HEAD CT SCAN

NORMAL ANATOMY
• Brain & spinal cord imaging  CT &
MRI
• Unenhanced CT of the brain : appears
white  bone (calcium) density or
blood
Fig.9-4: The X. 1 ,1 basic slice taken near the base of the
skull. A. Diagram of normal anatomy. B. CT image of normal
anatomy
9-5: The Star 2°d basic slice. A. Diagram of normal
anatomy. B. CT image of normal anatomy.
Fig.9-6: Mr. Happy 3rd basic slice. A. Diagram of
normal anatomy.
B. CT image of normal anatomy.
Fig.9-7: Mr. Sad 4th basic slice. A. Diagram of normal
anatomy.
B. CT image of normal anatomy.
Fig.9-8: The Worms 5 11, basic slice. A. Diagram of normal
anatomy. B. CT image of normal anatomy.
Fig.9-9: The Coffee Bean 6m basic slice. A. diagram of normal
anatomy. B. CT image of normal anatomy.
Fig.9-10: Vascular territories. A. The
anterior, middle and posterior
cerebral arteries grossly
supply the anterior, middle and posterior
part of the brain from the X to the Mr. Sad
levels. B. From
the Worms to the Coffee Bean l evel, the
anterior cerebral arteries supply most of
the midline.
Sulkus Kortikalis & FS

Ventrikel & sisterna

Lesi hiper / hipo

Diferensiasi Subs

Midline shifting ?

Batang otak &

cerebelum ?
Kondisi tulang
cranium ?
Non pathologic calcification

• Pineal Gland
• Choroid Plexus
• Falx and tentorium
• Basal ganglia
Falx
Normal calcifications 
White matter basal ganglia
Grey matter
 After administration of
iodinated contrast

Normal structure can enhance :

• Venous sinuses
• Choroid plexus
• Pituitary gland and stalk
 Indication for Head CT
• Congenital anomaly
• Infection (+ contrast)
• Neoplasm / metastatic process (+
contrast)
• Trauma
• Vascular anomaly (+ contrast)
 HEAD TRAUMA
• Choice : unenhance CT
• Parenchyma  brain window
• Fracture  bone window
• Linear, depressed, facial fractures
 HEMORRHAGE
3 Types of extra-axial, intracranial
hemorrhage :
 Epidural haematoma
 Subdural haematoma
 Subarachnoid hemorrhage
 EPIDURAL HAEMATOMA
• Hemorrhage into the potential space
between the duramater and the inner
table of skull
• Dura fused to the calvarium at the
margins of the sutures  EDH do not
crossed suture lines
• Injury to the middle meningeal artery or
vein
• 95% EDH have an associated skull
fracture
• High density, extra-axial, biconvex
lens-shaped mass lesion
• Most often at temporoparietal
• Can cross tentorium
• Acute – sub acute – chronic
• Conservative : Ø < 1,5cm, MS < 2mm,
neurologically intact
 SUBDURAL HAEMATOMA

• Hemorrhage into the potential space

between the duramater and the arachnoid
• Damage to the bridging vein
• Rare : rupture aneurysm or AVM
• Acute SDH : severe parenchymal brain
injury & ↑ ICP
 associated with a high mortality rate
 SUBDURAL HAEMATOMA

• Crescent shape (convex lateral border &

concave medial border)
• extracerebral band of high attenuation
• May cross sutures lines and enter
interhemispheric fissure
• Do not cross the midline
• ACUTE
• CHRONIC
Acute right-sided subdural hematoma
associated with significant midline shift
(ie, subfalcine herniation) shown on CT
scan.
 CHRONIC SDH

• ACUTE : few hours – 2 days

• SUBACUTE : 10 days
• CHRONIC SDH :
– Hypodense chronic SDH (type 1)
– Chronic SDH of inhomogenous density (Type
II)
– Isodense chronic SDH (Type III)
– Slightly hyperdense SDH (Type IV)
SDH KRONIS
SDH KRONIS
SUB ARACHNOID HAEMATOMA

• Damage to blood vessels in pia-

arachnoid
• Hyperdens in the sulci, Sylvian fissure,
basal cisterns, interhemispheric
fissure
• Rapidly cleared from subarachnoid
space  1 week appear N
• Flow of CSF may be obstructed
 CEREBRAL CONTUSION

• Traumatic compression & stretching of

the cerebral tissues causes
circumscribed tissue necrosis and
vascular lesion with extravasation of
oedematous fluid and blood
• Coup : shearing of small intracerebral
vessels
• Counter coup : acceleration / deceleration
injuries, brain is propelled
• Produced cerebral contusion
• Heterogenous increased density mixed
with or surrounded by ares of decreased
or normal density
• Mass effect +/- depends on lesion size
• Evolution several months
• 1 week : decreased density.
• 2 wks : isodens
• 1 months : focal encephalomalacia
 INTRAVENTRICULAR
HAEMATOMA
• Rupture if the ventricular wall with the
ependym and subependymal vessels
• Often collects in posterior horns
• Absorbed or washed out within max 10
days
• May occasionally hinder CSF drainage
and distend individual sections of the
ventricular system
 Diffuse Axonal Injury (DAI)
Among patients with severe HI, only 50% related to presence of

focal hematomas ( EDH, SDH, ICH/contusion )

• Introduced by Strich (1956), then successfully reproduced

experimentally by Genarelli (1982)
• Patient with obvious neurologic deficit or loss of
consciousness without significant lesion on CT scan
• Radiology: presence of hemorrhagic lesion without mass
effect (tissue tear or petechial hemorrhage), in subcortical
white matter, corpus callosum, basal ganglia, or brainstem
• Other fetaures: diffuse edema, t-SAH, and IVH
DAI : CT features
 TCDB Classification of HI based on CT

• Diffuse Injury I: No visible intracranial pathology on CT

• Diffuse Injury II: Presence of lesion densities (may include bone
fragment or foreign body) but not more than 25ml, cistern present,
midline shift may present but less than 5mm
• Diffuse Injury III (swelling): No high or mixed density lesion > 25ml,
midline shift <5mm, cistern compressed or absent
• Diffuse Injury IV (shift): No hugh or mixed density lesion >25ml, midline
shift >5 mm
• Evacuated Mass : Any lesion surgically evacuated
• Non Evacuated Mass: high or mixed density lesion < 25ml, not
evacuated ( from Marshall LF, et al. 1991)
 CT evidences of elevated ICP

• Loss of image of third ventricle

• Loss of image of perimesencephalic cistern
• In unilateral lesion :
1. Midline shift ( should be visualized at level of Foremen Monro )
2. Dilatation of contralateral ventricles
 STROKE

• Cerebrovascular disease
• Haemorrhage / ischaemic
• CT : cause of neurologic
impairment, hemorrhagic / ischemic,
infarct
 ISCHAEMIC STROKE
• Poorly demarcated zone of reduced density
• May also display signs of mass effect
• First appearance at CT : 4-6 hours after
onset
• Later : sharp contour
• Final stage : encephalomalacia  sharply
demarcated zone of fluid density which may
be combined with dilatation of the adjacent
ventricles and parts of the cisterns as a
result of parenchymal defect
 INTRACEREBRAL
HEMORRHAGE
• Fresh haematoma : round or oval focus of
homogenously increased density (55-90 HU)
• Can break through into subarachnoid
space, ventricles
• Perifocal oedema : narrow hypodense
margin
• Density of haematoma decreases slowly
(inhomogenous)
• 3-6 weeks : isodense
• Normal after complete absorption of blood ;
3-6 months
 INTRACEREBRAL
HEMORRHAGE
• Cause (majority of case) : hypertensive
arteriosclerosis
• Less frequent : vascular malformation,
anticoagulant therapy, tumor haemorrhage
 MENINGITIS
• CT is usually normal in uncomplicated
pyogenic meningitis, but it is useful for
detecting complications such as
hydrocephalus, subdural effusion,
abscess or cerebral infarction
• Meningeal enhancement is more
sensitive;
Cerebritis and developing abscess
formation in a patient with bacterial
meningitis. This contrast-enhanced
axial computed tomography scan
shows leptomeningitis and
parenchymal enhancement
(cerebritis) with a low-attenuating
area (edema) in the left basal ganglia.

Subdural empyema with strand in a

patient with bacterial meningitis. This
contrast-enhanced, axial computed
tomography scan shows a bilateral
subdural effusion with cortical
surface enhancement (empyema).
Note that the attenuation of the
effusion is higher than that of the
cerebrospinal fluid.
 ABSCESS
• Brain abscesses arise by haematogenous
dissemination, penetrating trauma or
direct spread from contiguous infection
• Abscesses are frequently subcortical or
periventricular
• Four stages of development are
described: early and late cerebritis and
early and late capsule formation
• cerebritis appears as ill-defined low
attenuation and shows thick ring
enhancement that may progress centrally on
delayed images
• With capsule formation the abscess shows
central low attenuation, because of pus or
necrotic debris and a rim of slightly higher
attenuation surrounded by low attenuation
vasogenic oedema
• After contrast medium, a ring of
enhancement corresponds to the capsule.
The enhancing rim typically has a smooth
inner margin and shows thinning of its
medial aspect[2]
Cerebritis and developing abscess
formation in a patient with bacterial
meningitis. This contrast-enhanced,
axial computed tomography scan was
obtained 1 month after surgery and
shows a small, ring-enhanced,
hypoattenuating mass (recurrence of
abscess) in the left basal ganglia and
a left lentiform-shaped subdural fluid
collection with enhanced meninges
(arrowhead).

Cerebritis and developing abscess

formation in a patient with bacterial
meningitis. This contrast-enhanced
axial computed tomography scan
shows a ring-enhancing, lobulated,
hypoattenuating mass (abscess) in
the left basal ganglia.
 METASTATIC LESION

• The primary neoplasms that most

commonly metastasize to the brain are
carcinoma of the lung, breast and
malignant melanoma
• Generally, metastases appear as multiple
rounded lesions with a tendency to seed
peripherally in the cerebral substance, at
the grey/white matter junction
• Can occur anywhere in the cerebrum,
brainstem or cerebellum and can also spread to
the meninges
• Metastases are characterized by oedema in the
surrounding white matter
• Most metastases enhance strongly with IV
contrast medium, either uniformly, or ring-like if
the metastasis has outgrown its blood supply.
• Most metastases from lung and breast are
similar in density to normal brain parenchyma
on CT, but some types are spontaneously
dense, particularly deposits from malignant
melanoma
 HYDROCEPHALUS

• CSF is produced within the ventricles by

the choroid plexuses, and absorbed at the
cranial vertex and in the spinal canal via
arachnoid villi.
• communicating hydrocephalus’
• noncommunicating’ or ‘obstructive’
hydrocephalus
 COMMUNICATING
HYDROCEPHALUS
• the hallmark of communicating
hydrocephalus is ventricular dilatation, often
marked and generalized, although the fourth
ventricle may be spared
• In young children the occipital horns are
often most affected, but in adults
enlargement of the frontal and temporal
horns is more striking
Thank You
 References
• Learning Radiology – William Herring, MD
• Clinical Radiology Made Ridiculously Simple
• CT and MR Imaging of the Whole Body vol 1 – Haaga
• Cerebral and Spinal Computed Tomography. Schering.
Sebastian Lange
• Emergency Neuroradiology
• Emergency Radiology
• Grainger & Allison Diagnostic Radiology
• http://www.medcyclopaedia.com/library/radiology/ch
apter09/9_5/9_5_1.aspx?tt_topic={312EF2CA-8E50-4F10-
9452-73DE01E03F7A}&tt_item={7C7ADDAD-7140-47BD-
9A9B-A7B2CD8067AF}
EDH
Fr. Basis
Fr. Basis
ICH
INFARK
INFARK HEMISFER
INFARK LUAS TEMPORAL
 KONTUSIO
HEMORRAGIK
IVH, ICH
ICH
IVH, ICH
ICH
INFARK