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Head CT Scan

dr. Rani Maria


FROM DARKNESS TO LIGHT
What is CT scan?
CT scan is an imaging method
that uses x-rays to create
pictures of cross-sections of the
body.
Gantry with a rotating x-ray
beam and multiple detectors in
various arrays (which
themselves rotate continuously
around the patient),
Sophisticated computer
algorithms to process the data,
a large number of two-
dimensional, slicelike images
What is CT scan?
CT image is composed of a matrix of thousands of
tiny squares called pixels, each of which is
computer-assigned a CT number from 1000 to
+1000 measured in Hounsfield units (HUs),
Sir Godfrey Hounsfield, developing the first CT
scanner (Nobel Prize in Medicine in 1979 with
Allan Cormack)
CT images are displayed or viewed using a range of
Hounsfield numbers preselected to best
demonstrate the tissues being studied
CT basic densities

Air : 1000 HU
Fat : 40 to 100 HU,
Water: 0 HU
Soft tissue : 20 HU to 100 HU.
Bone : HU to 600 HU
ANATOMY OF HEAD CT
Frontal lobes (F); temporal lobes (T); Suprasellar cistern (S); cerebral
temporal horns (white arrows); fourth peduncles (white arrows);
ventricle (4); cerebellum (C); pons (P). interpeduncular cistern (black
arrow).
Sylvian fissures (S); third ventricle (3); Frontal horns of the lateral ventricles
interpeduncular cistern (solid black (white arrow); caudate nuclei (c);
arrow); quadrigeminal plate cistern third ventricle (3); occipital lobes (O).
(white arrow).
Caudate nuclei (C); lentiform nuclei Genu of corpus callosum (dotted white
(L); calcified pineal gland (white arrow); lateral ventricles (L); septum
arrow pellucidum (dashed white arrow);
parietal lobes (P); occipital horn (black
arrow); calcified choroid plexus (solid
white arrows); occipital lobes (O).
Physiologic Calcifications

Pineal gland Choroid plexus


Basal ganglia Falx and tentorium
HEAD CT
Non Trauma Hemorrhagic Stroke
Ischemic Stroke

Trauma Fracture
Intracranial Hemorrhage
Epidural Hematoma (EDH)
Subdural Hematoma (SDH)
Intracranial Hemorrhage (ICH)

Diffuse Axonal Injury (DAI)


Stroke
Stroke is a nonspecific term that usually denotes an acute loss
of neurologic function that occurs when the blood supply to an
area of the brain is lost or compromised
Diagnosis of stroke is usually made clinically
Patients with suspected stroke are imaged to determine if there
is another cause of the neurologic impairment besides a stroke
(e.g., a brain tumor) and to identify the presence of blood so as
to distinguish ischemic from hemorrhagic stroke.
Most acute strokes initially imaged by brain CT scan (24 h
onset), mostly because of its availability.
CT findings may be present immediately after a hemorrhagic
stroke and within hours after the onset of symptoms for
ischemic stroke
Whether or not hemorrhage is present, may determine therapy
Ischemic stroke
Thromboembolic disease as a consequence of
atherosclerosis is the most common cause of an
ischemic stroke.
Source of the emboli can be from atheromatous
debris, arterial stenosis, and occlusion or from
emboli arising from the left side of the heart
(e.g., atrial fibrillation).
The most common finding of an acute,
nonhemorrhagic stroke is a normal CT scan (less
than 24 hours old).
Recognizing Ischemic stroke
On CT, the findings will depend on the amount of time that
has elapsed since the original event.
12 to 24 hours: Indistinct area of low attenuation in a
vascular distribution.
>24 hours: Better circumscribed lesion with mass effect
that peaks at 3 to 5 days and usually disappears by 2 to 4
weeks
72 hours: Though contrast is rarely used in the setting
lesions, contrast enhancement typically occurs when the
mass effect is waning or has disappeared.
>4 weeks: Mass effect disappears; there is now a well-
circumscribed, low-attenuation lesion with no contrast
enhancement
Ischemic Stroke
(CT) and DWI imaging (MRI) in acute
stroke. A, CT scan in this patient with
symptoms for 2 hours prior to the study
is normal. B, DWI MRI on the same
patient a few minutes later shows an
area of abnormally bright signal
intensity in the right frontoparietal
region (white arrow). DWI is an MRI
sequence that can be rapidly acquired
and which is extremely sensitive to
detecting abnormalities in normal water
movement in the brain so that it can
identify a stroke within 20 to 30 minutes
after the event.

Computed tomography, ischemic


stroke, newer and older
Lacunar infarcts
Hemorrhagic strokes
Hemorrhage occurs in about 15% of strokes.
Hemorrhage is associated with a higher
morbidity and mortality than ischemic stroke.
Hemorrhage from stroke can occur into the brain
parenchyma or the subarachnoid space.
In the majority of cases, there is associated
hypertension.
About 60% of hypertensive hemorrhages occur
in the basal ganglia. Other areas commonly
involved are the thalamus, pons, and cerebellum
Recognizing Hemorrhagic Stroke
Increased density on nonenhanced brain
CT scans immediately after the event, due
to protein in the blood (mostly
hemoglobin).
Dissection of blood into the ventricular
system can occur in hypertensive
intracerebral bleeds (IVH)
As the clot begins to form, the blood
becomes denser for about 3 days because
of dehydration of the clot. After day 3, the
clot decreases in density and becomes
invisible over the next several weeks. The
clot loses density from the outside in so
that it appears to shrink.
After about 2 months, only a small
hypodensity may remain
Subarachnoid hemorrhage (SAH)
Rupture of an aneurysm is the most common
nontraumatic cause of a subarachnoid hemorrhage
(80%) but not the only cause as trauma, arteriovenous
malformations, or breakthrough of an intraparenchymal
bleed can also produce subarachnoid hemorrhage
most frequent CNS aneurysm is berry aneurysm, which
develops from a congenital weakening in the arterial
wall, usually at the sites of vessel branching in the circle
of Willis at the base of the brain.
Hypertension and aging play a role in the growth of
aneurysms.
Classical history of a patient who has had a ruptured
aneurysm describes it as the worst headache of my life
Recognizing SAH
On CT, acute blood is
hyperdense and may be
visualized within the sulci
and basal cisterns
The region of the falx may
become hyperdense,
widened, and irregularly
marginated
Generally, the greatest
concentration of blood
indicates the most likely site
of the ruptured aneurysm.
Subarachnoid hemorrhage, unenhanced computed tomography (CT) scans.
Subarachnoid hemorrhage is frequently the result of a ruptured aneurysm. Blood may
be most easily visualized within the basal cisterns (A), in the fissures (B), and
interdigitated in the subarachnoid spaces of the sulci (C). The region of the falx may
become hyperdense, widened, and irregularly marginated.
Fracture
Skull fractures are usually produced by direct
impact to the skull
Most often occur at the point of impact.
Important primarily because their presence
implies a force substantial enough to cause
intracranial injury.
In order to visualize skull fractures, view CT scan
using the bone window
Skull fractures can be described as linear,
depressed, or basilar.
Brain & bone window
Skull fracture
Facial bone fracture
Intracranial hemorrhage
Skull fractures may be associated with
intracranial hemorrhage and/or diffuse axonal
injury.
There are four types of intracranial hemorrhages
that may be associated with head trauma:
Epidural hematoma
Subdural hematoma
Intracerebral hemorrhage
Subarachnoid hemorrhage (discussed with
aneurysms)
Epidural hematoma
Hemorrhage into the potential space between
the dura mater and the inner table of the skull
(Table 27-4).
Most cases are caused by injury to the middle
meningeal artery or vein from blunt head
trauma, typically from a motor vehicle accident.
Almost all epidural hematomas (95%) have an
associated skull fracture, frequently the
temporal bone
Recognizing EDH
High density, extraaxial, biconvex
lens-shaped mass most often
found in the temporoparietal
region of the brain (Fig. 27-8).
Dura is normally fused to the
calvarium at the margins of the
sutures, it is impossible for an
epidural hematoma to cross
suture lines (subdural hematomas
can cross sutures).
Epidural hematomas can cross the
tentorium, but subdural
hematomas do not.
Subdural Hematoma
More common than epidural hematomas
Usually not associated with a skull fracture.
Most commonly a result of deceleration injuries in motor
vehicle or motorcycle accidents (younger patients) or
secondary to falls (older patients).
Usually produced by damage to the bridging veins that
cross from the cerebral cortex to the venous sinuses of the
brain.
Hemorrhage into the potential space between the dura
mater and the arachnoid.
Acute subdural hematomas : presence of more severe
parenchymal brain injury, with increased intracranial
pressure, and are associated with a higher mortality rate.
Recognizing SDH
On CT: crescentshaped,
extracerebral bands of high
attenuation that may cross
suture lines and enter the
interhemispheric fissure.
Do not cross the midline.
SDH is concave inward toward
the brain (epidural hematomas
are convex inward)
Subacute and chronic SDH
Subacute subdural hematomas:
Subdural collections may demonstrate a fluid-fluid
level after 1 week, as the cells settle under serum
Isointense to the remainder of brain, look for
compressed or absent sulci or sulci displaced away
from the inner table as signs of SDH
Chronic subdural hematomas:
more than 3 weeks after injury.
usually low density compared with the remainder of
the brain
Subacute and chronic SDH
Intracerebral hemorrhage
Trauma is only one of the mechanisms that can lead to
intracerebral hemorrhage.
Intracerebral hematomas can also occur from ruptures of
aneurysms, atheromatous disease in small vessels, or
vasculitis.
Coup injuries: Injuries occurring at the point of impact
Contrecoup injuriesinjuries occurring opposite the point of
impact
Either of these mechanisms can produce a cerebral
contusion.
Hemorrhagic contusions are hemorrhages, with associated
edema, usually found in the inferior frontal lobes and
anterior temporal lobes on or near the surface of the brain
Recognizing Traumatic ICH
Multiple, small, well-demarcated areas of high
attenuation within the brain parenchyma
May be surrounded by a hypodense rim from
edema
Intraventricular blood may be present
Mass effect is common, may produce
compression of the ventricles and shift of the 3rd
ventricle and septum pellucidum to the opposite
side (can produce severe brain or vascular
damage)
These displacements are called brain herniations.
Intracranial Hemorrhage
Diffuse Axonal Injury
Diffuse axonal injury is responsible for the prolonged
coma following head trauma and is the head injury
with the poorest prognosis.
Acceleration/deceleration forces diffusely injure axons
deep to the cortex, producing unconsciousness from
the moment of injury. (motor vehicle accident)
The corpus callosum is most commonly affected, and
Initial CT scan may be normal or may underestimatethe
degree of injury.
CT findings may be similar to those described for
intracerebral hemorrhage following head trauma
MRI is the study of choice in identifying DAI.
Recognizing DAI
Thank You

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