Introduction to Head CT
Imaging
Ryan Hakimi, DO, MS
Assistant Professor
Director, Critical Care Neurology
Emmaculate Fields, APRN-CNP
Clinical Instructor
Department of Neurology
The University of Oklahoma Health Sciences Center
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DISCLOSURES
FINANCIAL DISCLOSURE
Nothing to disclose
UNLABELED/UNAPPROVED USES
DISCLOSURE
Nothing to disclose
Some slides have been adapted from
teaching modules at OU, UIC, and NSA
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LEARNING OBJECTIVES
Upon completion of this course, participants
will be able to:
Understand the basics of head CT imaging
Identify and describe basic cerebral
anatomy
Develop an approach to head CT
interpretation
Identify pathologic lesions found on head CT
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CT BASICS
CT uses x-rays
Provides axial brain view
CT scan measures density of the tissue being
studied
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CT Brain axial view
CT uses x-rays to
make cross-sectional
axial images
Right is on left and left
is on the right
Patient lying on a
stretcher with feet
coming toward you
and is slid through a
large open ring (CT
machine) Lateral view of skull is shown with imaging planes indicated by lines.
The true horizontal plane is approximated by the orbitomeatal line,
while the typical CT imaging plane is angled slightly upward anteriorly
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CT BASICS-density
Black
Structure/ Hounsfield
Tissue units
Air -1000 to -600
Fat -100 to -60
Water 0
CSF +8 to 18
White matter +30 to 41
Gray matter +37 to 41
Acute blood +50 to 100
Calcification +140 to 200
Bone +600 to 2000
White
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Hyperdense things on CT
ocular lens bone contrast (dye)
calcifications acute blood metal (bullets w/
streak artifact)
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Isodense things on CT
• Note that white matter is
less dense than gray
matter and therefore:
white matter is darker
than gray matter
Gray matter (cerebral
cortex)
Gray matter (basal
ganglia)
White matter
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Hypodense things on CT
fat
air
CSF
(water)
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Normal Brain anatomy
Eye Sella turcica
Optic nerve (contains pituitary
gland)
Sphenoid bone Petrous bone
Temporal lobe
Mastoid air cells
Pons
4th ventricle
Cerebellum
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Normal Brain Anatomy
Frontal lobe
Interhemispheric fissure
Sylvian fissure
Middle cerebral artery
Temporal lobe
Lateral ventricle (temporal horn)
Suprasellar cistern
Perimesencephalic cistern
Midbrain
Quadrigeminal plate cistern
Cerebellum (vermis)
Occipital lobe
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Normal Brain Anatomy
Frontal lobe
Lateral ventricle (frontal horn)
Caudate nucleus (head)
Sylvian fissure
Insula (cortex)
Lentiform nucleus
Internal capsule (post. limb)
Thalamus
Pineal gland (calcified)
Choroid plexus (calcified)
Occipital lobe
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Approach to Reading a CT scan- ABBBC
A- Air-filled structures (sinuses, mastoid air cells)
B- Bones (fractures)
B- Blood (subarachnoid, intracerebral, subdural,
epidural hematoma)
B- Brain tissue (infarction, edema, masses, brain
shift
C- CSF spaces (sulci, ventricles, cisterns,
hydrocephalus, atrophy)
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A- Air-filled Structures
Normal air spaces are black both on bone and brain
window (frontal, maxillary, ethmoid, and sphenoid
sinuses)
Mastoids are spongy bone filled with tiny pockets of air
When these pockets are opacified you will see a (gray or
white) shade
Air-fluid levels in the setting of trauma suggest a fracture
Mastoid opacification without trauma indicates
mastoiditis
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B- Bones
Useful when trauma is suspected
Window your image for bone reading
Recognize normal suture structures (usually
visible on both sides)
If fracture suspected, inspect the opposite
side for similar finding
If not present then look for abnormalities
associated with the fracture (air/pneumocephalus,
black spots within the hemorrhage)
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B- Blood
Location and shape of the blood Types of Intracranial Hemorrhage
Epidural hematoma: over brain convexity, not
crossing suture line, lens shaped (biconvex).
Subdural hematoma: over brain convexity,
interhemispheric, along the tentorium, SDH
will cross suture lines & it’s crescent shaped.
Intraparenchymal/Intracerebral hemorrhage:
within the brain matter, sizes/shape varies
dependent on etiology can be regular or
irregular.
Interventricular hemorrhage- inside ventricles,
can be isolated and or secondary to SAH,
ICH.
Subarachnoid hemorrhage- blood within the
subarachnoid spaces (sulci, sylvian fissure,
cisterns). Usually assumes shape of the
surrounding cerebral structure
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Epidural Hematoma
20% will have a lucid
period before clinical
worsening
Note the soft tissue
swelling adjacent to the
hematoma explaining the E
mechanism of the injury
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Epidural Hematoma
Arterial injury
following head trauma
Lens shaped
Confined between the
sutures
Most commonly
middle meningeal
artery
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Epidural Hematoma
Repeat CT brain (post-op)
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Subdural Hematoma (SDH)
Differentiate between acute, subacute,
chronic, or acute on chronic
Acute SDH
Bright white on CT
Can only be removed with a craniotomy
Doesn’t always require surgery, depends on the
patient’s neurological examination and
comorbidities
Usually related to shearing of bridging veins
between the dura and brain
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Acute Subdural Hematoma
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Acute and Chronic Subdural Hematoma
Patient may be
asymptomatic until
the event leading to
the acute component
Chronic component
can be drained using
a bedside burr hole
device such as the
Subdural Evacuation
Port System (SEPS)
http://www.hakeem-sy.com/main/files/subdural%20hematoma.jpg, accessed on 3/31/10
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ICH: Sites of Spontaneous ICH
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Calculating the ICH Volume
For standard
0.5 cm slices: AXBXC
4
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Predictor of Outcome
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Traumatic Intracerebral hemorrhage
Occurs at the time of
impact
Diffuse axonal injury
Inertial forces cause
deformation of the white
matter, aka shear injuries
Most commonly leads to
acute coma
CT (not very sensitive)
may reveal petechial
hemorrhages in the central
1/3 of the brain
(subcortical white matter,
corpus collosum, basal
ganglia, brainstem,
cerebellum)
MRI to evaluate extent of
injury
Gennarelli, et al J. Trauma 1994
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Traumatic Intracerebral hemorrhage
Focal parenchymal
contusions
Coup, contra coup,
intermediate coup
CT: hemorrhagic core
surrounded by low
density edema
Variable CBF in and
around contusion
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Intraventricular Hemorrhage
Variety of etiologies
Anticoagulation
Hypertension
Aneurysm
Substance abuse
Trauma (less likely)
Often will need an
external ventricular
drain with or without
intraventricular tPA
http://www.bing.com/image, accessed 6/12/14
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Subarachnoid Hemorrhage
Always exclude an aneurysm
even when head trauma is
obvious
Aneurysmal SAH has a poorer
prognosis than traumatic
subarachnoid hemorrhage
Traumatic subarachnoid
hemorrhage
Serially monitor the patient
clinically
Rarely required surgical
intervention
Usually has a good
prognosis
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Practice Reading CT scans-ABBBC
Brain tissue
A. In 1st few hours to day, A B
CT usually normal
(though may show
blurring of gray-white
junction & sulcal
effacement as seen on
next slide)
B. By day 2, CT shows
dark area with mass
effect (compression of Day 1 Day 3
surrounding Acute infarction Subacute infarction
structures)
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Herniation Syndromes
Figure 1. A, Normal anatomy; B,
tonsillar herniation;
C, uncal and subfalcine herniation;
and
D, central herniation.
By permission of Mayo Foundation
for Medical Education and
Research. All
rights reserved. Catastrophic
Neurologic Disorders in the
Emergency Department. 2nd ed.
New York:
Oxford University Press; 2004:67–
69.
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Practice Reading CT scans-ABBBC
Air filled structures
A B C
• A: Left parietoocipital pneumocephalus post-op
• B: Left temporal ICH
• C: Left sinus air fluid level with associated sinus fracture
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Thank you
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