AMIRUL MUKMIN BIN ZARAHMAN @ MUHAMAD  Sinuses seen in brain parenchyma are always black, if not

black then maybe got accumulation of fluid due to infection

ZULKARNAIN
or hematoma
01MBBS-2020090236  If got fracture of the skull, mention which bone, right or left
NEURORADIOLOGY side

1. ORIENTATION TO STUDY V. HAS I.V. CONTRAST BEEN GIVEN?

 Look for sites of normal vessels e.g. middle cerebral arteries,

I. CONSIDER CLINICAL INFORMATION basilar artery
 If the vessels are bright then contrast has been used
 Chief complaint, past history etc.

II. IDENTIFY PATIENT CHARACTERISTICS ON THE IMAGE

III. IDENTIFY IMAGING PLANE AND SLICE THICKNESS

 Transaxial (usually), coronal or sagittal

 Slice thickness usually 5 mm or 10 mm

IV. IDENTIFY WINDOW LEVEL WIDTH

 Brain windows (usually done) to see for hemorrhage

 Bone windows to see fractures of skull or bones
 If there is more than 1 CT image then mention brain or bone
window
BRAIN WINDOW VS BONE WINDOW
 2. EVALUATING BRAIN STRUCTURES 3. ANATOMIC DIAGNOSIS

 Midline look for shift
o Any lesion can cause midline shifting
o Interaxial or extraaxial
 Ventricles, cisterns, sulci
 Major lobes of the brain
o Compare each lobes right to left and see for any
abnormalities
o Grey and white matter can be appreciated
 Deep structures such as basal ganglia, thalami and corpus
callosum Cerebellum and brain stem
➢ Evaluate for size, asymmetry, distortion or
displacement and any change in density
 Intra-axial (lesion within brain parenchyma) versus extra-
axial (lesion outside of brain parenchyma between bone and
meninges layer)
 Focal (e.g. mass, abscess, bleed), multiple (e.g. brain
metastasis) or general lesion (e.g. oedema)
 Right, left or bilateral, specific location
o State right or left + exact location
 What is the density of the lesion?
o Hyperdense : more brighter/whiter than surrounding
brain parenchyma
o Isodense : similar density as surrounding brain
parenchyma/same colour
o Hypodense : more darker than surrounding brain
parenchyma
 Does the density increase (enhancement) after I.V contrast
 Does the lesion cause +ve or –ve mass effect

Positive Mass Effect Negative Mass Effect

This is right midline shift
with compression of right
lateral ventricle and
effacement of sulci
 Midline shift CSF space prominent
 Compression of the ipsilateral (occurs in chronic
lateral ventricle (e.g. lesion of infection : loss of
right will compress right lateral volume, so adjacent
ventricle) CSF space will be
 Cortical sulci effacement prominent)
 Sylvian fissure effacement
 Basal cisterns effacement
 Contralateral ventricle is dilated
4. CONCLUDING DIAGNOSIS

 Normal
o Some diseases even if present may not be seen on
CT but patient comes with sign and symptoms of
infarction
o E.g. acute small infarcts particularly in the posterior
fossa
 Pathologic Diagnosis Acute hematoma after 4 hours X after 4 days X 3 months after
o Infarction : Low density or hypodense in an arterial initial CT scan
territory
o Bleed : High density or hyperdense (e.g. basal ganglia  So, what can be observed from all 3 pictures of evolution of
bleed, subarachnoid bleed) hematoma?
o Tumor : Intra-axial bleed, so must give contrast.  Decreasing density of hematoma with time from
Must observe enhancing lesion with mass effect and hyperdense to isodense then finally to hypodense
with surrounding edema, consider neoplastic versus
granuloma or abscess
o Trauma : Subdural, subarachnoid or epidural
hematomas, contusion
o Degenerative : Atrophic changes. Usually in elderly
patient, ventricle, CSF spaces, cortical sulci would be
prominent. So, the diagnosis would be age related
cerebral atrophy
EXTRA-AXIAL VS INTRA-AXIAL
 INTRAPARENCHYMAL INTRAVENTRICULAR SUBARACHNOID SUBDURAL EPIDURAL
Location Inside the brain Inside the ventricle Between the arachnoid and Between dura and Between dura and skull
pia meter arachnoid
Imaging

Mechanism High blood pressure, Can be associated with Rupture of aneurysms or Trauma Trauma after surgery
trauma, arteriovenous both intraparenchymal arteriovenous
malformation, tumour and subarachnoid malformations or trauma
haemorrhages
Source Arterial or venous Arterial or venous Predominantly arterial Venous (bridging veins) Arterial
Shape Typically rounded Conforms to ventricular Tracks along the sulci and Crescent with concave Lentiform/biconvex shape
shape fissures inner margin with convex margin
Extension Within brain Ventricle Extend to cortical sulci, Extend for long distance limited sutures
parenchyma/within sylvian fissure, basal along convexity of brain
lobes cisterns, ventricle and to interhemispheric
(cerebellum/pons/basal interhemispheric fissure fissure but never to
ganglia/thalamus) cortical sulci/sylvian
fissure because limited by
arachnoid mater
Presentation Acute (sudden onset or Acute (sudden onset of Acute (worst headache of Maybe insidious Acute (skull fracture and
headache, nausea, headache, nausea, life) (worsening headache) altered mental status)
vomiting) vomiting)