CT Scans of the Head:
A Neurologists Perspective
Lara Cooke
January 15, 2009
Objectives
At the end of this session, residents should
be able to:
Identify key anatomic structures on CT
Apply an approach to reading a CT of the head
List reasons to image a patient with headache
Identify CT signs of raised ICP, early ischemia
Describe the clinical presentation of dural sinus
thrombosis
Distinguish between intracranial hemorrhages
General Principles of the CT
CT is basically a specialized X-Ray
We talk about density or attenuation
The image is a measure of absorption
of X-rays through different angles
through a given tissue and then
transformed mathematically
What is hyperdense vs
hypodense on CT?
Bone (dense calcium) (1000 HU)
Metal
Acute (but not hyperacute) blood (56-76 HU)
Thrombosis
Grey matter>white matter (30, 20 HU)
CSF (0 HU)
Fat (-30-100 HU)
Air (-1000)
General Principles:
Are there any fractures?
Use bone windows
Look around the orbits, skull base, zygoma
Remember to look at the sinuses (frontal,
maxillary, ethmoid, sphenoid, mastoid air
cells)
Should be black & full of air--look for hyperdense
fluid levels, thickening of mucosa,
[Link] when the patient complains of
headache
Bones
Fracture
Sinuses
Maxillary
Sphenoid
Frontal
Ethmoid
General Principles
Look at the dura
Is there anything extra between the brain
and the skull?
Hygroma
Blood
Tumor
Air
Things between skull & brain
that shouldnt be there
Hygroma
Subdural Meningioma
hematoma
Epidural hematoma
Pneumocephaly
General Principles
Look at the brain:
Grey-white differentiation
Basal ganglia
Internal capsule
Corona radiata
Is there blood? Is there edema? Is there
CSF due to encephalomalacia/cysts? Is
there a mass?
GW Differentiation
Anatomic Structures
Anterior horn of
caudate lateral ventricle
lentiform
Internal
Insular ribbon capsule
Sylvian (post.
fissure limb)
thalamus Pineal glan
3rd ventricle
General Principles
Look at the spaces
Ventricles:
Can you see all the ventricles?
Is there hydrocephalus?
Cisterns
Are the normal spaces around the brainstem still visible?
Dural Sinuses
Can you see them?
Are they thicker or brighter than usual?
Case
43 yo woman with headache x 3 weeks
Presents to hospital with double vision
Low grade fever
On examination, weakness of EOM of
left eye, mild proptosis, red eye
What do you see?
Sphenoid
sinusitis
CT is good at showing
Bony abnormalities
Acute blood
Large masses (and small enhancing masses
if contrast is given)
Calcified intracranial abnormalities
Edema
Large intracranial aneurysms (now we have
CTA which is very good at this!!!)
stroke
CT might miss
Subacute subdural (isodense to brain)
Isodense tumors/infections with little mass
effect/edema associated
Small aneurysms
Vasculitis
Vascular malformations
Dural sinus thrombosis
Lesions in the posterior fossa
Demyelination/white matter disease
Stroke
Meningeal processes
Diffuse axonal injury
Yield of CT for headache
CT is generally low yield if a thorough
neurologic exam is normal (including
LOC/mentation)
CT is higher yield with focal findings,
decreased LOC
In typical migraine with normal exam,
yield is 0.18%
Normal CT
Maxillary sinus
air-fluid
level
Brainstem
-medulla
Normal CT
Superior ophthalmic vein
Sphenoid sinus
Temporal lobe
Mastoid air cells
4th ventricle
Cerebellum
Normal CT
Internal carotid
artery
Basilar artery
Pons
Temporal horn of right
lateral ventricle
Normal CT
Left MCA
Suprasellar cistern
Cerebral aqueduct
Normal CT
Cerebral peduncle
Interpedulcular cistern
Normal CT Anterior horn
of left lateral
ventricle
Caudate
Lentiform
Posterior limb
of internal
capsule
Insular ribbon
Thalamus
Sylvian fissure 3rd ventricle
Normal CT
Normal CT
Falx cerebrei
Superior sagittal sinus
Normal or Not Normal?
Normal or not normal?
Normal or Not Normal?
Normal or Not Normal?
Raised Intracranial Pressure:
What to look for
Loss of basal cisterns
Loss of suprasellar cistern (unilateral or
bilateral)
Loss of sulcal/gyral pattern
Loss of grey-white differentiation
Enlarged trapped ventricles
Slit-like ventricles
Valproic Acid Overdose
Valproic Acid Overdose
Posterior Fossa
Posterior Fossa Day 3
When not to do an LP
Raised ICP
Do not do an LP if:
you suspect raised ICP
You see a mass or structural lesion with mass
effect (e.g. hematoma)
You see mass effect (displaced structures like the
falx, uncus, ventricles)
You cannot see the basal cisterns
You see hydrocephalus
You have not done a CT, there are neuro
findings/altered LOC and you work in a tertiary
care centre where this test is readily available
When should you image a
headache patient?
When should you order CT for
headache?
Any unexplained neurologic signs
Altered LOC
New headache type in an older patient
Change in pattern of previous headache
Progressive headache
Thunderclap headache
Refractory headache
Headache Red FlagsCT
please!
Abnormal neuro exam
Headache worst on waking in a.m.
Headache waking patient from sleep
Progressive headache
Worse with valsalva
Worse supine than upright
Abrupt onset headache
Other condition predisposing to CNS disease
(immune suppressed, cancer, clotting
disorder, anticoagulants, recent trauma, etc)
35 yo man, assaulted with pipe
Subarachnoid Obliteration of
hemorrhage ant horn of R
lateral ventricle
Epidural
hematoma
Intracerebral
hemorrhage
assault
Midline shift
66 yo man with subacute onset
of language difficulty
Hypodense mas
Edema
Midline shift
wet
Ring enhancing
47 yo man with RA and vertigo
Cerebellar
hemorrhage
Case
39 yo man with polycystic kidney
disease
CT head was done for headache
Normal neuro exam
What do you see?
Small hyperdense
lesion
Case
18 yo girl with a history of ITP
Presents with bizarre behaviour,
difficulty walking and headache
On exam appears indifferent to her
state
Moves both sides well with
encouragement
Left side lags behind when she gets off
bed
CT
Enlarged cortica
veins
MRV & MRI
Dural Sinus Thrombosis
May present with chronic progressive
headache
May present with thunderclap headache
May or may not have abnormal
neurosigns
Predisposing Factors
OCP +/-smoking
Pregnancy/post-partum
Clotting disorder (APA, ACA, Pr C, ATIII, S
deficiencies, Factor V Leiden, cancer, IBD,
nephrotic syndrome)
Dehydration
Local occlusion by trauma/tumor
Infection (meningitis, mastoiditis, sinusitis,
dental abscess)
What you might see on CT
Nothing at all
Hyperdense/misshapen/thickened dural sinus
or cortical vein
Hyperdense/empty delta (empty on enhanced
CT) (do not hang your hat on this to r/o DST)
Venous infarct (wedge shaped, grey-white
junction, associated hemorrhage, deeper
white matter, non-arterial territory
May be bilateral
Diffuse edema/raised ICP
DST
Often missed
25% dont have predisposing factors
Ask yourself if this is a possibility
whenever you want to scan a patient for
headache
Remember the redflags
Remember to look at the fundi
Case II
89 yo woman with progressive
confusion and intermittent spells lasting
10-20 min of word-finding difficulties
Headache for two weeks--moderate,
dull, holocephalic
1) additional history you would like?
2) do you want to do a CT?
Acute on chronic
SDH
Key Points:
Older people are at risk due to atrophy
+ tearing of bridging veins
Ask about anticoagulants
Ask about recent minor trauma
Scan older people who have new
headache
Scan people with TIAs
Small SDH
Acute on chronic
SDH
Case
29 yo male involved in a bar-fight this
evening
Punched in the head - brief LOC then
went home with his girlfriend
Brought in 2 hours later with
progressive decrease in LOC
On exam, comatose, right pupil sluggish
Do you want to do a scan?
Management?
Epidural hematoma
Acute on chronic
SDH
Epidural hematoma
Midline shift
Epidural hematoma
Case
55 yo man fell off of a stool and struck head
on concrete floor
Had had some EtOH
Wife brought him in because he had some
slurred speech and inappropriate behaviour
Headache
On exam, smells like EtOH. Slurred speech.
Behaviour inappropriate. Nil focal.
What do you want to do?
Subarachnoid
hemorrhage
Blood follows the pattern of
gyri/sulci
Subarachnoid
hemorrhage
Pentagon Sign
Subarachnoid
hemorrhage
Pentagon sign + hydrocephalus
Temporal horn of
lateral ventricle
Case
40 y.o. man with new onset mild
incoordination of the Left hand &
behavioural change
What do you want to know?
What do you want to do?
Loss of lentiform
nucleus
Hypodense region
& loss of G-W in M1
Early Ischemic Changes: Clues
to Stroke
ASPECTS
Out of 10
M1, M2, M3, M4, M5,
M6
Caudate
Lentiform nucleus
Internal capsule
Insular ribbon
Also, look at MCA
ASPECT Score
M1,2,3, IC, L, C
ASPECTS
M4-6
Looking for stroke
Time is brain
Stroke more than 12 hours old begins to
look quite hypodense (dark) in the affected
arterial territory
Acutely, there ARE subtle signs--which
may alter likelihood of getting TPa and risk
of hemorrhage
Subtle findings
Look at:
Grey-white differentiation
Presence/loss of sulcal/gyral pattern
Compare side to side - stroke is usually
unilateral--so you have a built-in comparator
Look for hyper dense, asymmetric, vessels
Look for loss of signal in deep structures (basal
ganglia, thalami, internal capsule)
Know the basics of vascular anatomy
80 yo man with dysphasia x 3hrs
Loss of G-W
Differentiation
In M1, M2, M3
Loss of insular
ribbon
Same scan, superiorly
Loss of GW
differentiation
in M4, M5, M6
12 hrs later
Case
68 yo man with DMII, htn.
Woke up with left-sided weakness, leg more
than hand.
What do you see?
Hypodense
Region - ACA
Case
43 yo waiter
Binge drinking
Awoke at 4 am feeling nauseated/headache
Awoke at noon unable to get out of bed
Discovered by his mother & brought to
hospital
Holiday Heart
Monday morning
Case
28 yo woman, 2 days post partum
Headache, left-sided, nausea, vomiting,
photophobia, phonophobia, worsening with
routine activity.
What else do you want to know?
What do you want to do?
What do you see?
Case
Pt 3 weeks post-partum develps severe
headache and left leg paresthesias
Throbbing pain, photophobia, phonophobia,
nausea, x 4 days
Worse with valsalva & lying down
Post-Partum Patient
Case
43 yo man works at packing plant
Developed acute onset of headache and left-
sided weakness
One exam, normal power on left, but
complete sensory loss to all modalities and
mild neglect
PMHx; htn, DM
Ran out of BP meds 2 months earlier
Left sensory loss & neglect
Thalamic ICH
Acute vertigo, N/V, then coma in
80 yo hypertensive man
Cerebellar
hemorrhage
Hypertensive Hemorrhages
Basal ganglia (putamen>caudate)
Thalamus
Pons
Cerebellum
Centrum semiovale
Intraventricular (from basal ganglia)
Case
68 yo RHD woman found wandering at
work, speaking incoherently.
PMHx: Htn, gout
Discontinued BP meds one month ago
Aphasia
Case
70 yo woman developed severe headache &
confusion
On examination, has receptive aphasia &
mild expressive problems
Right visual field abnormality
(homonymous hemianopia)
Headache & Confusion
Case
65 yo man with gradual onset of left-sided
weakness, now has decreased LOC.
?
Case
49 yo woman with known breast cancer
Presents with complaints of problems
seeing
Has L visual field defect
?
Multiple hyperdense
foci
Edema
Case
65 yo man with colon Ca
Presents with word finding difficulties and
headache.
Onset was acute.
?
Take-Home Messages
- dont LP if you think ICP might be up
- Remember to look at more than
parenchyma: Bones, dura, sinuses, cisterns,
ventricles, and dural sinuses
- Look for normal anatomy: grey-white
margin, basal ganglia, insula, internal
capsule
- Chronic blood is not bright--may be
isodense, and therefore subtle
Messages about Headache
If there are focal findings, decreased LOC
or red flag features: SCAN
Ask yourself if this could be a dural sinus
thrombosis
Do LP query SAH, encephalitis, meningitis
Do not LP if youre not sure about the CT
Do not LP without a CT in a tertiary care
centre (caveat--some clinical judgement
here)
Messages about Stroke
Compare side to side
Changes may be present under 3 hours
Image your TIA patients (sometimes they
have something else--eg. SDH)
A normal CT means better prognosis
Early subtle signs mean more damaged
tissue, greater risk of hemorrhage
Time is brain
Tests that sometimes dont
happen, but should.
If you think there may be a neuro problem, be sure
to always do these parts of the CNS exam--
otherwise you may miss the boat:
Look at the discs (dont be shy about dilating)
Check fields
Look at nasolabial folds & forehead
Look for drift
Check toes
Check for sensory extinction
Walk your patient
I dont know what the heck this
is
