21/31



click
WW: 80
WL: 35
22/31



click
WW: 80
WL: 35
23/31



click
WW: 80
WL: 35
24/31



click
WW: 80
WL: 35
25/31



click
WW: 80
WL: 35
26/31



click
WW: 80
WL: 35
27/31
Finding Strokes • Lastly, we need to check the vessels for the

click vessel sign
hyperdense
_______________________
click
6-12
• In the hyperacute setting, approximately the first ____
hrs, this may be the ONLY CT sign of a stroke.
• What did we say was a more sensitive modality?

• MRI!
• Begin at the foramen magnum in brain widows.
• Compare the two vertebral arteries (if visible) as

you scroll upwards.
• Continue upward follow the basilar.
• The posterior cerebral arteries (PCAs) and

posterior communicating arteries (PCOMMs) are
usually not well seen on noncontrast head CT, but
compare their expected courses anyway, it’s good
WW: 80
practice.
WL: 35
2/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
2/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
3/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
4/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
5/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
5/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
6/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
7/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
8/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
8/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
8/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
9/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
10/31

click vessel sign
hyperdense
_______________________
click
6-12

• MRI!

you scroll upwards.

WW: 80
practice.
WL: 35
11/31
Finding Strokes
• The PCOMMs lead you anteriorly to the internal carotids
(ICAs), compare each. Then move superolaterally to the
MCAs, again comparing all the way.
• Continue around the Circle of Willis, to the ACOMM and

ACAs. Follow the ACAs along the medial frontal lobes.
• Follow the superior sagittal sinus back to the torcula
• Follow the straight sinus and internal cerebral veins
• Compare the transverse and sigmoid sinuses
• Why check the veins?
• Venous sinus thrombosis can cause stroke too!
• Like thrombosed arteries, thrombosed veins/sinuses

may look expanded and hyperdense.
WW: 80
WL: 35
6/31
Finding Strokes


WW: 80
WL: 35
7/31
Finding Strokes


WW: 80
WL: 35
7/31
Finding Strokes


WW: 80
WL: 35
8/31
Finding Strokes


WW: 80
WL: 35
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Finding Strokes


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Finding Strokes


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Finding Strokes


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Finding Strokes


WW: 80
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10/31
Finding Strokes


WW: 80
WL: 35
11/31
Finding Strokes


WW: 80
WL: 35
11/31
Finding Strokes


WW: 80
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12/31
Finding Strokes


WW: 80
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13/31
Finding Strokes


WW: 80
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13/31
Finding Strokes


WW: 80
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14/31
Finding Strokes


WW: 80
WL: 35
15/31
Finding Strokes


WW: 80
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15/31
Finding Strokes


WW: 80
WL: 35
16/31
Finding Strokes


WW: 80
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17/31
Finding Strokes


WW: 80
WL: 35
18/31
Finding Strokes


WW: 80
WL: 35
19/31
Finding Strokes


WW: 80
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20/31
Finding Strokes


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21/31
Finding Strokes


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21/31
Finding Strokes


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22/31
Finding Strokes


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23/31
Finding Strokes


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Finding Strokes


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Finding Strokes


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Finding Strokes


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To Review: Click on the abnormality in the image

• For ischemic strokes the primary signs are:
Loss of click
the gray-white differentiation
•_________________________________
No, try again
•_________________________________
The hyperdense
click vessel sign
• Stroke windows help find ischemia because they have

narrow
a _______click emphasizing
click the gray-white
width, ____________
differentiation.
• For hemorrhagic strokes the primary sign is:

•______________________
parenchymal
click hematoma
mass effect which

• Parenchymal blood + edema = ____________
click
herniation
may cause _____________
click in severe cases.
• In the first 6-12 hours the only CT sign of an ischemic

click
stroke may be the _________________________
The hyperdense vessel sign ,
which is insensitive. A more sensitive modality is
click
MRI
_____.
Well done! There is a large right

MCA territory ischemic infarct.
B
To Review: A
• Name the parenchymal structures labeled in the image.

• Click the label to reveal the name below
A. Insular cortex
B. Caudate
C. Putamen
D. Globus pallidus
• Together the caudate, putamen and globus pallidus

basal ganglia
make up the ______________
click .
C
• Nicely done!
D
Examples:
Click each item below to view:
• Chronic small vessel ischemic disease
• Ischemic infarct
• Hemorrhagic infarct
• Hemorrhagic transformation
• Lacunar infarct
• Venous ischemic infarct
• Venous hemorrhagic infarct
• Sequela of prior infarct
Chronic Small Vessel Ischemia
Note: images are in

stroke windows
(explained shortly) to
accentuate the
findings.
• Chronic small vessel ischemia = chronic microangiopathy = lots of tiny infarcts from tiny vessel occlusions
• Usually in the cerebral white matter
• Look like patchy areas of low density
• Very common in older patient’s
• Like lacunar infarcts, unless you have a prior exam these are technically ‘age indeterminate’
but many people call them chronic anyway
Ischemic Infarct
Normal sharp demarcation Loss of the gray-white

between the brighter gray matter differentiation with more
and the darker white matter uniform low attenuation
Hemorrhagic Infarct
Large right
frontotemporal
parenchymal
hematoma
Hemorrhagic Transformation
Initial presentation Days later
Scattered new high attenuation

Right parietotemporal ischemic infarct
foci consistent with hemorrhage
Lacunar Infarcts
• Lacunar infarcts = small infarcts due to obstruction of small perforating vessels

• Usually in the basal ganglia or thalami
• Generally cause little mass effect, may get ‘ex vacuo dilatation’ of nearby ventricles (as seen above)
• Unless you have a prior study showing the same lesion these are ‘age indeterminate’
Venous Ischemic Infarct
• Venous infarct = venous occlusion leading to vascular congestion and ischemia

• May be ischemic with loss of the gray-white differentiation or hemorrhagic with hematoma
• Can demonstrate the hyperdense vessel sign (in this case the internal cerebral veins)
• Causes mass effect similar to other infarcts
• Think of venous infarct when there is ischemia in a non-arterial distribution
• Most common in pregnant women, oral contraceptive users, other hypercoaguable states
Venous Hemorrhagic Infarcts
Thrombosed
straight and
superior sagittal
• Venous hemorrhagic infarct = hemorrhage due to venous obstruction sinuses
• Usually caused by venous thrombosis, look for the hyperdense vein or sinus!
• Think of this when you see intraparenchymal hemorrhage in a pregnant women, young woman on OCPs, patient
with history of other hypercoagable state and no other history to explain bleeding (i.e. no trauma, etc).
Sequela of Prior Infarcts

Shift of midline structures towards the
area of low attenuation, also
suggesting volume loss
Encephalomalacia
from prior infarct
‘Ex vacuo’ dilation of the lateral ventricle,

a sign of adjacent volume loss
• What if you see an area with loss of the gray white differentiation, but no mass effect or even volume loss?
• Especially if the area doesn’t correlate with current symptoms?
• Probably a prior infarct, confirm by comparing to prior studies
Is there an aneurysm?
• Congratulations, you’re over half way through!
• You now know that when reviewing a head CT you should start by asking:
blood/mass effect
• Is there _________________?
click
• Is there _________________?
hydrocephalus
click
stroke
• Is there a _________?
click
• Next up, aneurysms!

Aneurysms
• Identification of aneurysms is important for a variety of reasons including:
• Mass effect on adjacent structures
• Leading to CN palsy, headache, etc
• rupture
click
Risk of ___________ leading to intracranial hemorrhage (ICH)
What Do Aneurysms Look Like?

Anterior cerebral artery
(ACA) aneurysm
• Aneurysms are focally enlarged blood vessels.

full of
click
• Visualizing vessels is easier when they are ________________ contrast (as in the image on the right).
• If you happen to have images with contrast on board, use those to look for aneurysm
• NOTE: When there is a high suspicion of aneurysm the CT exam of choice is a CT angiogram (CTA) where
0.625 mm slices and contrast bolus timing improve visualization of vessels.
• If you only have non-contrast images obviously use those, but the exam will be less sensitive.
blood
click
• Aneurysms are full of __________ thrombus
click
and/or _________
iso to click
hyperdense
• They appear _______________________ on non-contrast exams.
Looking For Aneurysms

• At the end of the stroke section we examine the
hyperdenseclick
vessel sign
vessels for the __________________________.
• Now, you can follow the same search pattern to look

for aneurysms.
• Brain windows.
• Vertebral arteries
• Basilar
• PCAs
• PCOMMs
• Internal carotids
• MCAs
• ACOMM
• ACAs.
• Use the series on the left to practice.
• Great work!
WW: 80
WL: 35
2/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
3/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
4/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
5/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
6/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
7/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
8/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
9/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
10/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
11/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
12/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
13/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
14/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
15/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
16/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
17/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
18/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
19/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
20/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
21/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
22/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
23/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
24/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
25/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
26/31

hyperdenseclick
vessel sign
vessels for the __________________________.

for aneurysms.
• Brain windows.
• Basilar
• PCAs
• PCOMMs
• MCAs
• ACOMM
• ACAs.
• Great work!
WW: 80
WL: 35
27/31
Review
• Aneurysms may cause:
clickeffect or _______________
• __________
Mass click
hemorrhage
• They look like:

click dilation / outpouching
• _________________________________
Focal vessel
• They are _____________

isoclick
to hyper dense compare to brain on non-contrast exams.
click
• The best CT exam to diagnose an aneurysm is a _________,
CTA but we look for them on non-contrast exams, too.
• What is the our overall non-contrast head CT search pattern? What was the mnemonic?
• Blood Mass effect Hydrocephalus Stroke Aneurysm Trauma Sinuses Orbits Neck.
• Boston Men Have Strong Accents That Sound Overly Nasal.

Example:
Click below to view:
• ACA aneurysm
ACA Aneurysm
Anterior cerebral artery
(ACA) aneurysm
• Aneurysms are focally enlarged blood vessels.

full of
click
• Visualizing vessels is easier when they are ________________ contrast (as in the image on the right).
• If you happen to have images with contrast on board, use those to look for aneurysm
• NOTE: When there is a high suspicion of aneurysm the CT exam of choice is a CT angiogram (CTA) where
0.625 mm slices and contrast bolus timing improve visualization of vessels.
• If you only have non-contrast images obviously use those, but the exam will be less sensitive.
blood
click
• Aneurysms are full of __________ thrombus
click
and/or _________
iso to click
hyperdense
• They appear _______________________ on non-contrast exams.
Is there evidence of trauma or

sinus disease?
• Getting close to the end! Only two sections to go!
• The first 4 questions you should ask yourself when interpreting a noncontrast head CT are:
click effect
• Is there ___________________?
blood/mass
• Is there ____________________?
click
hydrocephalus
• Is there a __________?
click
stroke
click
• Are there any ___________?
aneurysms
• Next we’ll move on to trauma and sinus disease.

Head Trauma
• A common indication for noncontrast head CT out of the ED
click
• Usually due to _______ MVA but also includes penetrating trauma (GSW, etc.)
fall or _______,
• If you pick up a rec and it says ‘h/o trauma, rule out ICH’, don’t immediately start looking for fractures or blood, you
may miss the stroke that caused the fall (we’ve done it!). Stick to your system. As you get more experienced maybe
you start shuffling the order, but for now learn an order and stick to it.
Head Trauma
• Fortunately the parts of the search pattern you’ve already learned will lead you to many of the findings in trauma
including (click to review):
• Subdural hematoma
• Epidural hematoma
• Subarachnoid hemorrhage
• Hemorrhagic contusions
• In this section we’ll tie up some loose ends.

Subdural Hematoma
Epidural Hematoma
• Causes mass effect including sulcal effacement and/or shift of midline structures
• Are usually temporal or along the ‘convexities’.

• Fill cisterns
Coronal
Fractures suture
Soft tissue
edema
• Fractures can be subtle on axial images, the scout is frequently helpful

• Check to make sure the ‘fracture’ is not symmetric, a suture may be fooling you!
• Fractures should also have sharp, non-sclerotic margins
• Sutures should have corrugated (small undulations), sclerotic margins
• These are ‘textbook’ features which are sometimes difficult to appreciate
• Look for the associated edema, hematoma or sinus opacification.
Pneumocephalus
• Pneumocephalus = intracranial air

• It had to come from somewhere, usually from a traumatic or iatrogenic source.
• Air is less dense than anything normally found in the head. Where is pneumocephalus most commonly seen?
• Non-dependent areas
• Over the frontal convexities
• Frontal horns lateral ventricles
Soft Tissues
• Lacerations, soft issue defects and hematomas often occur over ________
click
broken bones (although not above).
• If you see a soft issue injury check for foreign bodies

• May be either hyperdense (bright) or hypodense (dark)
• Soft tissue gas is frequently associated with lacerations
Sinus Opacification
click suggesting an adjacent fracture.

blood
• High attenuation fluid filling a sinus or airspace may represent ______,
• Low attenuation fluid filling the airspaces around the skull base (sinuses, middle ear, or mastoids) is nonspecific,
but can be an indicator of acute infection. The clinician will have to correlate with the clinical picture.
• Other causes of sinus opacity include:

• Chronic mucosal inflammation
• Mucosal retention cysts
Finding Trauma • Just go to Detroit…sorry bad joke.
• Helpful search by pulling up the scout image.
• A quick check of the skull and upper cervical spine may

reveal fractures or c-spine injuries difficult to see on the
axial images.
Finding Trauma
• Then, open the bone algorithm with bone windows (these
are wide enough to make the soft tissue readily visible).
• Start above the orbits. Compare the soft tissue over the
frontal bones as you scroll upwards all the way to the vertex.
• As you scroll down compare the parietal and occipital soft

tissues.
• Move anteriorly and compare the temporal soft tissues.
WW: 4000
WL: 1000
1/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
2/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
3/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
4/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
5/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
6/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
7/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
8/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
9/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
10/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
11/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
12/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
13/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
14/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
15/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
16/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
17/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
18/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
19/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
20/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
21/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
22/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
23/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
24/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
25/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
26/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
27/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
28/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
29/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
30/31
Finding Trauma

tissues.
WW: 4000
WL: 1000
31/31
Finding Trauma • Start by examining the air filled spaces including the:
• Frontal sinuses
• Ethmoid air cells
• Maxillary sinuses
• Sphenoid sinuses
• Middle ear cavities
• Mastoid air cells
• Any abnormal opacification?
• Any mucosal thickening?
• Now check the bones, comparing side to side:

• Nasal bones
• Ethmoid septae and lamina papyracea
• Walls of the orbits and maxillary sinuses
• Zygomatic arches
• Sphenoid wings
• Clivus and occipital condyles.
• Temporal bones
• Occipital bones (watch out for the lambdoid suture)
• Parietal bones (lambdoid and sagittal sutures)
• Frontal bones (watch out for the coronal suture)
WW: 4000
WL: 1000
• Any fractures?
1/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
1/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
1/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
1/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
1/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
2/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
1/31
2/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
3/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
3/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
3/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
3/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
3/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
3/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
3/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
4/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
4/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
4/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
5/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
5/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
5/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
6/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
6/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
7/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
8/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
9/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
10/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
11/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
12/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
13/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
13/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
14/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
15/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
16/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
17/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
18/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
19/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
20/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
21/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
22/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
23/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
23/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
24/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
25/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
26/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
27/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
28/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
28/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
29/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
30/31
• Frontal sinuses

• Nasal bones
• Sphenoid wings
• Temporal bones
WW: 4000
WL: 1000
• Any fractures?
31/31
Finding Trauma • If there’s no history of trauma or surgery this next part is

really just a bonus. But practice it anyway!
• Switch to lung windows, which are very wide and quickly

scan from vertex to skull base.
• Look for pneumocephalus over the frontal lobes. Then

check in the frontal horns of the lateral vents.
click ,
• Since most patients are scanned lying on their _____
back
click
nondependent
these areas are _____________ , where gas will tend to
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!



click ,
back
click
nondependent
accumulate.
• Great work!
Review 2
• After looking for blood/mass effect, hydrocephalus, stroke,

and aneurysms we finish our trauma evaluation by looking for:
• ________
click
fractures / soft tissue injury
click disease
• ________
sinus 1
click
pneumocephalus
• ________
• Unlike sutures, acute fractures:

• Should be ___________
click
asymmetric
click
hematoma/edema
• Are usually surrounded by soft tissue _______________
click
high attenuation fluid in adjacent sinuses.
and ______
3
• Name the structures labeled in the image (click labels to reveal):

• (1) Ethmoid air cells 4
• (2) Lamina papyracea
• (3) Clivus
• (4) Mastoid air cells
click
infection
• Low attenuation fluid in the sinuses or mastoid air cells can be due to acute ____________, but is
nonspecific. In the setting of trauma and tenderness near the opacified sinus/mastoids, CSF leak is another
(albeit unlikely) possibility you should make sure the clinician is aware of.
Examples
Click each to review
• Skull fracture
• Soft tissue defect
• Pneumocephalus
• Mastoid opacification
• Sinus Disease
• Fracture with hemorrhage in sinus
Coronal
Skull Fracture suture
Soft tissue
edema
• Fractures can be subtle on axial images, the scout is frequently helpful
• Check to make sure the ‘fracture’ is not symmetric, a suture may be fooling you!
• Fractures should also have sharp, non-sclerotic margins
• Sutures should have corrugated (small undulations), sclerotic margins
• These are ‘textbook’ features which are sometimes difficult to appreciate
• Tips: 1) Look for the associated edema, hematoma or sinus opacification to confirm a fracture
• Ask for thin section reformats (1.25 mm or 0.625 mm) or create 3D reconstructions
Pneumocephalus
• Pneumocephalus = intracranial air

• It had to come from somewhere, usually from a traumatic or iatrogenic source.
• Air is less dense than anything normally found in the head where is it most commonly seen?
• Non-dependent areas
• Over the frontal convexities
• Frontal horns lateral ventricles
Soft Tissue Defect
• Lacerations, soft issue defects and hematomas often occur over ________
click
broken bones (although not above).
• If you see a soft issue injury check for foreign bodies

• May be either hyperdense (bright) or hypodense (dark)
• Soft tissue gas is frequently associated with lacerations
Fracture with blood in sinus
click suggesting an adjacent fracture.

blood
• High attenuation fluid filling a sinus or airspace may represent ______,
Sinus Disease
• Low attenuation fluid filling the airspaces around the skull base (sinuses, middle ear, or mastoids) is nonspecific,
but can be an indicator of acute infection. The clinician will have to correlate with the clinical picture.
• Other causes of sinus opacity include:

• Chronic mucosal inflammation
• Mucosal retention cysts
Mastoid Opacification
• Opacification of the mastoid air cells by low attenuation fluid has several possible causes:
• Incidental and of no clinical significance
• Mastoiditis (look for associated middle ear opacification)
• CSF leak (in the setting of trauma and tenderness or frank fracture nearby)
Are the visualized orbits and

upper neck normal?
• Head CT is not designed to look at the orbits.
• In fact it is designed specifically to AVOID the orbits. Why?

• The lenses are radiation sensitive
• So, sometimes it’s easy to forget that part of the eyes are in sight (so to speak) on a head CT. You’ve already
looked at the bones surrounding the eyes, but it’s important to remember to look at the orbits themselves.
What am I looking for?

• Bad things that happen in/around the orbits:
• Click each to view
• Globe rupture
• Lens dislocation
• Foreign bodies
• Masses
• Pre / post septal cellulitis
Globe rupture
• Globes rupture = hole in the sclera (outer layer of the globe)

• Causes a somewhat deflated appearance (some liken it to a flat tire)
• Note: CT is NOT sensitive to globe rupture, but look anyway!
• Frequently associated with intraocular blood which should look _________
click
hyperdense/bright
• Often only one will rupture at a time, so you can easily compare the injured side to the normal side.
Lens Dislocation Vitreous hemorrhage

adjacent to lens
Dislocated
Normal lens lens
• The lenses look like bright disks near the front of the globes.
• Are they present in similar positions
• Again, usually only one lens is abnormal at a time.
Foreign Bodies
• Like all foreign bodies these can appear bright or dark depending on composition
• Small gas bubbles under the eye lids are very common, don’t let them fool you!
Masses
• May involve the globe itself or be in the surrounding soft tissue (as above)
• Any number of causes (beyond the scope of this module)
• Suffice to say you don’t want to miss one!
Cellulitis
Orbital septum
• The orbital septal connective tissue divides the preseptal space (anteriorly) and post septal space (posteriorly)
• Medial attachment at the back of the nasolacrimal duct
• Lateral attachment on the zygoma
• Cellulitis causes ‘fat stranding’, i.e. the normal homogeneous dark fat becomes heterogeneous and brighter
• Preseptal cellulitis can be treated with oral antibiotics (click for example)
• Post septal cellulitis requires IV antibiotics (click for example)
• CT is the only way to tell the difference!
Pre Septal Cellulitis

Fat stranding confined
to preseptal tissue
Orbital septum
• To return to the example of normal anatomy, click here

Post Septal Cellulitis Fat stranding in

pre and post septal spaces Subperiosteal abscess
along lamina papyracea
Orbital septum

Looking at the orbits

• Brain algorithm and soft tissue windows
• Approx WW = 350, WL = 50
• First, look at the globes themselves.
• Are they round and symmetric?
• Are the lenses in a similar position?
• Are the muscles, post septal fat and optic nerves

symmetric?
• Does the fat look nice and dark or there fat stranding?
• Are the preseptal soft tissues symmetric and thin?
• Is there fat stranding?
• Do you see any foreign bodies?

• Remember these can be dark or bright

• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?


• Approx WW = 350, WL = 50

symmetric?

Looking at the neck

• On a typical head CT, there are only a few neck
structures that are visible. Nevertheless, they’re part of
the exam and you should look at them before you close
the study.
• Use soft tissue windows and, as always, symmetry is

your friend.
• Are the muscles, fat spaces, and soft tissues the
same on both sides?
• Is there any fluid, fat stranding, or bright blood?
• Any gas collections?
• Often, you won’t be able to see much, but always look!

Looking at the neck

the study.

your friend.
same on both sides?

Looking at the neck

the study.

your friend.
same on both sides?

Looking at the neck

the study.

your friend.
same on both sides?

Looking at the neck

the study.

your friend.
same on both sides?

Looking at the neck

the study.

your friend.
same on both sides?

Looking at the neck

the study.

your friend.
same on both sides?

Looking at the neck

the study.

your friend.
same on both sides?

Review E C
• The orbital septum attaches: B
click aspect nasolacrimal duct
• Medially at the ________________
posterior
• Laterally at the ________________
click zygoma
anterior
D
oralclick
• Preseptal cellulitis is treated with ___________
antibx
IVclick
• Post septal cellulitis requires _________
antibx
click
Rupture
• ________ causes the globe to look deflated
A
click
• CT is ___________
insensitive for globe rupture
• Name the structures by clicking on their label:

with its label in the image:
• Optic nerve
• Extraocular muscle
• Lamina papyracea
• Zygoma
• Nasolacrimal duct
• Excellent!
Examples
• Click each to view
• Globe rupture
• Lens dislocation
• Foreign bodies
• Masses
• Pre / post septal cellulitis
Globe rupture
• Globes rupture = hole in the sclera (outer layer of the globe)

• Causes a somewhat deflated appearance (some liken it to a flat tire)
• Note: CT is NOT sensitive to globe rupture, but look anyway!
• Frequently associated with intraocular blood which should look _________
click
hyperdense/bright
• Often only one will rupture at a time, so you can easily compare the injured side to the normal side.
Lens Dislocation Vitreous hemorrhage

adjacent to lens
Dislocated
Normal lens lens
• The lenses look like bright disks near the front of the globes.
• Are they present in similar positions
• Again, usually only one lens is abnormal at a time.
Foreign Bodies
• Like all foreign bodies these can appear bright (as above) or dark depending on composition
• Small gas bubbles under the eye lids are very common, don’t let them fool you!
Masses
• May involve the globe itself or be in the surrounding soft tissue (as above)
• Any number of causes (beyond the scope of this module)
• Suffice to say you don’t want to miss one!
Cellulitis
Orbital septum
• The orbital septal connective tissue divides the preseptal space (anteriorly) and post septal space (posteriorly)
• Medial attachment at the back of the nasolacrimal duct
• Lateral attachment on the zygoma
Pre Septal Cellulitis

Fat stranding confined
to preseptal tissue
Orbital septum

Post Septal Cellulitis Fat stranding in

pre and post septal spaces Subperiosteal abscess
along lamina papyracea
Orbital septum

Well done!
You’ve completed the entire search pattern!
Obviously that is a lot to remember. Don’t expect yourself to remember everything perfectly the first time through.
With time and practice it will become second nature. Until then, focus on the big questions:
1. Is there any blood or mass effect? Boston Men

2. Is there hydrocephalus? Have
3. Is there a stroke? Strong
4. Are there any aneurysms? Accents
5. Is there evidence of trauma or sinus disease? That Sound
6. Are the visualized orbits and neck normal? Overly Nasal
If you are interested in a sample dictation which follows our search pattern click here.
Thank You!
That completes the module, we hope you found it helpful.
If you would like, please take the post-test and survey now.
Putting the pieces together

An example dictation incorporating our search pattern:
“There is no acute intracranial hemorrhage. There is no mass, mass effect, effacement of basal
cisterns, or shift of midline structures. The overall brain volume is appropriate for patient age.
Ventricular size is proportional to brain volume. The gray white matter differentiation is intact. The
osseous structures are unremarkable. The visualized paranasal sinuses and mastoid air cells are well
aerated. The visualized orbital structures are unremarkable.”

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Noncontrast Head CT:

Relax and Learn

• Recognize common, emergent pathology on a non-contrast head CT

• Generally scrolling will be available when

• When scrolling is available the

• Try scrolling each direction.

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• When scrolling is available the

• Try scrolling each direction.

• If text appears highlighted click on it to

• Try it out: lateral ventricles

• Click the name again to remove the

• If a question appears highlighted, click to

• Okay, enough with that, let’s get started.

2) Find all of the abnormalities

3) Place the abnormalities in the correct anatomic location to develop a DDX

4) Narrow the DDX using other available information:

4) Click for answer

A Word About Technique

• First, this module focuses on NONCONTRAST head CT, why?

Window Width and Window Level

• Similarly, depending on what you are looking for on a CT

• Window width (WW, →) is similar to contrast, or the ability

• Window Level (WL, →) is similar to brightness, or the

WW: WW: WW:

Now, let’s move on to algorithms.

Brain Algorithm Bone Algorithm

Brain Algorithm Bone Algorithm

• Let’s move on to the search pattern.

The Search Pattern

The Search Pattern

1. Is there any intracranial blood or mass effect?

The Search Pattern

Boston Men Have Strong Accents That Sound Overly Nasal.

Is there any blood or mass effect?

• Why look for acute blood?

• But what does acute blood look like?

• So what does subacute or chronic blood

• Over a 2 week period the density of blood

• Why does the density change?

Types of Intracranial Hemorrhage

• Intra-axial = inside brain parenchyma