What is CT?

Computed Tomography or CT uses digital processing to generate a 3-D image from a large number of 2-D X-rays taken around a single axis of rotation. A picture of a modern CT scanner is seen below. It shows the scanner in the background with the control panel in the foreground. In CT the patient lies supine on the table and the donut shaped scanner rotates taking a large number of x-rays in a single slice. Patients will then move through the scanner to allow a different number of slices to be taken through the anatomical area of interest. These x-rays are then re-formatted by the computer and can be viewed by the radiologist in multiple plains. Interpreting the CT Images on CT are seen as various shades of grey based on how much radiation a tissue absorbs. When reporting x-rays it is useful to know something about two key words.

Attenuation defined as the process by which a beam of radiation is reduced in intensity when passing through material. If a tissue has low attenuation it would suggest that it is relatively transparent, where as high attenuation is a denser material. In terms of CT low attenuation appears dark (air) where as high attenuation (bone) objects appear brighter.

Hounsfield Units (HU) Units of x-ray attenuation used in CT scanning. Each tissue has a volume based on how bright/dark it appears; the brighter the tissue, the higher the HU; Bone +1000, Water 0, Air -1000

Head CT: some basics It is worth knowing how you would expect tissues on CT head to appear. Keeping attenuation and HU in mind you can work out that:

CSF in the brain will appear black Bone will appear white. Grey and white matter within the brain have different attenuations; the densely packed nerve cell bodies of the grey matter have a higher attenuation than the nerve axons of the white matter, meaning that perversely white matter is darker than grey matter on CT (TOP TIP: always look for the grey white matter boundary; loss of this boundary can be an early sign of brain injury.)

Blood contains protein making it dense and areas of acute bleeding appear high attenuation (bright) on CT. Areas of dead or damaged brain tissue will become less dense, meaning that they will appear darker than the surrounding brain (low attenuation)

Contrast IV contrast in CT highlights blood vessels or vascular areas of the brain. It is also useful for identifying areas of high cell turn over such as tumours and infection. Aneurysms, tumours and abscesses all become brighter post contrast administration on head CT. Keeping all this in mind we have ten CT heads for you to look at. Dont panic, just say what you can see, is it higher or lower attenuation than the surrounding brain? Where in the brain is the abnormality? What shape is it? Think about your brain anatomy and remember to take clues from the history. Enjoy! Case (1) Extra Dural Haematoma A 24 year old female fell from her horse during a cross country competition, hitting her head on a wooden fence on the way to the ground. She was taken by ambulance to A&E where on examination she had a Glasgow coma scale of 11/15. CT scan is shown below.

Describe the two radiological abnormalities shown above Soft tissue swelling over the right parietal bone Right sided hyper-dense eliptical area

Soft tissue swelling over the right parietal bone Right sided hyper-dense eliptical area Powered By WordPress Tabs And SlidesBusby SEO Test Give a radiological diagnosis Acute Extra-dural Haematoma Acute Extra-dural Haematoma Powered By WordPress Tabs And SlidesBusby SEO Test What other abnormality should always be looked for in these cases? Skull fracture- 80+% of subdural haematomas are associated with a skull fracture

Skull fracture- 80+% of subdural haematomas are associated with a skull fracture Powered By WordPress Tabs And SlidesBusby SEO Test Learning point Difference between extradural and subdural Extradural Source of Blood Size Shape Crosses sutures? Crosses Midline? Position related to injury Attenuation Middle meningeal artery Usually small as limited by skull vaults Convex EGG Unable to cross sutures May Cross midline Directly adjacent to injury site High attenuation Subdural Dural Veins Large Concave BANANA Can cross sutures Does not cross midline Often distant from injury site contre coup High attenuation in acute phase, can also be low (chronic) or mixed attenuation (acute on chronic)

(2) Subdural Haematoma An 84 year old male nursing home resident presents with increasing drowsiness. The care assistant who attended with him informs you he has become increasingly unsteady and confused over the past two weeks since falling in the bathroom and has deteriorated rapidly over the past 24 hours. CT scan was performed and is shown below

Report this CT scan, describe what you can see? Left -sided low density subdural collection with an area of high density within. Midline shift to the left with effacement of sulci and the right lateral ventricle

Left -sided low density subdural collection with an area of high density within. Midline shift to the left with effacement of sulci and the right lateral ventricle. Powered By WordPress Tabs And SlidesBusby SEO Test What is your radiological diagnosis? Acute on Chronic Subdural haemorrhage Acute on Chronic Subdural haemorrhage Powered By WordPress Tabs And SlidesBusby SEO Test What is responsible for the different densities seen on CT? Fresh blood is denser on CT than older areas of bleeding.

Fresh blood is denser on CT than older areas of bleeding. Powered By WordPress Tabs And SlidesBusby SEO Test Bleeding in the brain changes in density with time as shown in the table below Learning points Phase Acute 7-10 days 21-30 days (Chronic) Density Hyperdense Isodense Hypodense Appearance on CT Bright Difficult to distinguish Dark

So why does acute bleeding appear more hyperdense on CT? Blood contains haematocrit and a high concentration of protein. Protein has a high electron density and therefore an evolving bleed in the brain has high attenuation. Slowly over the time the protein is reabsorbed via the CSF and the area of haemorrhage becomes isodense again. (3) Subarachnoid Haemorrhage A 46 year old male with known Adult Polycystic Kidney Disease (APKD) presents to his GP with sudden onset headache associated with nausea and vomiting. This patient has APKD, what vascular abnormality does this pre-dispose to? Berry aneurysms particularly in the circle of willis Berry aneurysms particularly in the circle of willis Powered By WordPress Tabs And SlidesBusby SEO Test

His CT scan is shown below

What is the diagnosis? Subarachnoid haemorrhage (SAH) Subarachnoid haemorrhage (SAH) Powered By WordPress Tabs And SlidesBusby SEO Test What does his CT scan show? What complication is he developing?

Ruptured aneurysm Blood in the subarachnoid spaces Hydrocephalus enlarged temporal horns of the lateral ventricle

Ruptured aneurysm Blood in the subarachnoid spaces Hydrocephalus enlarged temporal horns of the lateral ventricle Powered By WordPress Tabs And SlidesBusby SEO Test In what part of the circle of willis do you think his aneurysm arose from? Anterior communicating artery (ACOM). This can be determined by the distribution of the haemorrhage. Anterior communicating artery (ACOM). This can be determined by the distribution of the haemorrhage. Powered By WordPress Tabs And SlidesBusby SEO Test Learning Points By far the most common cause of SAH is trauma, although ruptured aneurysms are the most common non-traumatic cause. SAH is defined as a haemorrhage into the subarachnoid space so when looking on CT look for high attenuation in the basal cisterns, sylvian fissure, in the ventricles and the interhemispheric fissure (although this is rare). (4) Hypertensive Haemorrhage A fifty five year-old smoker develops a sudden onset right sided hemi-paresis associated with nausea during a five a side football competition. He is a known hypertensive and on questioning admits to being hit and miss with his medication and is not usually very active.

On arrival at A&E he has developed a headache and is having difficulty with his speech

Describe the abnormality seen on CT High attenuation/density mass on the left side of the brain in the region of the basal ganglia intra-parenchymal haematoma High attenuation/density mass on the left side of the brain in the region of the basal ganglia intra-parenchymal haematoma Powered By WordPress Tabs And SlidesBusby SEO Test

What is the diagnosis? Hypertensive haemorrhage Hypertensive haemorrhage Powered By WordPress Tabs And SlidesBusby SEO Test What risk factors from the history make this diagnosis most likely? Poorly controlled hypertension Smoking Powered By WordPress Tabs And SlidesBusby SEO Test

Poorly controlled hypertension Smoking Learning Point Hypertensive bleeds These bleeds commonly manifest with symptoms of sudden onset hemiparesis and hemiplegia alongside speech difficulties, headache and nausea. Symptoms often occur during periods of activity. Long periods of hypertension wear away at blood vessel walls. In the brain this can lead to vessels become blocked and blood leaks into the brain parenchyma. Blood collects to form a haematoma which radiologically is most often seen in the region of the basal ganglia and thalamus. (5) Infarct 75 year old smoker presents to A&E with a 24 hour history of increasing right sided weakness.

Report his CT scan what can you see? Large area of decreased density in the left hemisphere with a well defined margin. Involvement of both grey and white matter Large area of decreased density in the left hemisphere with a well defined margin. Involvement of both grey and white matter. Powered By WordPress Tabs And SlidesBusby SEO Test Which blood vessel supplies this part of the brain? Left Middle Cerebral Artery Left Middle Cerebral Artery Powered By WordPress Tabs And SlidesBusby SEO Test Name the different types of stroke Ischaemic (85%) and haemorrhagic (15%)

Ischaemic (85%) and haemorrhagic (15%)

Powered By WordPress Tabs And SlidesBusby SEO Test Learning point Remember that stroke is a clinical diagnosis; imaging is required to confirm the diagnosis and the type of stroke. It is important to know whether or not you have a haemorrhagic stroke as a haemorrhagic stroke can not be treated with thrombolysis!!! Haemorrhagic strokes are represented by hyperdense areas within a vascular territory. (6) Hydrocephalus 19 year female presents to A&E after falling down a flight of stairs after a night out. She describes a sudden onset worse ever headache associated with nausea and vomiting over the past 3 hours.

A non contrast CT head was performed.

What is your initial working diagnosis? SAH following trauma SAH following trauma Powered By WordPress Tabs And SlidesBusby SEO Test Report this CT? Dont panic, just say what you see?

Blood in the sub-arachnoid space Inter-ventricular blood within the left lateral ventricle Enlargement of the lateral ventricles-more on the left than the right

Blood in the sub-arachnoid space Inter-ventricular blood within the left lateral ventricle Enlargement of the lateral ventricles-more on the left than the right Powered By WordPress Tabs And SlidesBusby SEO Test Is this communicating or non communicating hydrocephalus? Communicating Powered By WordPress Tabs And SlidesBusby SEO Test Communicating Learning Point Hydrocephalus can be classed into two categories, communicating and non communicating. Non-communicating obstruction to CSF flow is caused by blockage within the ventricles i.e. from an intra-ventricular mass Communicating there is free flow of CSF out of the fourth ventricle and the obstruction is due to a defect in re-absorption of CSF. This is often secondary to disease within the subarachnoid space such as meningitis or in this case subarachnoid haemorrhage. (7) Skull Fracture A 20 year old pedestrian is hit by a car travelling approximately 25mph. He is thrown to the ground some distance away by the impact and sustains multiple injuries including a head injury. Upon arrival at A&E his GCS is 13/15. CT scan is shown below, using the bone window filters

Report the CT scan, what can you see? Linear skull fracture in left parietal bone Left sided soft tissue swelling

Linear skull fracture in left parietal bone Left sided soft tissue swelling Powered By WordPress Tabs And SlidesBusby SEO Test Although difficult to see on this setting, what else would you expect to see given the type of injury he has sustained? Extradural haematoma Extradural haematoma Powered By WordPress Tabs And SlidesBusby SEO Test Why can it be tricky to see skull fractures in some paediatric patients?

In young children the skull sutures have not fully fused. A fracture may be mistaken for an open suture. Avoid this by remembering sutures are often asymmetrical and less straight with cortex seen at their edges In young children the skull sutures have not fully fused. A fracture may be mistaken for an open suture. Avoid this by remembering sutures are often asymmetrical and less straight with cortex seen at their edges. Powered By WordPress Tabs And SlidesBusby SEO Test Learning Points There are two main types of skull fractures Linear by far the most common type, straight, single break in the bone, beware though, there could be more than one Comminuted or Depressed rarer and often the result of more severe trauma. Bone breaks in multiple fragments and fragments are depressed into the skull vault. Two rarer types but vital not to miss are Diastic fracture causes the bone to separate and widen at the skull sutures. Seen in younger patients Basilar breaks in the bones at the base of the skull. These fractures are often the result of severe trauma. Warning signs that should lead to a suspicion of skull base fracture are blood in the sinuses, CSF leaks from nose and ears and racoon eyes due to bruising of orbits as blood collects. (8) Brain Abscess A 24 year old builder is brought to A&E by his worried girlfriend. He has a one week history of fever associated with fatigue and headache and has deteriorated rapidly over the past 24 hours; developing vomiting and increasing confusion and drowsiness. His girlfriend informs you that he has been suffering from toothache on and off for the past fortnight but has been unable to get an appointment with his dentist.

What are the significant points from his history? Fever infective Drowsiness and confusion Raised intracranial pressure Powered By WordPress Tabs And SlidesBusby SEO Test His post contrast CT is seen below Fever infective Drowsiness and confusion Raised intracranial pressure

Report the abnormality, what can you see? Left sided rim enhancing lesion within the left cerebral hemisphere. The lesion is compressing the frontal horn of the left lateral ventricle. Left sided rim enhancing lesion within the left cerebral hemisphere. The lesion is compressing the frontal horn of the left lateral ventricle.

Powered By WordPress Tabs And SlidesBusby SEO Test What is your diagnosis? Cerebral abscess secondary to dental abscess Cerebral abscess secondary to dental abscess Powered By WordPress Tabs And SlidesBusby SEO Test What is the most likely causative organism in this case? Streptococcus Viridans Streptococcus Viridans Powered By WordPress Tabs And SlidesBusby SEO Test Learning Point A brain abscess should always be suspected if a patient has symptoms of infection in combination with symptoms of raised intracranial pressure (headache, vomiting, confusion and coma) and focal neurological damage (seizure, hemiparesis). Most abscesses are caused by spread from local infection such as ear infection; dental abscess and infection of the paranasal sinuses so always keep a look out for these factors in the history and imaging. Brain abscesses can also occur in immuno-comprimised patients such as those with HIV and cancer patients undergoing chemotherapy and these tend to be atypical organisms. (9) Primary Brain Tumour A forty year old female teacher presents to her GP after suffering an episode which on description appears to be a generalized seizure. On taking a full history in addition to the seizure she has been suffering from a gradually worsening headache over the past month.

Post contrast CT scan is seen below

Describe the abnormality seen on the CT scan A right-sided circular mass lesion of low attenuation with ring enhancement. A right-sided circular mass lesion of low attenuation with ring enhancement. Powered By WordPress Tabs And SlidesBusby SEO Test Is the lesion supra or infra tentorial

Supra tentorial- The tumour is centred on the thalamus Supra tentorial- The tumour is centred on the thalamus Powered By WordPress Tabs And SlidesBusby SEO Test What radiological abnormalities in the brain could present with seizures? Tumour Primary Tumour secondary Infection abscess Haematoma

Tumour Primary Tumour secondary Infection abscess Haematoma Powered By WordPress Tabs And SlidesBusby SEO Test What is your diagnosis? Primary brain tumour The tumour in this case is a glioma a tumour arising from the glial cells (nerve support cells). Gliomas are named after the type of cell it most closely resembles with the main types of glioma being Ependymomas ependymal cells Astrocytoma astrocytes Oligodendroglioma oligodendrocytes Mixed More then one type of glial cell

Primary brain tumour The tumour in this case is a glioma a tumour arising from the glial cells (nerve support cells). Gliomas are named after the type of cell it most closely resembles with the main types of glioma being

Ependymomas ependymal cells Astrocytoma astrocytes Oligodendroglioma oligodendrocytes Mixed More then one type of glial cell Powered By WordPress Tabs And SlidesBusby SEO Test Learning points There are over 100 different types of primary brain tumour that can be difficult to distinguish between on CT. You can however gain clues as to the type of tumour by the position in the brain. Try to determine if the lesion is:

extra-axial or intra-axial infra or supra-tentorial Intraventricular

(10)

Cerebral Metastases A 48 year old female with a significant past history of right breast carcinoma presents with a three week history of headache, nausea and vomiting and dizziness. Her CT scan is seen

below.

Describe the radiological abnormalities? Round increased density lesions, with surrounding low density Round increased density lesions, with surrounding low density Powered By WordPress Tabs And SlidesBusby SEO Test How many are there and give regions in the brain? Three one in right frontal lobe, one in right temporal lobe and one in the cerebellar vermis Three one in right frontal lobe, one in right temporal lobe and one in the cerebellar vermis Powered By WordPress Tabs And SlidesBusby SEO Test What would you expect to happen if contrast was given? Three one in right frontal lobe, one in right temporal lobe and one in the cerebellar vermis The rim would enhance Powered By WordPress Tabs And SlidesBusby SEO Test

What is the most likely diagnosis? Cerebral metastases breast primary Cerebral metastases breast primary Powered By WordPress Tabs And SlidesBusby SEO Test Learning points There is a large differential diagnosis of ring enhancing lesions in the brain. You can help decide what pathology is most likely by looking at the areas of the brain, how many lesions there are and the clinical history. Brain abscess Colloid cysts Target lesion multiple sclerosis Demylination Primary Brain tumour Haematoma

Thrombosed aneurysms Thrombosed vascular malformations

Calcification

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