CT Imaging (Brain) in

Clinical Practice
Dr Vaibhav Yawalkar
MD
Imaging in ER
 Cranial computed tomography (CT) is an extremely useful
diagnostic tool used routinely in the care of ER patients.

 The attending physician needs to be able to accurately

interpret and act upon certain CT findings without
specialist (e.g., radiologist) assistance, because many
disease processes are time dependent and require
immediate action.

 It has been shown that even a brief educational

intervention can significantly improve the physician’s ability
to interpret cranial CT scans.
PRINCIPLE
 Collimated X-rays are passed through the patient
and information is obtained with a detector on
the other side.

 The X-ray source and the detector are

interconnected and rotated around the patient
during scanning period.

 Digital computers then assemble the data that is

obtained and integrate it to provide a cross
sectional image (tomogram)
 A 2D image is obtained at
each level by 360 degree
rotation of Xray source and
detectors around the patient,
which gives information about
inside of tissue.

 Sequential 2D images can be

combined to obtain full 3D
image.
 X-rays are absorbed to different degrees by different
tissues. Dense tissues such as bone absorb the most x-
rays, and hence allow the fewest passing through the
body part being studied to reach the film or detector.

 This ability to block x-rays as they pass through a

substance is known as attenuation.

 In CT, these attenuation coefficients are mapped to an

arbitrary scale between −1000 hounsfield units [HU] (air)
and +1000 HU (bone)
 Imagine a CT film to be bright grey(silver
coloured) to start with and the xrays
falling on it makes that particular area
darker.

 Morethe exposure to xrays darker will

be the area.
 DIFFERENT SHADES OF GREY
 The reference density for comparison is the brain,
being the largest component inside the skull. Anything
of the same density as the brain is called ISODENSE.

 Anything of higher density (whiter) than the brain is

called HYPERDENSE, and the skull is the best example
of a hyperdense.

 Similarly, anything of lower density (darker tone) than

brain is described as HYPODENSE. The cerebrospinal
fluid (CSF) is the typical example of a hypodense
structure in the brain CT scan. Air is also hypodense
and surrounds the regular outline of the skull in CT.
DESCRIPTION Approx. HU DENSITY

Calcium > 1000 Hyperdense

Acute blood 60-80 Hyperdense
Grey matter 38 (32-42) Hyperdense
White matter 30 (22-32) Isodense
CSF 0-10 HYPODENSE
Fat -30 to - 100 Hypodense
Air - 1000 Hypodense
INDICATIONS
 To diagnose CNS infections and their
complications
 Stroke: to distinguish infarct from hemorrhage
 Acute changes in mental status
 Focal neurologic findings
 Trauma
 Suspected SAH
 CNS tumors or ICSOLs
 Ct angiography before thrombolysis
 Ct venogram for cerebral venous thrombosis(cvt)
CT
 Advantages –
 Easy availability / Low cost
 Fast
 Better for bone and acute haemorrage,
lesions of skull base and calvarium
 Calcification
 Less limited by patient factors

 Disadvantages-
 High radiation
 Poor visualisation of posterior fossa lesions
Viewing Planes

 Axial

 Coronal

 Sagittal
INTERPRETATION OF CT
BRAIN
 1-GENERAL INFORMATION
 2-EXTRACRANIAL TISSUE
 3-CRANIAL BONE
 4-BLOOD
 5-CSF FLOW
 A-VENTRICULAR SYSTEM
 B-CISTERNS
 6-BRAIN TISSUE
 A-MASS LESIONS
 B-SULCI & GYRI
 C-GRY & WHITE DIFFERENTIATION
 A
B

C
D
E
F

G
 A

B
C
D
E
F

G
A
B

F
A
B
C
D
E
F
G
H

I
 A
B
C
D
E
F

G
A
B

C
D
E

G
A
B
C

D
IDENTIFYING CNS PATHOLOGY ON
CRANIAL CT SCANS

SYMMETRY–MIRROR IMAGE

 First step is to simply compare one half of the

scan against the other half. If there are
significant differences (for instance if the
right and left halves are not the same), then
the scan is abnormal.
IDENTIFYING CNS PATHOLOGY ON
CRANIAL CT SCANS
 Radiologists use a “center-out” technique, in which the examiner
starts from the middle of the brain and works outward.
 Clinicians advocate a problem-oriented approach, in which the
clinical history directs the examiner to a particular portion of the
scan.
 A preferred method, one that has been demonstrated to work in
the ER is to use the mnemonic “blood can be very bad”.
 In this mnemonic, the first letter of each word prompts the
clinician to search a certain portion of the cranial CT scan for
pathology.
 The clinician is urged to use the entire mnemonic when
examining a cranial CT scan because the presence of one
pathologic state does not rule out the presence of other.
What to look for:
“ Blood Can Be Very Bad”

 Blood
 Cisterns
 Brain
 Ventricles
 Bone
 Blood

 Blood is the most common hyperdense

abnormality found on a brain CT scan. So if a
hyperdense appearance is not in the right
location for bone then it must be blood, until
proven otherwise.

 So the rule of thumb is that ‘anything white in

the CT scan is either blood or bone’.
Exceptions:
 There are two common exceptions to this rule.

 The Pineal gland is a little Calcified speck in the

middle of the CT scans of most adults.

 The second exception is the calcified choroid

plexus, which is located in the body of each
lateral ventricle
Calcified Pineal
gland

Calcified
Choroid plexus
 Physiologic calcifications
 Choroid plexus- rare before 10yrs

 Basal ganglia- rare before 40ys

 Pineal gland- common after 30 year

 Falx

 Dentate nuclei
 Blood—Acute hemorrhage appears hyperdense
(bright white) on CT. This is due to the fact that the
globin molecule is relatively dense and hence
effectively absorbs x-ray beams.

 As the blood becomes older and the globin breaks

down, it loses this hyperdense appearance,
beginning at the periphery and moving towards
centre.

 Localization of the blood is as important as

identifying its presence.
 On the CT scan, blood will become isodense with the brain at 1 to
2 weeks, depending on clot size, and will become hypodense with
the brain at approximately 2 to 3 weeks.
Peidural hematoma Subdural hematoma
Convex shape Cresent shape
Intra parenchymal hemorrhage Sub arachnoid hemorrhage
in putamen ( hyperdensities in sylvian fissure, basal cysterns)
Intraparenchymal haemorrhage
with intraventricular extension
 Infarcts
 Infarctions can be seen as early as 2 to 3 hours following the
event, but most will not begin to be clearly evident on the CT scan
for 12 to 24 hours. Infact immediate CT scans may be completely
normal in these cases.

 The earliest change seen in areas of ischemia is loss of gray-white

differentiation, due to influx of water into the metabolically active
gray matter.

 The release of osmotically active substances (arachidonic acid,

electrolytes, lactic acid) from the necrotic brain tissue
causes cerebral edema. This is aggravated by vascular injury and
leakage of proteins in the interstitial space. By 3-4 days, interstitial
fluid accumulates in the infarct and around it.
 Infarcts

 The key principle behind successful use of the CT scan

in dealing with ischemic stroke is KNOWING WHERE TO
LOOK, AND WHAT TO LOOK FOR! And WHEN TO LOOK!

 The golden rule with stroke as with most of emergency

neurosurgery or neurology is that, the clinical symptoms
reign supreme.
Non-contrast CT scan of a 61-year-old male with sudden onset right
hemiplegia two and a half hours prior to the CT scan. He is
diabetic and hypertensive.

The CT findings are often only as important as the question it was

intended to answer! What was the clinical question in requesting a CT scan
Here?
Non-contrast CT scan of the same patient after 8 hours now
showing the obvious left basal ganglia infarct

Justifying the need of follow up scans.

 One specialized type of stroke frequently
identified on CT imaging is a lacunar infarction,
which are small, discrete nonhemorrhagic
lesions usually secondary to hypertension and
found in the basal ganglia region.

 They frequently are clinically silent.

Lacunar infarct in
Basal ganglia.
Infarcts

Anterior cerebral
artery infarct
Middle cerebral artery infarct Hyper dense MCA sign

Internal cerebral artery infarct

ACA+MCA
Posterior cerebral artery infarct
Cisterns
 Cisternsare potential spaces formed
where there is a collection of CSF
surrounding the Brain.

 There are four key cisterns that the

physician needs to be familiar with in
order to identify increased intracranial
pressure as well as the presence of
blood in the subarachnoid space.
 Cisterns
 Circummesencephalic: Hypodense CSF ring around
the midbrain; most sensitive marker for increased
intracranial pressure; will become effaced first with
increased pressure and herniation syndromes.
 Suprasellar: Star-shaped hypodense space above the
sella and pituitary; location of the circle of Willis, hence
an excellent location for identifying aneurysmal
subarachnoid hemorrhage.
 Quadrigeminal: W-shaped cistern at the top of the
midbrain; can be a location for identifying traumatic
subarachnoid hemorrhage, as well as an early marker
of increased intracranial pressure.
 Sylvian: Bilateral CSF space located between the
temporal and frontal lobes of the brain; another good
location to identify subarachnoid haemorrhage.
 A B

CT appearance of increased intracranial pressure:

A: normal intracranial pressure
B: elevated intracranial pressure.
Ventricles:
 Pathologic processes can cause either dilation
(hydrocephalus) or compression/shift of the ventricular
system.
 Hydrocephalus frequently is first evident in dilation of
the temporal horns, which are normally small with a slit-
like morphology.
 It is likely that enlargement is the result of brain volume
loss rather than the increased ventricle size, particularly
in older ages.
 Conversely, if the ventricles are large, but the brain
appears “tight” with sulcal effacement and loss of
sulcal space, then the likelihood of hydrocephalus is
high.
Increasing degrees of temporal horn
Dilatation in worsening hydrocephalus
Gross hydrocephalus, showing dilatation of frontal horns,
body and occipital horns.
Effacement of sulci due to raised
ICP
Evan’s Index for Hydrocephalus
 Maximum transverse diameter of Frontal Horns divided
by Maximum internal transverse diameter of cranium

If Index is > 0.3 , suggests

Hydrocephalus.
CNS infections

 Meningitis:

Radiological signs:
 Meningeal enhancement
 Cerebral edema
 To look for fractures of skull base
and other complications.
 In cases of suspected bacterial meningitis with
clouded consciousness, an immediate cranial CT is
recommended before lumbar puncture to rule out
causes for swelling that might lead to herniation.

CT findings are mostly normal. Contrast-enhanced CT

may show beginning meningeal enhancement,
which becomes more accentuated in later stages of
disease.

CT is important and sufficient to define pathology of

the base of skull that may be causative and require
rapid therapeutic intervention and surgical
consultation.
Meningeal enhancement in case of meningitis
Space occupying lesions
(SOL)
 Brain Abscess

 Primary Tumors

 Metastases
Space occupying lesions
 Such lesions will present with one or more of the following
clinical problems:

 Features of raised ICP

 Convulsions
 Headache
 Focal neurological deficits
 With/without altered level of consciousness.
 Fever in brain abscesses.

 Slow-growing tumours may give rise to a longer duration of

symptoms.
Points to be considered to
study ICSOLs

 Mass effect
 Enhancement on contrast
 Appearance
 Location
 Mass effect
 The side with a tumour or abscess is more likely to have the sulci
squeezed (effaced) and often the lateral ventricle on that side is
also compressed ,and in more severe cases there is midline shift
towards the normal side.

 This is often the first clue that there may be a lesion ,prompting
the intravenous injection of contrast to see if the lesion takes up
contrast and become brighter.

 Most brain tumours will declare their presence by a significant

mass effect from their size or by the severe oedema around them
Non-contrast CT scan showing alterations of the normal
sulcal pattern as evidence of mass effect from an
 A) isodense meningioma
 B) a low-density glioma
 C) hyperdense meningioma
Enhancement
 “Enhancement simply means it is appearing clearer” that is
higher density compared to the pre-contrast scan.
 When injected intravenously the contrast material concentrate
in vascular areas of the brain including tumours and abscess
walls thereby making them appear hyperdense and hence
easier to see.
 Meningiomas and lymphomas tend to enhance uniformly and
intensely whereas malignant gliomas and abscesses may show
an intermediate degree of enhancement in which there is an
outer enhancing ring surrounding a core of non-enhancing low
density (necrotic centre), which fails to take up the contrast.
 Abscesses typically show THIN UNIFORM enhancing wall
surrounding the pus whereas the ring of enhancement in
gliomas is thicker with more solid tumour in the wall
 In general abscesses have a thinner and
smoother enhancing ring with no chunk of
enhancing tumour along the wall.
 Whereas the enhancing ring in malignant
gliomas and metastatic tumours tends to be
thicker and irregular and there may be an
asymmetric large chunk of enhancing tumour
as part of the wall.
 Hypodensities in INFARCTIONS will have DIFFUSE
margins as compared to SMOOTHER margins in
above lesions.
 Tumours such as Meningiomas are obvious
and call for little differential diagnosis.

Pre- and post-contrast CT scans of a 22-year-old male that presented

with seizures. Effect of contrast is obvious.
 Brain Abscess

Contrast-enhanced CT scan showing a brain abscess

in a patient on immunosuppression therapy for SLE.

Lesions show smooth outline of the rings of enhancement.

Contrast-enhanced brain CT scan illustrating a uniformly enhancing
left parafalcine meningioma. It is solid and very Unlikely an abscess.

It is benign and carries a good prognosis

 Malignant gliomas and metastatic tumours share the
property of ring enhancement with abscesses and are
therefore the subject of much clinical controversy.

 A patchy irregular enhancement will suggest a partially

solid and cystic tumour like a glioma, and a ring
enhancing, circular lesion with central hypodensity will
suggest an abscess with the important differential
diagnosis of a metastasis.
Contrast CT scan showing a left frontal irregularly enhancing tumour
with solid and cystic components.

This is a typical appearance for a high-grade glioma usually

glioblastoma.
 Glioblastoma multiforme

Cystic, solid and partially calcified with Irregular enhancement

Location
 A uniformly enhancing tumour with a broad based
attachment to the dura, it is a meningioma until
proven otherwise.

 A ring-enhancing lesion located deep in the white

matter, is most likely
A Glioblastoma (if soild/cystic/ irregularly enhancing) or
 An abscess (if thin ring enhancement and hollow core)
 A metastasis (if multiple)
Thin Ring of Abscess Thick ring of glioma
Lesions mimicking abscess, but multiple lesions and
clinical history if available favours METASTASIS
Metastasis
DDs for multiple ring
enhancing lesions
 Tuberculoma
 Neurocysticerosis
 CNS cryptococcosis
 Metastasis
 Abscess
 Glioblastoma
 Granulomas
 Toxoplasmosis / Lymphoma (common in AIDS)
 Neurosarcoidosis
Ring Enhancing Lesions
with Perilesional Edema

 TUBERCULOMA

VS

 NEUROCYSTICERCOSIS
 Cysticerci are usually round in shape, 20 mm or less in
size with ring enhancement or visible scolex, and
cerebral edema severe enough to produce midline shift
and focal neurological deficit is not seen.
 Tuberculomas are usually irregular, solid and greater
than 20 mm in size. They are often associated with
severe perifocal edema and focal neurological deficits.
 A lesion greater than 20 mm is likely a Tuberculoma.
 Visualization of an enhancing or a calcified eccentric
dot which represented the scolex, could be considered
a definite imaging feature of cysticercus etiology
Tuberculomas with perilesional Edema
Multiple NCC
Multiple NCC in Vesicular stage:
scolex can be seen inside cysts
Contrast Nephropathy
 Rise in serum creatinine level of at least 1 mg/dL
within 48 hours of contrast administration.
 Incidence more when used Ionic contrast material.
 Mechanism of Injury:
 Renal Tubular Obstruction
 Endothelial cell damage
 Immunological Reactions

 There is favourable prognosis and creatinine levels

return to normal in 1-2 weeks.
Risk Factors:
 Age > 80 Years

 Pre-existing renal disease [Creatinine > 2 mg/dL]

 Solitary Kidney

 DM / Dehydration / Paraproteinemia

 Patients on Nephrotoxic Medications

Prevention
 Using non-ionic contrast
 Using low dose of contrast
 Prior Hydration
 Using bicarbonate and
acetylcysteine
Allergic Reactions to
contrast
 Incidence 0.04 % with Non-ionic contrast.
 History of Atopy, bronchial asthma or other allergies are at
more risk.
 If patient has history of prior contrast allergy and if contrast
absolutely required:
Premedicate with:
 12 Hours before administration: Prednisolone 50 mg PO
 2 Hours before: Prednisolone 50 mg + Cimetidine 300 mg
 Just before administration : IV Diphenhydramine 50 mg