Brain CT Essentials: Alexander Mamourian, MD

BRAIN CT
ESSENTIALS
HANDBOOK
Alexander Mamourian, MD
Table of contents
Abbreviation list 4
Chapter 1: The basics

Describing the basic anatomy of the brain 7
Describing the basic anatomy of the skull 14
Recognizing the effect of window and level on CT images 24
Chapter 2: Trauma imaging

Recognizing extra-axial hemorrhage 33
Defining shear injury 43
Identifying intra-axial hemorrhages 48
Discussing subarachnoid hemorrhage in trauma patients 54
Recognizing common pitfalls in CT interpretation 62
Chapter 3: Stroke imaging

Identifying early CT findings of infarctions 71
Describing the evolution of infarcts 78
Explaining the effects of thrombolysis 86
Demonstrating the role of CT angiography and perfusion CT 92
in the acute stroke patient
Chapter 4: Nontraumatic hemorrhage

Recoginizing subarachnoid hemorrhage on CT 97
Identifying common locations for aneurysms 104
Describing CT features of cavernomas and arteriovenous malformations 113
Diagnosing parenchymal hemorrhage 122
Describing isolated intraventricular hemorrhage 134
Chapter 5: Brain tumor imaging

Recognizing intra- versus extra-axial tumors on CT 141
Distinguishing common adult extra-axial tumors 153
Recognizing intra-axial tumors 159
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Chapter 6: Seizures and epilepsy
Describing CT findings in patients with seizures 169
Explaining the role of CT and MRI in patients with seizures 177
Chapter 7: Metabolic disorders, infections,

and demyelination
Describing abnormalities in the basal ganglia 182
Identifying brain abscess and encephalitis 193
Describing the CT findings of demyelination 198
Chapter 8: Skull abnormalities

Describing the typical appearance of skull fractures 204
Identifying benign disease and malignant bone lesions of the skull 212

Abbreviation list
ACA anterior cerebral artery
ACoA anterior communicating artery
ADEM acute disseminated encephalomyelitis
AVM arteriovenous malformation
CPA cerebellopontine angle
CSF cerebrospinal fluid
CT computed tomography
CTA computed tomography angiography
CTV computed tomography venography
DAI diffuse axonal injury
DSA digital subtraction angiogram, or digital subtraction angiography
FLAIR fluid-attenuated inversion recovery
HU Hounsfield units
INR international normalized ratio
IPH intraparenchymal hemorrhages
MCA middle cerebral artery
MRI magnetic resonance imaging
MRA magnetic resonance angiogram, or magnetic resonance angiography
MS multiple sclerosis
PICA posterior inferior cerebellar artery
PCA posterior cerebral artery

PCoA posterior communicating artery
PACS picture archive and communication system
SWI susceptibility weighted magnetic resonance imaging
TBI traumatic brain injury
TDL tumefactive demyelinating lesion

Chapter 1
THE BASICS
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Describing the basic anatomy of the brain
Before going into detail about how to read and interpret brain computed tomography
(CT) images, first, let’s review how axial CT images are displayed. When you view an
axial CT scan, the convention for left and right is established by imagining that you
are looking at the scan while standing at the feet of the patient. This means that as
you look at the axial CT images, your left is the patient’s right side.
Figure 1. When reading a brain computed tomography (CT), the left side of the image depicts the patient’s
right side, and the right side of the image depicts the patient’s left.
High and low attenuation on a brain CT scan

The word attenuation is used to describe how tissues interact with the x-ray
beam. X-rays easily pass through structures with low attenuation, and they are
represented as such on the image with a shade of gray on a CT scan. Structures
with high attenuation will limit x-ray passage and be displayed as shades of white.
Fluid, fat, and air are dark because they have low attenuation. Bone and metal, on the
other hand, are displayed on a CT image as white because of their high attenuation.

Figure 2. Fluid, air, and low-density tissues such as fat have low attenuation and appear as shades of gray on
a computed tomography (CT) scan. Metal and high-density tissues such as bone have high attenuation and
appear as shades of white.
Using CT imaging for clinical diagnoses

While some may think the goal when viewing a CT is to look for a focal abnormality
(like a hemorrhage or mass), it is just as important to look for normal structures. An
absence of normal structures on brain CT, in many cases, will lead you to the correct
diagnosis, especially when the abnormalities are symmetric or subtle.
As an analogy, if you were asked what is wrong with the image of a house after
a hurricane, you would need to know that there used to be a chimney on the roof
before you could recognize that it is missing. Similarly, it’s important to know what
key anatomical features look like on a normal CT scan, so you can recognize when
they are absent.

Five key anatomical structures to identify
on a brain CT scan
So, before considering anything else, you should make it your routine to identify the
following five anatomical structures on a patient’s CT scan. This is imperative, since
noticing an absence of any one of these five structures could lead you to a correct
diagnosis.
Here are the five anatomical structures you’ll want to identify when reading a CT scan:
• Fourth ventricle
• Ambient cistern
• Basal ganglia and thalami
• Pituitary gland
• Foramen magnum
Identifying the fourth ventricle on a brain CT scan
One of the five important structures to identify on a CT scan is the fourth ventricle.
It should be in the midline and have low attenuation, since it is filled with fluid. The
fourth ventricle should be visible on all normal CT scans.
Figure 3. The fourth ventricle is an important structure to identify on a computed tomography (CT) scan and
should be visible on all normal CT scans. It can be found in the midline and has low attenuation.
The remaining contents of the posterior fossa are usually poorly visualized on most
CT scans, because of artifacts from surrounding bones. A change in the normal
shape and location of the fourth ventricle may be the only evidence of a tumor or
subacute hemorrhage nearby.

For example, in this patient with a right-sided tumor, the fourth ventricle is visibly
compressed and displaced to the patient’s left side (Fig. 4). By viewing magnetic
resonance imaging (MRI) scans of the patient and then looking back at the CT, it
becomes easier to identify the abnormality.
Figure 4. In this patient case, the abnormal shape and location of the fourth ventricle in brain computed
tomography (CT) is the only sign of a large tumor nearby. The two magnetic resonance imaging (MRI) scans
of the same patient reveal not just one but two metastatic lesions within the cerebellum.
When reading a brain CT, you should also look within the fourth ventricle, since both
benign and malignant tumors can appear there.
Sometimes, the fourth ventricle is not visible at all! This can be the result of
compression or because it is filled with blood causing it to have a higher attenuation
than normal (and appear gray like the surrounding structures).
Figure 5. Sometimes the fourth ventricle is not visible at all on brain computed tomography (CT). In these
examples, a choroid plexus metastasis from an osteogenic sarcoma of the femur is visible within the fourth
ventricle, and the fourth ventricle is not visible at all because it is filled with blood.

Identifying the ambient cistern on brain CT
The second structure you should identify on all brain CT scans is the ambient
cistern. This is a fluid-filled space lateral to the cerebral peduncles.
Figure 6. Brain computed tomography (CT) scan of a normal ambient cistern in relation to the left and right
cerebral peduncles.
By looking for the ambient cistern on all CT scans you read, you will develop a sense
of what is normal at different patient ages. In other words, don’t just look at the
ambient cistern when you are looking for a midbrain mass.
An absence of a visible ambient cistern can be a sign of a brain herniation. A CT

image may not look concerning at first glance, until you notice the absence of the
ambient cisterns. This is frequently due to severe brain swelling that leads to a
downward herniation of the cerebral hemispheres.
Figure 7. The absence of the ambient cistern (left image) in a brain computed tomography (CT) scan is a sign
of a brain herniation.

Identifying the basal ganglia and thalami on brain CT
The basal ganglia and thalami are symmetric, deep structures in the brain. Since
they are frequently symmetrically abnormal, you’ll need to look for them in each
brain scan you see so that you’re familiar with their normal appearance on CT.
The lentiform nucleus and the caudate are two components of the basal ganglia.
Since these structures have a higher attenuation than white matter, they, along with
the thalami, are normally defined along one border by the white matter of the internal
capsule (which has lower attenuation).
Figure 8. Brain computed tomography (CT) scan featuring normal basal ganglia and thalamus.
On this CT scan of a patient who survived drowning, you can see the basal ganglia
well (Fig. 9). But only because the basal ganglia are abnormally low in attenuation.
Remember, they should have higher attenuation than the internal capsule. This
finding indicates a bilateral infarction of the basal ganglia from prolonged hypoxia.
Figure 9. Brain computed tomography (CT) scan of a patient who survived drowning depicting abnormally low
attenuation of the basal ganglia, indicating bilateral infarction from prolonged hypoxia.

Identifying the pituitary gland on brain CT
In adults over 40 years of age, the pituitary gland sits inside the sella turcica and
does not normally extend above the dorsum sellae (the posterior wall of the sella
turcica). On a normal brain CT scan, you will see a fluid space in the region just
anterior to the dosum sellae.
Considered in relation to anatomical position, this cerebrospinal fluid (CSF)-filled

space is sitting the above the pituitary gland. Loss of this fluid space can indicate
that the pituitary gland is enlarged.
Figure 10. On a normal brain computed tomography (CT) scan, you can note a low attenuation cerebrospinal
fluid (CSF) space that lies anterior to the dorsum sellae.
Sometimes, soft tissue—rather than fluid attenuation—appears anterior to the

dorsum sellae. This may be due to a pituitary tumor. It is one abnormality that is
frequently overlooked when only axial CT images are reviewed, so pay attention to
this site on brain CT!

Figure 11. Brain computed tomography (CT) scan featuring an abnormal pituitary. Instead of a fluid space,
an area of abnormally high attenuation due to a soft tissue mass appears anterior to the dorsum sellae due
to a pituitary tumor.
Identifying the foramen magnum on brain CT
The foramen magnum is at the bottom of the skull where the brain joins the spinal
cord. Normally, you should be able to see the cerebellar tonsils and the medulla as
separate structures within the foramen magnum.
Figure 12. Brain computed tomography (CT) scan featuring a normal foramen magnum with the medulla and
cerebellar tonsils visible within.

On the other hand, mass effect from a tumor may cause the foramen magnum to
appear featureless on a brain CT scan. Abnormalities at the foramen magnum are
frequently missed on axial CT images.
Figure 13. Brain computed tomography (CT) scan with an abnormal foramen magnum. The foramen magnum
appears featureless due to a tumor along the clivus.
The foramen magnum may also appear featureless due to a low cerebellar tonsil
position called a Chiari malformation. A Chiari malformation is much easier to see
on a CT sagittal reconstruction.
Figure 14. The foramen magnum appears featureless on brain computed tomography (CT) due to a low
cerebellar tonsil position called a Chiari malformation.
Don’t be lulled into thinking a head CT is easy to read because the brain is
symmetric! Always look for these five normal anatomic features, since the most
critical observation you make on a CT scan may be what you don’t see.

Describing the basic anatomy of the skull
Just as it’s important to be able to identify key anatomical features of the brain on
computed tomography (CT) images, you should make it a habit to find the anatomical
features of the skull base, since their absence can be a sign of disease.
Of course, you should always look at the calvarium in all cases, since many diseases
such as multiple myeloma, or focal skull abnormalities like depressed skull fractures
will present there!
Figure 1. Examining the skull as well as the brain on all computed tomography (CT) scans will allow you
to identify diffuse skull abnormalities such as multiple myeloma, and focal skull abnormality such as this
depressed skull fracture.
Throughout this guide, you will frequently be shown abnormalities on both CT and
magnetic resonance imaging (MRI). Viewing an abnormality such as bone destruction on
an MRI often makes it easier to visualize when you look back at the CT scan.
Figure 2. Bone destruction is visible on a computed tomography (CT) scan, but it is easier to see the soft tissue
mass on CT after you have already seen it at the same level on magnetic resonance imaging (MRI).

Five important anatomic features in the skull base
The following five anatomic features found at the skull base are vital to identify on a
CT scan, since their absence is considered abnormal:
• Carotid canals
• Foramen ovale
• Foramen spinosum
• Petrous apex
• Dorsum sellae
Identifying the carotid canals on brain CT
The bony carotid canals in the skull base are normally symmetric.
Figure 3. The carotid canals in the skull base are normally symmetric.
Sometimes on vascular imaging, a normal-sized carotid will be evident on one

side but will appear narrow on the other. While this can be due to a carotid stenosis,
you should also consider carotid hypoplasia.

Figure 4. Brain magnetic resonance imaging (MRI) and computed tomography (CT) scans of asymmetric
bony carotid canals. A normal carotid is visible on the MRI but only on one side. This may be due to carotid
occlusion, stenosis, or hypoplasia. The CT scan of the same patient shows a smaller right bony carotid canal
than the left. This bony asymmetry indicates that the carotid asymmetry is due to congenital hypoplasia on
the patient’s right canal.
Identifying the foramen ovale on brain CT
There are a pair of symmetrical openings in the skull base—the foramen ovale. The
third division of the fifth cranial nerve carries sensory fibers from the face to the
brainstem, that enter the skull through the foramen ovale.
Figure 5. The foramen ovale in the skull base are normally symmetrical.

If a patient’s CT scan shows a larger foramen ovale on one side, this could be due
to a tumor! In this case, the tumor extended from the cavernous sinus through the
foramen ovale which led to its enlargement (Fig. 6). This was much more evident on
an MRI with contrast.
Figure 6. An enlarged and asymmetric foramen ovale suggests expansion by a tumor. In this case, the tumor
involved the cavernous sinus and Meckel’s cave.

Identifying the foramen spinosum on brain CT
The small foramen just posterior to the foramen ovale is the foramen spinosum. The
middle meningeal artery, a branch of the external carotid, enters the skull through
this foramen. On a magnetic resonance angiogram (MRA), you may be able to see the
small middle meningeal arteries entering the skull through the foramen spinosum.
Figure 7. A normal foramen spinosum visible just posterior to the foramen ovale. A magnetic resonance
angiogram (MRA) shows the middle meningeal arteries entering the skull through the foramen spinosum.
Sometimes, the foramen spinosum may not be visible on a CT scan in its usual
location posterior to the foramen ovale. This finding suggests either a vascular
variant of the middle meningeal artery or an aberrant course of the carotid artery.
Figure 8. The absence of the foramen spinosum posterior to the foramen ovale suggests the presence of
either a vascular variant of the middle meningeal artery or an aberrant course of the carotid artery.

Identifying the petrous apex on brain CT
The petrous apex is the medial portion of the petrous bone that lies just posterior to
the carotid canal. Infections, aneurysms, tumors, and cysts can involve the petrous
apex.
On a CT scan, you can identify bony remodeling of one petrous apex by comparing
it to the other. Remodeling of the petrous apex can be due to benign and malignant
disease. Here, it was from a benign mass called a giant cholesterol cyst, which can
be seen on MRI.
Figure 9. Bony remodeling of the left petrous apex can be seen when compared to right petrous apex on a
computed tomography (CT) scan. A benign mass called a giant cholesterol cyst is the cause of this remodeling,
which is more evident on a magnetic resonance imaging (MRI) scan.
Identifying the dorsum sellae on brain CT
The sella turcica is a depression on the upper surface of the sphenoid bone that
contains the pituitary gland. We often use the term sella to refer to this depression.
On a normal brain CT, you can see the back wall of the sella turcica—the dorsum
sellae.
On a CT scan, a normal adult sella contains low attenuation cerebrospinal fluid

which sits on top of the pituitary gland. On computed tomography angiography
(CTA) images, you can often see this normal low attenuation fluid anterior to the
dorsum sellae.

Figure 10. Computed tomography angiography (CTA) images showing normal low attenuation anterior to the
dorsum sellae.
A sellar and suprasellar mass is one reason you may see abnormally high attenuation
inside the sella, anterior to the dorsum sellae on a CT scan.
Figure 11. As seen in these adjoining slices from a computed tomography (CT) scan, this patient has
abnormally high attenuation within and above the sella due to a sellar and suprasellar tumor.
Keep in mind that not all sellar enlargement arises from the pituitary gland.
Sometimes you may be looking at an aneurysm, which may be more evident on a
coronal reconstruction of a CTA image.

Figure 12. Enlargement of the sella may be due to a giant aneurysm rather than a pituitary gland mass.
In this section, you have learned how to identify five important anatomic features in
the skull base. You should look for these on every scan, so you can become familiar
with variations that may occur with patient of different ages, as well as different
angles of the scan reconstruction.

Recognizing the effect of window and level
on CT images
Let’s review how window, level, and filtering all contribute to computed tomography
(CT) image display. Manipulating these options when viewing a brain CT image can
help you minimize diagnostic imaging errors.
While there was a time when CT images were printed on large sheets of film, CT
images are now stored electronically and viewed on a computer screen using a
Picture Archive and Communication System (PACS). PACS not only makes the
images widely available, but it also allows you to manipulate their appearance.
By using varying window, level, and filtering options, the same CT data can be
displayed in different ways. Certain settings show bony structures well, while the
brain is better visualized using other settings.
Figure 1. The same computed tomography (CT) scan displayed with different window, level, and filtering of
data. In this way, the same data can be used to display bony structures and the brain with different settings.

Keep in mind that the terms window and level refer only to the way we display the
CT data. They should not be confused with the parameters used to acquire CT data
such as x-ray tube current, peak voltage, and detector slice thickness.
Why adjust window and level on a CT scan image?

It is important to understand the role of window and level settings in CT diagnosis,
since they can either reveal or hide important findings on CT. For example, when the
same scan is viewed with two sets of window and level settings, it’s possible that
only one will reveal an abnormality of the skull!
Figure 2. The same computed tomography (CT) scan data viewed with two different window and level settings.
Only the left image makes it obvious that the skull defect on the patient’s right was filled with an acrylic
cranioplasty.
How CT scan data is displayed

Computed tomography scan data is collected using an x-ray source on one side of
the patient, and multiple x-ray detectors on the other side. The CT scan image uses
shades of gray or white to indicate the magnitude of the x-ray beam’s interaction
with the scanned body parts.
For example, since the bony skull blocks (i.e., attenuates) the passage of x-rays
considerably more than the brain, its high attenuation is represented on the CT
image with a shade of white. But, the air-filled sinuses allow the x-ray beam to
pass through unimpeded, so it provides little attenuation of the x-ray beam and is
represented as a shade of gray on the image.

Figure 3. Brain computed tomography (CT) scan displays bone, that has high attenuation of the x-ray beam,
as white and tissues with low attenuation as shades of gray.
How x-ray attenuation is reported on a CT scan

The magnitude of the x-ray attenuation during the CT scan can be calculated
and reported using Hounsfield units (HU). These attenuation values on a patient
scan can range from -1000 to +1000 HU, reflecting the wide differences in x-ray
attenuation in the skull and brain.
If you then try to display this data on one black and white image, it would require
hundreds—if not thousands—of shades of gray! Unfortunately, our human eye-brain
interface is limited in perception and can only distinguish about 20 shades of gray
between black and white. This represents a substantial limitation to displaying all of the
available CT information. The solution? Display only a portion of the data at one time.
Figure 4. The attenuation values on a computed tomography (CT) scan would require using hundreds—if not
thousands—of shades of gray, but the human eye can only distinguish about 20 shades.

Defining window and level settings for CT images
The terms window and level when discussing CT imaging indicate how much of that
information we choose to display on the image at one time. Window indicates the
range of HU values you choose to display, and level represents the midpoint of that
range. You might think it would be possible to show the most information at one
time by using a very wide window, but that means tissues of dissimilar attenuation
values will be represented with the same shade of gray.
Figure 5. X-ray attenuation scale for a CT scan showing a window of 80 and a level of 40.
How to choose the right window and level

settings for a CT scan
In order to choose the best window and level settings to view CT images, consider
first what it is that you are looking for. If you are looking for an acute brain infarction,
it is best to use a very narrow window since we know that there is only a small
difference in attenuation between the normal brain and an acute infarct. While it
provides the best possible contrast for detection of an infarct, all the tissues with
attenuation values either above and below the selected window to be lumped
together into all gray or all white.
Figure 6. It’s important to first consider what you are looking for when choosing a window and level setting.
For example, brain infarctions are best viewed in a very narrow window since there is a small difference in
attenuation between a normal brain and an acute infarct.

To put this another way, imagine you are a wine reviewer and know from experience
that you can only perceive differences in five different wines a day. You are up
against a deadline for a story about wines from a local vineyard that offers 30 wines
that range in price from $20 to $500 a bottle. You decide to select five wines in a
narrow but popular price range.
You choose a range of $30 to $50 bottles, resulting in only five wines to review. All
wines below $30 will be lumped together as inexpensive and all those above $50 will
be labelled as more expensive.
Figure 7. Example of selecting window and level settings. A wine reviewer limits their review to a certain group
of wines priced within a range of $30-50.
Now, let’s say that your editor tells you that your approach won’t do since the
magazine subscribers are a very affluent crowd. She asks you to review all the wines
from $90 to $500, but you have only one day left before the deadline and can only
review five wines.
Since there are ten wines in that range, you decide to pour together the $90 and $100
bottles, the $150 and $200 bottles, and so on, until you have only five mixed wines
to taste. Your window is much larger, and level is higher, but you can see that this
approach of mixing wines is of limited value. You can no longer perceive differences
between the $90 and $100 bottles, for example, because you poured them together.

Figure 8. Example of selecting window and level settings. A wine reviewer limits their review to a certain group
of wines in a price range of $90-500.
This is conceptually how we display CT images. Whenever you choose a wide window
for a CT image, there will be more mixing of attenuation values into a same shade
of gray. As a result, tissues of similar attenuation values may be indistinguishable
on a CT image.
Now, let’s leave the vineyard and go back to the clinic.
A brain CT scan of a 55-year-old woman with new neurological symptoms revealed

no abnormal findings when viewed with standard CT soft tissue window and level
settings. However, if you were to review the same CT scan with a more narrow window
of only 40 HU, an area of abnormally low attenuation in the frontal lobe becomes more
conspicuous because there is less blending of similar attenuation values.
Figure 9. Window and level settings affect your ability to identify abnormalities on brain computed tomography
(CT) scans. Abnormally low attenuation in the frontal lobe is only apparent in a CT scan image with a window
of 40 HU and level of 40 HU.

Notably, the brain abnormality was even more evident on a magnetic resonance
imaging (MRI) scan obtained for this patient on the same day. A brain biopsy
revealed that this was due to a primary brain tumor.
Why use filtering when reading a CT scan?

You should also be familiar with how filtering CT data alters the images. The scanner
collects an enormous volume of data during each scan. That data is then processed
to form an image using a reconstruction algorithm such as back projection or
mathematical modeling.
Filtering occurs after the data collection but before image reconstruction. Different
filters, which are also called kernels, are selected to optimize imaging of either soft
tissue or bone.
Once the data is filtered, no amount of adjustment of window and level will allow
the images to look the same. So even if the soft tissue filtered image is windowed
appropriately for bone, it will not have the same diagnostic quality as one that used
data filtered for viewing bone.
Figure 10. Filtering will affect your ability to identify certain abnormalities on brain computed tomography (CT)
scans. These brain CT images have identical window and level settings, but the one on the right uses a bone
filter while the one on the left was reconstructed from data processed with a soft tissue filter. Note how much
sharper the margins of the bones are on the right image.
One immediate advantage to using bone filtering to review the head CT data is that it
makes fractures more obvious. The improved detail may allow us to see even subtle
fractures like the one below (Fig. 11).

Figure 11. A brain computed tomography (CT) scan filtered for bone shows a subtle right-sided skull base fracture.
Changing the window and level settings will increase the detection of some
abnormalities—but can obscure others. For example, when reviewing this patient’s scan
with a standard CT window setting of 80 HU and a level of 25 HU, the right subdural
hematoma blends in with the skull since both are assigned the same shade of white. At
this setting, it looks as though the patient has a thickened skull on the right side!
When a wider window and higher level are used to display the same scan, you can
now see the subdural hemorrhage. This illustrates why you need to review the CT
scan using more than one window and level setting.
Figure 12. Changing the window and level settings will increase the detection of some abnormalities. What
looks like a thickened skull on the right side of the head is actually a subdural hemorrhage. This is more
conspicuous when a wider window and higher level are used to display the computed tomography (CT) data.
When you consider the benefit of reviewing images at several windows, as well as
multiplanar reconstructions, you should accept that you will be reviewing a lot of images
with each head CT scan! No one said this was going to be easy, but being conscientious
and consistent in your review will maximize your ability to detect abnormalities.
Return to table of contents.

Chapter 2
TRAUMA IMAGING
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Recognizing extra-axial hemorrhage
Blood that lies outside the arteries and veins within the brain and skull is abnormal.
The ability to recognize hemorrhages on computed tomography (CT) is important
since hemorrhages are frequently a sign of significant underlying disease.
So, let’s review the typical appearance of several different types of hemorrhages on
brain CT scans and how to determine their location!
Anatomy of the meninges

Let’s begin with some basic anatomy. If we were to drill down through the skin over
the skull, then pass from the skull towards the brain, we would first encounter a dense
and fibrous layer called the dura. Next, we would find a much finer membrane called
the arachnoid, and then a layer called the pia that covers the surface of the brain.
Figure 1. Anatomy of the meninges includes the dura, arachnoid, and pia.
As a result of these well-defined meningeal layers, there are three potential spaces
for blood to collect outside the brain:
• The epidural space—outside the dura but within the skull

• The subdural space—between the dura and arachnoid layers
• The subarachnoid space—between the arachnoid and pia

Figure 2. The epidural, subdural, and subarachnoid spaces are potential compartments for blood and fluid to
collect outside of the brain.
Identifying subdural hematomas on brain CT

scans
When the patient has a subdural hematoma, the hemorrhage lies between the dura
(outer layer of the meninges) and the arachnoid layer. Just as submarine means
below the water, the term subdural indicates that the hemorrhage lies below the
dura.
Subdural hematomas are usually the result of significant head trauma, but
occasionally appear after a seemingly trivial fall or injury in older patients. Keep in
mind that subdural hematomas can be difficult to see on CT—particularly on axial
images when the subdural blood is at the top or bottom of the skull.

For example, a tentorial subdural hematoma may be much more evident on a coronal
scan than on an axial scan. Normally, the tentorium is difficult to see and should be
pencil-thin and symmetric from left to right.
Figure 3. Axial and coronal brain computed tomography (CT) scans of a small right tentorial subdural
hematoma. The asymmetry and abnormal thickness of the right tentorial leaf, indicating a hematoma, are
more apparent on the coronal reconstruction of the patient’s CT.
Identifying an acute subdural hematoma
So, how do you identify an acute subdural hematoma on a CT image? Well, there are
two main findings to look for:
1. Attenuation
2. Shape
The attenuation of an acute subdural hematoma on a CT image is between the brain

cortex and the skull. In other words, an acute subdural hematoma has a higher
attenuation than the normal brain due to the clot retraction of the blood products.
You can rely on the shape of the blood collection to predict which space it resides in.
For example, a crescent moon shape is the typical contour of blood in the subdural
space.

Identifying a chronic subdural hematoma
A subdural hematoma will appear to have lower attenuation than the brain on follow-
up scans at about four- to six-weeks post-injury. This is caused by the breakdown
of red blood cells and an influx of water, which represents the normal evolution of
blood products in the subdural space. In this phase, it is called a chronic subdural
hematoma.
Figure 4. The appearance of a subdural hematoma changes over time on a brain computed tomography (CT)
scan. In the acute phase, the attenuation of a subdural hematoma is between the brain cortex and the skull.
One month later, its attenuation is lower than the brain.
Distinguishing between a chronic subdural hematoma and a wide

subarachnoid space
A chronic subdural hematoma can be easily confused with a wide subarachnoid

space in both older adults and children. One visual clue on CT that can help determine
whether the patient has a chronic subdural hematoma, or a wide subarachnoid
space is the shape and location of the cortical veins.
A subdural fluid collection will displace the cortical veins away from the inner table
of the skull. The larger cortical veins will usually be visible on non-contrast CT scans.

Figure 5. Enhanced brain computed tomography (CT) showing a chronic subdural hematoma with cortical
veins displaced away from the inner table of the skull.
Identifying an isodense subdural hematoma
At some point in time between the acute and chronic stages—usually about two- to
three-weeks after the injury—the subdural hematoma will have the same attenuation
as normal brain tissue. This is called an isodense subdural hematoma and can be
particularly difficult to perceive on CT scans.
For example, in the following CT scan, there is subtle high attenuation along the
margin of the right hemisphere of the brain representing blood in the subdural
space. But if you keep looking, you will notice that the cortex appears unusually
thick on the other side of the brain.
The patient’s magnetic resonance imaging (MRI) revealed bilateral, subacute

subdural hematomas. The reason that the hematoma on the patient’s left is
so difficult to see is because it is isodense, meaning that it has nearly the same
attenuation as the brain. So, when you see an unexplained mass effect on the brain,
look carefully at the thickness of the cortex!

Figure 6. Axial brain computed tomography (CT) and magnetic resonance imaging (MRI) scans of a patient
with bilateral isodense subdural hematomas. Note the subtle high attenuation in the right subdural space and
the subtle apparent thickening of the cortex in the other hemisphere of the brain. MRI reveals this patient has
bilateral subacute subdural hematomas.
Identifying epidural hematomas on CT scans

Epidural hematomas are less common than subdural hematomas and are usually
seen with a skull fracture. They are the result of blood accumulating at a relatively
high pressure, which pulls the dura away from the inner table of the skull.
Epidural hematomas can enlarge rapidly since they are often the result of arterial
injury accompanying the skull fracture. The shape of the blood collection in the
epidural space on CT differs from a subdural hematoma since it will have a biconvex,
or lens shape, rather than a crescent moon shape.
Figure 7. Coronal brain computed tomography (CT) scan of a right-sided epidural hematoma, highlighting
its typical biconvex or lens shape along with a nearby skull fracture.

When epidural hematomas enlarge rapidly, there can be significant displacement
and compression of the adjacent brain. A rapidly enlarging acute epidural bleed may
require emergency brain surgery to drain the blood collection.
After timely surgery for an epidural hematoma, the patient’s brain usually appears
normal on subsequent scans. This differs from cases needing surgery for a traumatic
subdural hematoma. In these patients there is frequently a traumatic injury of the
underlying brain as well.
Figure 8. Brain computed tomography (CT) scans of a large epidural hematoma highlighting the brain-epidural
hematoma interface, lens shape of the epidural blood collection, and resulting brain displacement. The brain
typically appears normal after timely surgery in subsequent scans.
Identifying a subarachnoid hemorrhage on CT

When blood collects between the arachnoid layer and the brain, it is called a
subarachnoid hemorrhage. Trauma is a common cause of a subarachnoid
hemorrhage, but it can also be caused by a ruptured intracranial aneurysm or
another vascular abnormality.
The appearance of subarachnoid intracranial bleeding differs from both epidural

and subdural hematomas. This is because the blood in the subarachnoid space
conforms to the shape of the cortical sulci.

Figure 9. Brain computed tomography (CT) scan of a subarachnoid hemorrhage conforming to the shape of
the central sulci of the brain.
Detection of small subarachnoid hemorrhages will require careful evaluation of all

reconstruction planes of the CT scan; it may be helpful to review sections thinner
than the usual 5 mm to make the hemorrhages more visible.
But not all subarachnoid hemorrhages found on a CT scan are the result of trauma.
When the findings are out of proportion to the magnitude of the trauma, you should
consider the possibility of an underlying vascular cause.
For example, a CT was obtained in the emergency room after a patient had an
unwitnessed car accident. It demonstrated a small subarachnoid hemorrhage. A
subtle area of high attenuation was visible between the left and right frontal lobes.
A subsequent CT image then showed subarachnoid hemorrhage within the

interpeduncular cistern. A hemorrhage there takes on the cistern’s triangular shape,
so it is worthwhile to look carefully for blood in the interpeduncular cistern whenever
a subarachnoid hemorrhage is suspected.

Figure 10. Brain computed tomography (CT) of a patient in an unwitnessed car accident showed a small
subarachnoid hemorrhage identified as an area of high attenuation between the right and left frontal lobes. A
subsequent CT found a subarachnoid hemorrhage in the interpeduncular cistern.
In this patient, an anterior communicating aneurysm was later demonstrated on

a computed tomography angiogram (CTA) and confirmed on a digital subtraction
angiogram (DSA).
Digital subtraction angiogram requires the navigation of a small catheter through the
arterial system, accessed through blood vessels in the leg or arm so that contrast
can be injected within a cerebral artery. Digital subtraction angiogram allows high-
resolution imaging of the brain arteries and veins.
Figure 11. An anterior communicating aneurysm is evident on computed tomography angiogram (CTA) and
can be confirmed on a digital subtraction angiogram (DSA).

In patients with equivocal findings of subarachnoid blood on CT after trauma,
consider reviewing the thinnest possible reconstruction thickness of the CT scan
data. Another option is to obtain magnetic resonance imaging (MRI) and carefully
review the fluid-attenuated inversion recovery (FLAIR) images since they often
demonstrate subtle abnormalities in the subarachnoid space. Blood products are
much more evident on FLAIR since they appear white while the cerebrospinal fluid
normally appears black.
Figure 12. Fluid-attenuated inversion recovery (FLAIR) scans using magnetic resonance imaging (MRI) can reveal
a small hemorrhage in the subarachnoid space when it is much less evident on computed tomography (CT).
It is critical to recognize a hemorrhage in a brain CT of trauma patients. With this

information, you should be able to both identify hemorrhages on brain CT scans and
correctly predict the compartment where it resides!

Defining shear injury
A shear injury is a type of traumatic brain injury (TBI) usually caused by rotational
forces that damage the connections between the white and gray matter. So, what
are the causes of shear injuries, and how do you identify shear trauma on a brain
computed tomography (CT) scan?
Shearing occurs when forces are directed in opposite directions. A simple example
is when you tear paper with your hands. Each hand pulls the paper in opposite
directions, resulting in a separation (e.g., tearing) of the paper.
Figure 1. Tearing a paper with your hands is an example of shear force.
Shearing can occur in complex patterns in both air and in liquids as well. One easy
demonstration you can try is using shear force to tell if an egg is hard boiled.
If you spin a fresh egg on a table, and then gently rest your finger on it to stop it from
spinning, it keeps spinning a bit because the liquid contents continue to rotate after
the shell stops. A hard-boiled egg, on the other hand, will stop completely because
the inside is solid. In the case of the fresh egg, shearing forces occur at the interface
between the eggshell and the moving inner contents of the egg, which continue
briefly after you stop its rotation.
Figure 2. Rotational forces can be demonstrated by spinning a fresh egg and a hard-boiled egg. The fresh
egg continues to spin momentarily after a finger is rested on the shell to stop it, indicative of shearing forces
occurring between the eggshell and the moving inner contents of the egg.

How do rotational forces cause damage during a TBI?
During a TBI, rotational forces are often experienced by the brain. When this happens,
shear forces typically occur at the interface between gray and white matter in the
cortex, presumably because of differences in their structures.
Shear forces can also be the result of movement of the brain inside the skull, like
the egg contents in the shell. Trauma-induced shear forces frequently result in
structural damages in the brain. This is because the brain is among the softest
organs in the body and behaves more like gelatin than a rigid solid!
Figure 3. Shear forces at the gray-white matter junction can occur as a result of rotational forces and
movement of the brain inside the skull during a traumatic brain injury (TBI).
There is some speculation that the woodpecker does not experience brain injury
during its avid pecking because the direction of impact of its beak with the tree is
linear, thus minimizing the rotational forces on the brain.
Identifying shear hemorrhages on a CT scan

The effect of shearing along the interface between gray and white matter can result
in small hemorrhages, which are most evident on susceptibility weighted magnetic
resonance imaging (SWI), a magnetic resonance imaging (MRI) technique used to
detect blood products.
While shear hemorrhages are not as evident on CT as they are on MRI, you should
look for any small parenchymal hemorrhages both at the level of the midbrain and
the junction of the gray and white matter. These hemorrhages are typically the result
of shearing or distraction forces at the time of a traumatic brain injury (TBI), and
while only one or two are visible, the injuries may be more extensive than is apparent
on CT or MRI.

Figure 4. Brain computed tomography (CT) and magnetic resonance imaging (MRI) scans of shearing brain
trauma that is visible as punctate parenchymal hemorrhage at the level of the midbrain (left image), and the
gray-white matter junction (right image).
Always consider shear hemorrhages when you see high attenuation at the gray-
white matter junction, the corpus callosum, or the midbrain in a trauma patient.
High attenuation may be the tip of the iceberg with regard to overall brain injury. This
is because the shearing forces may cause other non-hemorrhagic axonal injuries in
the brain. When widespread, it can result in what is called diffuse axonal injury or DAI.
Figure 5. Shear force hemorrhages will appear on a brain computed tomography (CT) scan as an area of high
attenuation at the gray-white matter interface.

Identifying diffuse axonal injury (DAI) on a brain
CT scan
At one time, DAI was an autopsy finding that indicated a widespread disruption of
connecting fibers in the white matter as the result of trauma. Many of those patients
with DAI never regained consciousness.
You may see the term DAI used on CT reports when there are appropriate symptoms
and small hemorrhages at the gray-white matter interface.
Figure 6. Diffuse axonal injury (DAI) is a term used to describe the findings on computed tomography (CT) in
a trauma patient when there are appropriate symptoms and multiple small hemorrhages at the gray-white
matter interface.
Clinical case: Multiple shear injuries but minimal

symptoms
A brain CT scan of a college basketball player who fell on the wooden court
floor during a layup demonstrated a skull base fracture and a focal area of high
attenuation at the gray-white junction (Fig. 7). He was briefly unconscious and
disoriented after the fall, but he recovered completely soon afterwards except for
persistent headaches. At that point, an MRI was ordered for him as an outpatient.
The SWI from his MRI demonstrated multiple punctate hemorrhages in the left frontal
lobe, many more than were seen on CT. At one time this might have been considered
a sign of DAI, but this patient was neurologically normal and had returned to school.

Figure 7. Brain computed tomography (CT) and susceptibility weighted magnetic resonance imaging (SWI)
scans of a patient with a skull base fracture, highlighting a focal area of high attenuation at the gray-white
junction (left image), and multiple punctate hemorrhages in the left frontal lobe (right image).
The sensitivity of MRI has made small shear injuries much more apparent, so they can
be detected in patients without significant neurological deficits after trauma. So, be
mindful that not all patients with multiple shear hemorrhages have symptoms of DAI.

Identifying intra-axial hemorrhages
Hemorrhages within the brain are called intraparenchymal hemorrhages (IPH).
While you should look everywhere in the brain for evidence of traumatic injury, there
are specific locations within the brain where IPH may appear after trauma.
The pattern of brain injury is influenced by multiple factors that include the
magnitude of the injury, the mix of rotation and linear forces at the time of the
injury, and the age of the patient. But, once you know where to look you will be more
likely to recognize traumatic hemorrhages, even for subtle findings on computed
tomography (CT) images.
The typical locations for intraparenchymal hemorrhages are the corpus callosum,
the gray-white matter interface, the midbrain, the inferior frontal and temporal lobes,
and the brainstem. Let’s take a look at some of the most common (and the most
important) locations that you need to carefully inspect when reading CT images.
Figure 1. Typical locations where intraparenchymal hemorrhages may appear, a) inferior frontal and temporal
lobes, b) corpus callosum, midbrain, and brainstem, and c) gray-white matter interface.

Identifying a corpus callosum hemorrhage on a
brain CT scan
A common location for a traumatic hemorrhage is the splenium of the corpus
callosum. The splenium is the posterior part of the corpus callosum. One reason
that this is a common site for a post-traumatic hemorrhage may be its proximity to
the posterior falx (falx cerebri).
A hemorrhage within the splenium of the corpus callosum may be subtle on CT but
is usually quite evident on magnetic resonance imaging (MRI). In this case, it can be
seen on a sagittal T1-weighted image (Fig. 2).
Figure 2. Computed tomography (CT) and magnetic resonance imaging (MRI) scans of a traumatic hemorrhage
within the splenium of the corpus callosum.
While the posterior falx itself is difficult to see on MRI, its course can be predicted
by the location of the inferior sagittal sinus. The splenium of the corpus callosum
is adjacent to the posterior margin of the sinus—and therefore adjacent to the
posterior falx as well.

Figure 3. A midline sagittal reconstruction of a computed tomography angiogram (CTA) demonstrates the
position of the inferior sagittal sinus that indicates the inferior margin of the posterior falx. Its close proximity
to the splenium of the corpus callosum may explain why the splenium is more frequently injured after head
trauma than the anterior corpus callosum.
As a result of brain trauma, the splenium of the corpus callosum may come into
contact with the relatively rigid posterior falx, leading to a traumatic hemorrhagic
contusion.
Notably, there is also support for the theory that this injury is the result of shearing
forces. Regardless of its cause, look for hemorrhages in the posterior corpus
callosum on CT and MRI after head trauma.
Identifying a midbrain hemorrhage on a brain CT

scan
Another common site of intraparenchymal brain hemorrhages after trauma is
the lateral midbrain. A hemorrhage in the lateral midbrain is less common than
a hemorrhage in the corpus callosum, and its presence usually suggests a poor
prognosis for the patient.
Just as a splenium injury may be due to its proximity to the falx, a midbrain
hemorrhage may be the result of its proximity to the medial edge of the tentorium
cerebelli. But, a midbrain hemorrhage may also be the result of distracting forces
between the relatively fixed brainstem and the more mobile cerebral hemispheres.
Be careful not to mistake a subarachnoid hemorrhage in the ambient cistern for a
parenchymal hemorrhage—since they have very different clinical implications!

Figure 4. Brain computed tomography (CT) axial scan of a midbrain intraparenchymal hemorrhage.
Using a diffusion-weighted MRI (a technique that involves measuring the random

motion of water molecules in a tissue), you may be able to detect an area of restricted
diffusion in the midbrain without a hemorrhage. Restricted diffusion in the midbrain
can occur as the result of a traumatic brain injury at the level of the midbrain and
upper pons.
Coronal reconstruction of a brain CT illustrates the proximity of the midbrain to the

medial edge of the tentorium. The midbrain normally resides within the tentorial
notch or aperture (the space between the tentorial medial edges).
Figure 5. Diffusion-weighted magnetic resonance imaging (MRI) scan of a midbrain hemorrhage. The coronal
computed tomography (CT) scan highlights the proximity of the midbrain to the medial edge of the tentorium.

Identifying an inferior frontal or temporal lobe
hemorrhage on a brain CT scan
The inferior frontal lobes are a common site for traumatic brain injury. Damage to
this region may be associated with loss of sense of smell in patients, since the
olfactory bulbs reside there.
With regard to the skull base, there are three important areas where you should look
for abnormalities on head CT in a patient presenting with head trauma:
• Along the inferior frontal lobes

• The tip of the temporal lobes
• The ambient cisterns
Along the inferior frontal lobes, you may be able to note an area of high attenuation
from blood products or low attenuation without hemorrhage due to a cortical
contusion. The tip of the temporal lobe is also a common site of traumatic
hemorrhage. Both sites are prone to injury because of their relationship to the skull.
Brain swelling after trauma may lead to the loss of ambient cisterns on CT images.
The absence of ambient cisterns can be difficult to appreciate as you develop your
familiarity with head CT. So, it is important to look for the normal ambient cisterns
in every head trauma case.
Figure 6. Brain computed tomography (CT) scan depicting high attenuation from blood products at the inferior
frontal lobes, and loss of the ambient cisterns.

Identifying a brainstem hemorrhage on a
brain CT scan
The brainstem is another common location for intraparenchymal traumatic
hemorrhage. When an intra-axial hemorrhage is present within the brainstem,
a common location is the posterior pons at the midline on a brain CT scan. This
finding may indicate a Duret hemorrhage, which follows brain herniation and is
thought to be the result of venous compression after herniation of the brain through
the tentorial hiatus.
Figure 7. Brain computed tomography (CT) scan highlighting a Duret hemorrhage within the brainstem.
So, we’ve covered several common sites of intraparenchymal hemorrhages in

patients who experienced head trauma. Hemorrhages can occur throughout the
brain and depending on the mechanism and magnitude of the brain injury, you
will find it worthwhile to examine these sites on any brain CT scan of your trauma
patients!

Discussing subarachnoid hemorrhage in
trauma patients
Subarachnoid hemorrhages are frequently noted on computed tomography (CT)
scans of patients after head trauma. It is important to consider this finding carefully
since a subarachnoid hemorrhage can contribute to the cause of the traumatic
event rather than its consequence.
A reasonable approach is to first consider if the extent of the subarachnoid

hemorrhage corresponds with the magnitude of the trauma. This is usually based
on history and the physical examination as well as CT signs of head trauma (e.g.,
scalp swelling and fractures). Traumatic subarachnoid hemorrhages are frequently
limited to a few sulci over the convexities of the brain, but patterns of hemorrhage
alone are not sufficient to predict the cause.
Figure 1. Axial brain computed tomography (CT) scans of a trauma patient with traumatic subarachnoid
hemorrhages limited to a few sulci over the convexities of the brain.
In addition to considering the severity of the trauma, the nature of the traumatic injury
is also an important predictive factor. For example, a subarachnoid hemorrhage on
the brain CT scan of a pedestrian struck by a car while crossing the street is most
likely traumatic.
But, a diffuse subarachnoid hemorrhage in a 50-year-old patient who was found

unconscious after an unwitnessed, minor car accident should lead you to consider
that the hemorrhage could be secondary to an underlying ruptured aneurysm—
rather than trauma.

Let’s consider four of the most common causes of subarachnoid hemorrhages on
a brain CT scan:
• Vascular causes
• Trauma
• Pseudoaneurysm
• Penetrating injury
Identifying a subarachnoid hemorrhage with a

vascular cause on brain CT
Whenever there is little evidence of substantial head injury, it may be worthwhile to
obtain a computed tomography angiography (CTA) to look for a vascular cause of a
subarachnoid hemorrhage.
Case 1: A subarachnoid hemorrhage with no vascular cause
In our first case, the patient was noted to have a subarachnoid hemorrhage on CT
after a motor vehicle collision. Because of poor history about the nature of this
patient’s accident, and no evidence of a significant head injury, this patient had a
CTA with volume reconstructions to look for a vascular cause of the hemorrhage.
The CTA was negative with no visible vascular cause and no further imaging was
recommended.
Figure 2. Computed tomography angiography (CTA) scan with volume reconstructions confirmed there was no
vascular cause for the subarachnoid hemorrhage in a patient involved in a motor vehicle collision.

Case 2: A subarachnoid hemorrhage with a vascular cause
In another case, a 45-year-old woman was examined after being found unconscious
off the road in a car that had hit a tree. The event was unwitnessed, and she had no
memory of the accident (which is common in many cases of head trauma). Her brain
CT scan revealed a diffuse subarachnoid hemorrhage and an incidental colloid cyst.
Based on the extent of the hemorrhaging on her brain CT scan, vascular imaging
was obtained. Her digital subtraction angiogram (DSA) demonstrated an anterior
communicating artery (ACoA) aneurysm. Essentially, her acute subarachnoid
hemorrhage was the result of a ruptured aneurysm that most likely caused the
accident!
Figure 3. Brain computed tomography (CT) and digital subtraction angiography (DSA) scans depicting a
diffuse subarachnoid hemorrhage, an incidental colloid cyst, and an anterior communicating artery (ACoA)
aneurysm which was identified as the cause of the hemorrhage.
Identifying a subarachnoid hemorrhage caused

by trauma on brain CT
Case 3: A subarachnoid hemorrhage due to trauma
Brain CT imaging from another patient after a car accident revealed scattered
subarachnoid hemorrhages in the cortical sulci as well as several hemorrhages
typical to traumatic brain injuries. These included hemorrhages in the splenium of
the corpus callosum and in the left frontal lobe.

In a case like this, unless there is compelling clinical history suggesting otherwise,
the imaging is entirely consistent with the diagnosis of a subarachnoid hemorrhage
secondary to trauma.
Figure 4. Brain computed tomography (CT) scans of a subarachnoid hemorrhage caused by trauma. The
scans highlight typical traumatic hemorrhages in the splenium of the corpus callosum, left frontal lobe, and
scattered subarachnoid hemorrhages in the cortical sulci.
Even when you see uncommon patterns of hemorrhages, it’s important not to jump
to concluding that the cause is due to trauma. Don’t dismiss the possibility that the
hemorrhaging is due to a ruptured aneurysm.
For example, if you note a subarachnoid hemorrhage filling the basilar cisterns
accompanied by a parenchymal hemorrhage, you shouldn’t rule out the possibility
that both the hemorrhages could have been caused by a ruptured aneurysm.
So, keep looking! In some cases, you may find other abnormalities associated
with aneurysmal subarachnoid hemorrhages. For example, if the temporal horns
are dilated, it is a sign of communicating hydrocephalus, which is not commonly
encountered with traumatic subarachnoid hemorrhages…but it is frequently
associated with aneurysmal causes!
Figure 5. Brain computed tomography (CT) scan of a subarachnoid hemorrhage with dilated temporal horns
and blood filling the basilar cisterns suggest an aneurysmal cause for the hemorrhage.

Identifying subarachnoid hemorrhages caused by
a traumatic pseudoaneurysm on brain CT
A few times in your career, you may see cases where there was a rupture of a
pseudoaneurysm caused by a traumatic injury to an arterial wall. A pseudoaneurysm
differs from a typical aneurysm because it has fewer layers in its wall.
Case 4: A subarachnoid hemorrhage due to traumatic

pseudoaneurysm
For example, a patient was found unconscious in her car after going off the road
at night at a high velocity. Her brain CT scan revealed an unusual pattern of
subarachnoid hemorrhages along with the pericallosal cistern above the corpus
callosum, rather than the typical traumatic hemorrhage that lies within the corpus
callosum. A CTA was ordered while the patient was still in the emergency room.
Figure 6. Brain computed tomography (CT) scans of a subarachnoid hemorrhage caused by a pseudoaneurysm.

These scans show an unusual pattern of subarachnoid hemorrhage along the pericallosal cistern rather than
the typical traumatic hemorrhage that lies within the corpus callosum itself.
Sagittal reconstructions of the patient’s CTA revealed a small pseudoaneurysm

of the distal anterior cerebral artery, which was confirmed on DSA. The change in
appearance between the CTA and DSA suggested there was an enlargement of the
pseudoaneurysm in the interval.

Figure 7. Computed tomography angiography (CTA) and digital subtraction angiography (DSA) scans of
a traumatic pseudoaneurysm with a change in the appearance of the pseudoaneurysm in the time between
scans suggesting an enlargement.
This particular injury of the anterior cerebral artery has been reported after trauma.
It’s thought to be the result of an injury to the pericallosal artery wall as a result of a
vascular injury as it strikes the falx during trauma.

Identifying a subarachnoid hemorrhage caused
by a penetrating injury on brain CT
Case 5: A subarachnoid hemorrhage due to a penetrating injury
Also rare (but worth considering) are hemorrhages and pseudoaneurysms due
to penetrating injury of the skull. For example, a patient had a CT scan after a
knife entered the skull that resulted in a parenchymal hemorrhage and diffuse
subarachnoid hemorrhage filling the suprasellar and interpeduncular cisterns.
A DSA, in this case, revealed that the cause of the subarachnoid hemorrhage was a
middle cerebral artery pseudoaneurysm that was caused by the penetrating injury.
Figure 8. Brain computed tomography (CT) images of a penetrating injury causing parenchymal and
subarachnoid hemorrhages that fill the suprasellar and interpeduncular cisterns. Digital subtraction
angiography (DSA) found the subarachnoid hemorrhage was caused by a pseudoaneurysm from the
penetrating injury.

These last two unusual cases illustrate that a subarachnoid hemorrhage in a patient
after trauma is not always caused by just trauma alone or ruptured aneurysm alone.
On rare occasions, the subarachnoid hemorrhage may be caused by a ruptured

pseudoaneurysm that is formed at the time of the trauma.
In the emergency room, a CTA is a valuable and noninvasive test. It can be very
helpful in establishing a diagnosis—especially in cases when uncertainty regarding
the cause of a subarachnoid hemorrhage persists.

Recognizing common pitfalls in
CT interpretation
There are several artifacts that can appear on computed tomography (CT) scans
that may be mistaken for significant disease. When that happens, the patient
undergoes unnecessary follow-up imaging, a longer stay in the emergency room,
and even unwarranted treatment.
Let’s review the six extremely common pitfalls that you will likely encounter within
the first twenty CT scans you view:
1. Beam hardening
2. Focal high attenuation in parenchyma
3. Low attenuation fluid in meningeal spaces
4. Low attenuation in parenchyma
5. Air in unexpected spaces
6. Isodense subdural collections
Pitfall 1: Beam hardening

Beam hardening is due to the alteration in the mean energy of a CT x-ray beam
as it passes through the patient’s bone and soft tissue. Since the bone and tissue
reduces the number of low energy x-rays that exit the head on the other side, there is
an increase in the mean energy of the x-ray beam. As a result, the CT reconstruction
software may introduce an artifact in the reconstruction since there seems to be too
many x-rays arriving at the detector.
Figure 1. Beam hardening can produce an artifact on computed tomography (CT) that can be misinterpreted
as an abnormal finding.

Beam hardening causes low attenuation artifacts along the beam path during
reconstruction. This low attenuation frequently resembles a chronic subdural
hematoma along the inner table of the skull.
You can usually recognize this as an artifact because it has an odd, straight medial
border and usually appears in a depression along the inner table of the skull.
Another clue is that an acute traumatic hemorrhage will have high attenuation, not
low attenuation, in most patients.
Figure 2. Brain computed tomography (CT) image with a beam hardening artifact that resembles a chronic
subdural hematoma along the inner table of the skull. Straight medial border, location, and low attenuation
suggest an artifact.
Pitfall 2: Focal high attenuation in parenchyma

Not all patients with focal high attenuation in the brain parenchyma on CT have
a traumatic hemorrhage. A high attenuation lesion could also be a cavernoma!
Magnetic resonance imaging (MRI) can be used to identify the presence of a dark
hemosiderin ring characteristic of a cavernoma.
Figure 3. Cavernoma on brain computed tomography (CT) is visible as an area of high attenuation and can be
confirmed by a characteristic dark hemosiderin ring on a magnetic resonance image (MRI).

Pitfall 3: Low attenuation fluid in meningeal
spaces
Enlarged, low attenuation fluid spaces around the brain can indicate a resolving
subdural hemorrhage, brain atrophy that leads to the appearance of a wide
subarachnoid space, or a traumatic subdural hygroma caused by a tear in the
arachnoid membrane.
Figure 4. Enlarged, low attenuation fluid spaces around the brain can indicate a resolving subdural hemorrhage,
brain atrophy leading to the appearance of a wide subarachnoid space, or a traumatic subdural hygroma
caused by a tear in the arachnoid membrane.
It is important to determine which of these three possibilities is the correct diagnosis.

It can be helpful to look at the position of the cortical veins, and how they relate to
the brain surface. If they are displaced away from the inner table of the skull and lie
on the brain (within cortical sulci), it is more likely that the patient has a subdural
hematoma.
Figure 5. Computed tomography (CT) scan highlighting cortical veins lying within cortical sulci, away from the
inner table of skull, suggestive of a resolving subdural hemorrhage rather than wide subarachnoid spaces.

But if the patient’s cortical veins lie along the inner table of the skull, you can suspect
your patient has wide subarachnoid spaces due to atrophy.
Figure 6. Magnetic resonance imaging (MRI) of a patient with cortical veins that are displaced away from
the inner table of the skull and lying within the cortical sulci as a result of a chronic subdural hematoma. An
enhanced computed tomography (CT) scan in a second patient shows the cortical veins lying along the inner
table of the skull suggesting wide subarachnoid spaces.
Pitfall 4: Low attenuation in parenchyma

Not all low attenuation in the brain parenchyma seen in trauma patients represents
a traumatic contusion! In some patients, this can indicate a low-grade cortical brain
tumor, which can be confirmed on an MRI.
Figure 7. A computed tomography (CT) scan highlighting an area of low attenuation visible in the brain
parenchyma, beside a magnetic resonance imaging (MRI) confirming an undiagnosed cortical brain tumor.

Let’s take a look at a clinical example. A patient was found in her car with deployed
airbags after an unwitnessed single-car crash. The CT scan in the emergency
room demonstrated some low attenuation in the brain that could be confused for a
contusion, but the overlying cortex was normal in appearance.
The patient was sent for an MRI with contrast. That exam demonstrated a frontal lobe
abnormality that proved to be a metastatic lesion from her previously-treated breast
cancer. The cortical lesion may have resulted in a seizure that led to the accident.
Figure 8. Computed tomography (CT) scan of an area of low attenuation that was proven to be a metastatic
lesion in a magnetic resonance imaging (MRI) scan showing frontal lobe abnormality.
Pitfall 5: Air in unexpected spaces

On CT, air can be seen within veins in the neck and head in unexpected places—
especially in trauma patients. When misinterpreted, it can lead to unnecessary
procedures and follow-up scans.
Air surrounding the trachea on a CT suggests the possibility of a traumatic airway

injury. However, sometimes air may appear to be constrained with mostly linear
boundaries. If there is no evidence of an anterior neck injury and the findings resolve
on subsequent CT scans, the findings are likely due to air trapped within neck veins.
Air in the left and right cavernous sinuses from intravenous air is a common finding
on trauma head CT scans. Air can also be seen in many other places on head CT and
is a source of undue concern! Air in the superior ophthalmic vein is one example.
The finding of air in veins is almost always the result of inadvertently injecting air
into peripheral veins during an infusion of intravenous fluids and not the result of a
penetrating injury or fracture of an air-containing structure.

Figure 9. Computed tomography (CT) scans showing intravenous air surrounding the trachea, in the left and
right cavernous sinuses, and in the superior ophthalmic vein.
Pitfall 6: Isodense subdural hematomas

Since subdural hematomas start out with higher attenuation than the normal brain,
and some weeks later show lower attenuation than the brain, there is a short period
of time when the brain and the resolving hematoma have the same attenuation.
These isodense subdural hematomas can be very difficult to perceive on non-

contrast CT but can be detected by focal increase in the thickness of the cortex and
asymmetry of the cortical sulci. A magnetic resonance fluid-attenuated inversion
recovery (FLAIR) scan can better demonstrate the subdural collection.
Figure 10. A non-contrast CT scan showing an isodense subdural hematoma identified by a focal increase
in the thickness of the cortex and asymmetry of the cortical sulci. A magnetic resonance fluid-attenuated
inversion recovery (FLAIR) scan better demonstrates the subdural collection in the same patient.

Let’s consider a patient that presented with left-sided weakness. The coronal image
from their CT scan showed a shift of the midline structures in the brain from right to
left. The septum pellucidum (which lies between the frontal horns of the ventricles)
is a good landmark to measure the magnitude of this shift.
Notably, the right ventricle appeared compressed in comparison to the left ventricle
on CT. While it is reasonable to consider that this shift was due to a mass in the right
hemisphere, you should consider the possibility of an isodense subdural hematoma
if there is a loss of sulci and thickening of the cortex.
In the patient mentioned above, their right-sided subdural hematoma became more
apparent on a CT scan two days later. As a result of the evolution of blood products,
the subdural was then a lower attenuation than the brain.

Figure 11. Coronal computed tomography (CT) scans of an isodense subdural hematoma. The early scan
shows a shift of the septum pellucidum from right to left, compression of the right ventricle compared with the
left, and loss of sulci and appearance of thickening of the cortex. Two days later, the hematoma had a lower
attenuation than the brain.
Keeping these six pitfalls in mind when reviewing CT scans will help you make
accurate diagnoses, reduce interpretation errors, and reduce unnecessary follow-up
imaging for patients who have experienced head trauma!

Chapter 3
STROKE
IMAGING
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Identifying early CT findings of infarctions
The term stroke is used to describe the acute onset of neurological symptoms, such
as sudden difficulty with language or unilateral weakness. However, it is important
to note that these symptoms do not always mean the patient has had an acute brain
infarction. In some cases, a hemorrhage or brain tumor can cause similar symptoms!
Since the diagnosis of acute infarction cannot be made by physical symptoms

alone, one of the goals for the initial computed tomography (CT) evaluation is to
determine if the patient has evidence of a brain hemorrhage; intracranial blood can
be the result of an underlying vascular lesion, a venous thrombosis, or a brain tumor.
While hemorrhage can be secondary to an acute brain infarction, this is rarely the
case when a CT scan is obtained immediately after the onset of symptoms.
Figure 1. Brain computed tomography (CT) scan of a brain hemorrhage.
There are six findings on the initial brain CT that support the diagnosis of an acute
infarction:
1. Dense middle cerebral artery (MCA) sign
2. Dot sign
3. Insular ribbon sign
4. Basal ganglia asymmetry
5. Loss of gray-white boundary
6. Low attenuation of the cortex

Keep in mind, you must know the nature of the patient’s symptoms so that you
know where in the brain to look for these findings since they are frequently subtle
on CT. For example, knowing that a patient is experiencing right-hand weakness
should lead you to pay particular attention to any subtle brain CT findings on the
patient’s left.
Dense middle cerebral artery (MCA) sign

An early sign of acute infarction is a thrombus in the MCA, which appears unusually
white on CT because clotted blood has higher attenuation than flowing blood.
Why is this sign associated with the MCA in particular? Because it requires
comparison with an artery on the other side (which is possible with the MCA) to be
a reliable indicator of infarction.
For example, if a patient has acute aphasia, that function is usually on the left side
of the brain, so the right MCA can be used as a normal reference. Since we have a
single basilar artery, diagnosis based on its attenuation is less reliable.
On a patient with acute left-sided hemiparesis, the right MCA may appear to have
a slightly higher attenuation than the left when viewed with a standard 5 mm thick
reconstruction of the CT scan data. However, most modern CT scanners can acquire
data using detector collimation of 1 mm or less.
When 1 mm axial CT images are reconstructed from the CT data of the patient, the
high attenuation of the patient’s right MCA is more evident (Fig. 2). This finding is
called the dense MCA sign. You will have a higher chance of making this diagnosis
on CT when images are reconstructed at thin sections and displayed using a narrow
window and level of about 40 Hounsfield units (HU).

Figure 2. The dense middle cerebral artery (MCA) sign is more clearly seen on brain computed tomography
(CT) with 1 mm reconstruction thickness.
Dot sign
The dot sign is a variation of the dense MCA sign. It indicates a thrombus in the
more distal middle cerebral artery branches within the Sylvian fissure where they
turn perpendicular to the image slice.
Figure 3. Brain computed tomography (CT) scan demonstrating the dot sign, which is a variation of the dense
middle cerebral artery (MCA) sign.

Insular ribbon sign
Medial to the Sylvian fissure there should be a thin, high attenuation zone of normal
cortex. In the appropriate clinical setting, when this is absent, it is an early sign of an
acute MCA occlusion that is called the insular ribbon sign.
The insular ribbon sign is subtle and only hints at what is to come. Often, subsequent
scans show the true size of the infarction. This should serve as a reminder that the
detection of acute infarcts on CT depend on the recognition of subtle changes in
tissue attenuation!
Figure 4. A brain computed tomography (CT) scan of the insular ribbon sign, an early sign of an acute middle
cerebral artery (MCA) occlusion, which is the absence of a thin, white line of normal cortex just medial to the
Sylvian fissure. A scan 1 day later shows the true size of the infarction.
Basal ganglia asymmetry

Asymmetry in the basal ganglia is another early sign of an MCA territory infarction
since the small arteries that supply blood flow to the basal ganglia come from the
proximal middle cerebral artery. For example, you may be able to notice that the
putamen is harder to see on the affected side.

Figure 5. Brain computed tomography (CT) scan showing asymmetry in the basal ganglia as an early sign of a
middle cerebral artery (MCA) territory infarction, with reduced visibility of the right putamen compared to the
normal putamen on the patient’s left.
Loss of the gray-white matter interface

Focal loss of the normal borderline between the gray matter and white matter on
brain CT is another sign of an acute infarction. When observing this finding, look
carefully at both sides of the brain for comparison.
In a normal patient, you should be able to follow the relatively high attenuation of the
cortical ribbon around the hemispheres on a good-quality brain CT scan. Loss of the
gray-white matter interface is a subtle finding, and your chances of seeing it increase
if you know where to look based on a patient’s symptoms. As well, you may want to
order a follow-up CT scan since infarctions often become more evident over time.
Figure 6. Brain computed tomography (CT) scan of an acute infarction with focal loss of the gray-white matter
interface on the patient’s left. The infarct becomes more evident across time.

Low attenuation of the cortex
Focal low attenuation in the cortex is an important finding to recognize in patients
with suspected infarctions. Keep in mind that this finding is often inapparent or due
to an artifact—especially if there is age-related atrophy of the cortex.
Figure 7. Brain computed tomography (CT) scan of a cerebellar infarct with focal low attenuation in the cortex.
Small, acute cortical infarctions may vary in their ease of detection between patients.
Knowing details about a patient’s symptoms can help with detection of infarcts.
For example, if you know that a patient’s symptoms include the acute onset of right-
handed weakness, you are more likely to find a small left-sided cortical infarction.
Pay particular attention to areas of low attenuation evident in the left precentral
gyrus since this is where hand motor function resides.
Figure 8. Brain computed tomography (CT) scans of focal low attenuation which suggest small acute
infarctions.

Don’t assume low attenuation in the basal ganglia is an old
lacunar infarction
Do not routinely attribute low attenuation in the basal ganglia to an old lacunar
infarction unless you have a prior CT or magnetic resonance imaging (MRI) scan
that shows it! An area of low attenuation may initially be thought to indicate an old
lacunar infarction, but it’s important to consider the patient’s symptoms.
If the patient has acute weakness on one side, an MRI with diffusion images may
prove helpful, as it did for this patient with acute left-handed weakness (Fig. 9). The
MRI demonstrated restricted diffusion in the same location, which is characteristic
of acute infarction. Again, patient history was crucial for the correct interpretation
of CT in this stroke patient.
Figure 9. Magnetic resonance imaging (MRI) scan demonstrating an area of restricted diffusion characteristic
of an acute infarction, which suggests that the low attenuation in the basal ganglia on the computed
tomography (CT) scan is an acute infarction and not an old lacunar infarction.
Always remember to use appropriately windowed images that improve soft-tissue

contrast with thin sections when needed, and do not try to interpret the CT scan
without knowing the patient’s symptoms. The findings are so subtle that reading
a brain CT scan without a history in this setting can lead to both false positive and
false negative interpretations.
Now that you’re aware of these six early findings for an acute infarction on brain CT,
you should be significantly more effective in detecting brain infarctions!

Describing the evolution of infarcts
Oftentimes, in the first few hours after a brain infarct, there are no corresponding
abnormalities visible on computed tomography (CT). While acute infarctions may be
difficult to initially find on CT, they tend to become more evident over time.
Using a series of brain CT scans from ten patients, you’ll learn about the appearance
of several types of infarcts (pre- and post-craniectomy), and how acute infarctions
evolve over time.
Acute infarction case 1: Right hemispheric infarction

A CT scan was obtained from a patient who presented to the emergency room
after developing an acute onset of left-sided facial weakness, suggesting a right
hemispheric infarction. On the initial CT scan, there was some blurring of the lateral
border of the basal ganglia, but the right insular cortex appeared to be normal.
On a CT scan 3 days after the incident, the patient’s right-sided infarction became
clearly evident, with a well-defined zone of low attenuation involving the patient’s
right hemispheric cortex and white matter. The influx of fluid into the damaged brain
cells lead to cytotoxic edema, which is visible on CT as regional low attenuation.
Cytotoxic edema accounts—in part—for the difficulties encountered in the medical

treatment of infarctions. The swelling that initially occurs after a brain infarction
is largely intra-cellular. Intra-cellular edema is not as responsive to steroids as
vasogenic edema, which is extra-cellular and accompanies most primary and
metastatic tumors.
By 5 days after the incident, the full extent of the infarction became visible as low
attenuation in the cortical and subcortical white matter when compared to the other
side of the brain. The infarction-induced swelling results in the loss of the cortical
sulci and the Sylvian fissure when compared to the patient’s unaffected side.
But 11 days after the incident, the patient’s infarction became less evident. While
it would be nice to think that this indicates that the brain has recovered due to
treatment, this is one pattern of infarction evolution that is deceptive and infrequently
encountered. The apparent improvement is due to a phenomenon called fogging.

Figure 1. Evolution of brain computed tomography (CT) findings over time for a patient with a right hemispheric
infarction. Cortical and subcortical white matter low attenuation can be seen on days 3 and 5, but there is
reduced visibility on day 11 due to fogging.
Like the fog that rolls in from the sea and makes it hard to see the landscape,
the fogging of brain CT in this circumstance is caused by a combination of
revascularization, inflammatory cells, and hemorrhaging in the infarcted tissues.
This results in a small increase in the attenuation of the infarcted cortex. Since the
infarct is normally lower in attenuation than the normal brain, the infarction will then
appear similar to the normal brain.
After a few more days, the infarction will reappear and then eventually involute and
contract so that the infarction territory will have an attenuation that resembles fluid
on CT. This late phase of a chronic infarction is usually called encephalomalacia.

Figure 2. The late phase of a chronic infarction is called encephalomalacia. After resolution of the edema, the
brain infarct will eventually involute and contract, and the infarction territory will then have an attenuation
that resembles fluid.
Acute infarction case 2: Perinatal infarction

The next case demonstrates the late effect of perinatal infarctions on the brain of a
child. In this patient, there were multiple areas of fluid attenuation in the cortex and
central structures that can be described as macrocystic encephalomalacia (Fig. 3).
Figure 3. Brain computed tomography (CT) scan demonstrating the late effect on the brain of perinatal
infarctions in a child. Macrocystic encephalomalacia—areas of fluid attenuation in the cortex and central
structures—can be seen on computed tomography (CT).

Acute infarction case 3: Acute left-sided hemipa-
resis without aphasia
A CT scan of a patient with acute left-sided hemiparesis without aphasia
demonstrated several of the subtle changes expected with an early middle cerebral
artery (MCA) territory infarction. This includes a dense MCA sign.
At a higher image level, asymmetry of the basal ganglia can be seen with the normal
left lentiform nucleus visible since it has a higher attenuation than the surrounding
white matter. However, the patient’s right lentiform nucleus is poorly seen. Early
changes due to ischemia cause it to resemble white matter.
A CT scan taken 2 days later better demonstrated the right basal ganglia infarction.
You will note that there is sparing of the right thalamus, since it is supplied by
arteries arising from the posterior circulation, and not the MCA branches that supply
the basal ganglia.
Figure 4. Brain computed tomography (CT) scans demonstrating the late effect on the brain of an acute left-
sided hemiparesis without aphasia. Early stage brain CT images show a dense middle cerebral artery (MCA)
sign and a poorly visible right lentiform nucleus. A brain CT after 2 days shows the right basal ganglia infarction.

Acute infarction case 4: Small left MCA territory
infarction
This patient’s early CT scan demonstrated a small left MCA territory infarction (Fig.
5). On a CT scan 2 weeks later, linear high attenuation in the cortex was visible in the
same distribution, but with no mass effect on the cortical sulci.
High attenuation in the cortex in the days to weeks after an infarction is common
and often due to fine petechial hemorrhages. It does not carry the same treatment
implications as a true hemorrhagic infarction.
Figure 5. Brain computed tomography (CT) scan from a patient with a small left middle cerebral artery (MCA)
territory infarct showing the evolution of linear high attenuation in the cortex, which is commonly due to fine
petechial hemorrhages.
Acute infarction cases 5 and 6: Hemorrhagic

infarcts
The next cases show CT scans from two different patients, both illustrating the
appearance of hemorrhagic infarctions (Fig. 6). Hemorrhagic infarctions are
associated with a larger area of high attenuation along with the loss of cortical
sulci, indicating some mass effect. The use of anticoagulation and revascularization
therapies may increase the likelihood of bleeding into an infarction, but significant
hemorrhaging occurs in less than 10% of infarctions.

Figure 6. Brain computed tomography (CT) scans showing hemorrhagic infarctions in two different patients,
illustrating the larger area of high attenuation along with loss of cortical sulci, indicating some mass effect.
Acute infarction case 7: A small infarction escalating

to a large hemorrhage with mass effect and shift
The next case involves a relatively small infarction, visible on CT by its focal loss
of the gray-white border and cortical sulci. However, just 6 hours later, this patient
showed worsening of symptoms and a second CT scan was obtained (Fig. 7).
The second CT scan, performed at the same level, shows a large hemorrhage
in the region of the infarction with increased mass effect and shift, indicated by
the displaced septum pellucidum relative to the midline of the skull. This focal
hemorrhage is an important finding and urgent notification of clinical services is
required since the finding alters subsequent treatment.
Figure 7. Early stage brain computed tomography (CT) scan showing a focal loss of the gray-white border and
cortical sulci. Imaging 6 hours later shows a large hemorrhage in the region of the infarction with increased
mass effect and shift, indicated by the displaced septum pellucidum.

Acute infarction case 8: Right-sided MCA
territory infarction
This patient case involves a large right-sided MCA territory infarction, with diffuse
swelling and loss of the cortical sulci over the entire right hemisphere when
compared to the normal left side (Fig. 8). The CT scan showed displacement of the
ventricle and midline structures due to a large area of cytotoxic edema.
Figure 8. Brain computed tomography (CT) scan from a patient with a large right-sided middle cerebral artery
(MCA) territory infarction, highlighting the diffuse swelling of the brain and loss of the cortical sulci over the
entire right hemisphere, as well as displacement of the ventricle margin.
Acute infarction cases 9 and 10: Large vascular

territory infarctions
Because of the limitations of medical treatment for infarctions and expected
swelling within the first week post-infarction, patients with large vascular territory
infarctions (typically involving the MCA) may require removal of the skull for survival.
This procedure is called a craniectomy. The patient’s skull flap is frozen and is not
replaced until the infarct swelling subsides.
When the swelling is severe in the first week after an infarction, it can result in brain
herniation and death. This is certainly a risk with occlusion of vessels that supply a
large volume of the brain. Infarcts with brain swelling and substantial midline shift
are sometimes called malignant infarctions, because of the poor prognosis for the
patient.

Figure 9. Brain computed tomography (CT) scan of a patient with craniectomy intended to reduce brain
herniation and subsequent death from swelling due to a large vascular territory infarct. Notice where a portion
of the skull has been removed.
The next case example is a patient who survived a right-sided carotid occlusion
with infarction after treatment with a craniectomy. At 3 weeks after the infarction,
the swelling has subsided and there is very little mass effect evident. While there is
evidence of a prior right-sided infarct, there is no midline shift.
After craniectomy and resolution of brain swelling, the bone flap can then be
reattached to the skull.
Figure 10. Craniectomy is important for reducing midline shift. A brain CT scan (left image) taken 3 weeks after
a right-sided carotid occlusion with infarction shows swelling has subsided and there is little mass effect. In
a second patient (right image), the bone flap was reattached once swelling after a left middle cerebral artery
(MCA) territory infarction subsided.
While acute infarctions are frequently difficult to initially detect on CT, they appear
more visible upon subsequent scans over the days and weeks to follow.
With the knowledge gained from these case studies, you will find it easier to
recognize the evolution of infarcts on brain CT scans over time.

Explaining the effects of thrombolysis
Computed tomography (CT) scans can be useful for identifying complications after
thrombectomy. So, let’s examine pre- and post-thrombectomy CT scans to illustrate
the benefits of this type of imaging!
When should you consider intraarterial

thrombectomy?
Let’s take a look at an example. A patient presented with acute onset of right
hemiparesis and aphasia. Their brain CT showed an abnormally high attenuation in
the left carotid artery, suggesting a blood clot or calcified embolus within the vessel.
A coronal reconstruction from a CT angiography (CTA) shows an absence of contrast

enhancement in the distal left carotid artery (Fig. 1). You can see that the proximal
anterior cerebral artery (ACA) and middle cerebral arteries (MCA) are also involved
but are enhanced distally. This is most likely the result of filling by collateral flow or
a small amount of contrast getting beyond the thrombus.
There is an occlusion of the distal internal carotid artery along with the proximal
anterior and middle cerebral arteries, known as a T occlusion because it resembles
that letter on a coronal or frontal projection.
Figure 1. Brain computed tomography (CT) showing abnormally high attenuation in the left carotid artery
suggesting a blood clot or calcified embolus. Computed tomography angiography (CTA) showing the absence
of contrast enhancement in the distal left carotid artery and involvement of the proximal anterior cerebral
artery and middle cerebral arteries but with enhancement evident in distal branches of those vessels.

Based on these findings, this patient is diagnosed with acute brain infarction from a
large vessel occlusion, so decisions about treatment need to be made immediately.
For many patients who present immediately after the onset of symptoms, there is
a medical treatment option using an intravenous drug used to dissolve the blood
clot. But, in patients with large vessel occlusion and late presentation, it is usually
best to restore flow and remove the thrombus with a catheter intervention called
intraarterial thrombectomy or thrombolysis.
How is intraarterial thrombectomy performed?

Intraarterial thrombectomy is appropriately named since current devices allow for
the extraction of the clot within the artery. The data suggests that restoration of flow
improves clinical outcomes after infarctions when performed in selected patients—
even after 12 or more hours have elapsed since the time of symptom onset!
There are currently a variety of devices that can be delivered to the point of vascular
occlusion through a long catheter inserted into an arm or groin artery that can be
precisely positioned using x-ray fluoroscopy. These include a metal stent that can
be placed into the clot and then recovered into the catheter and a small suction
catheter that directly removes the clot.
Figure 2. During intraarterial thrombectomy, a device used to extract the clot is delivered to the occlusion
through a long catheter.
For example, the digital subtraction angiography (DSA) image of a patient confirmed
an occlusion of the distal carotid artery. After the placement of a treatment catheter
into the cavernous carotid artery, an interventional device was used to reopen the
distal internal carotid artery and MCA. This procedure, performed urgently, restored
flow to the left MCA and the proximal ACA.

Figure 3. Digital subtraction angiography (DSA) scans before and after placement of a catheter into the
cavernous carotid artery for the treatment of an occlusion of the distal carotid artery. The treatment restored
flow to the left middle cerebral artery and proximal anterior cerebral artery.
Let’s take a look at another example. After presenting with left-sided weakness, the
patient in our next case had a CTA scan, which demonstrated a large vessel occlusion
(Fig. 4). The patient was sent directly to the angiography suite for treatment of their
complete occlusion of the right proximal MCA, called the M1 segment.
After intraarterial thrombectomy, blood flow was restored to the MCA. While catheter-
based vascular intervention has been available for decades, recent improvements
in hardware and techniques make it possible to open large intracranial arteries
rapidly—frequently in 20 minutes or less from the start of the procedure!
Figure 4. Computed tomography angiography (CTA) images showing a complete occlusion of the right
proximal middle cerebral artery (MCA), called the M1 segment, and restored blood flow to the MCA after
intraarterial thrombectomy.

Shortly after the patient’s thrombectomy, a CT scan was obtained. On the CT, a
focal area of high attenuation was seen in the right basal ganglia. While alarming
in appearance (since it resembles blood), high attenuation is frequently seen in the
territory of an occluded vessel after an intervention.
This finding on CT post-thrombectomy is frequently due to contrast staining of

the brain from repeated injections of contrast during the procedure. However, the
question in this case remained as to whether this could represent a hemorrhage.
Figure 5. Post-thrombectomy computed tomography (CT) showing a focal area of high attenuation in the right
basal ganglia, which could be due to contrast staining from the procedure or a hemorrhage.
How can you differentiate between contrast

staining or a hemorrhage post-thrombectomy?
Repeat the scan 24 hours later
One way to tell the difference between high attenuation that’s due to contrast
staining and high attenuation that’s due to a hemorrhage is by repeating the CT
scan 24 hours later.
In the case of the patient who presented with left-sided weakness, the CT scan was
repeated after 24 hours. The persistent high attenuation visible on this repeat scan
indicates that there was some hemorrhaging in the region of the infarction, since
contrast staining should have largely resolved at 24 hours.

Figure 6. Persistent high attenuation visible on a computed tomography (CT) scan 24 hours post-
thrombectomy indicates that there is hemorrhaging in the region of the infarction, since contrast staining
should have largely resolved at 24 hours.
Obtain a virtual non-contrast CT scan
Another way to tell whether the high attenuation on a CT scan after thrombectomy
is due to a hemorrhage is by obtaining a virtual non-contrast CT scan. In our next
case, a CT scan was obtained immediately after the patient’s left MCA occlusion
was treated with intraarterial thrombectomy. This CT also demonstrated high
attenuation in the basal ganglia.
The hospital had a dual-energy CT scanner available for imaging that was used
to obtain the post-procedure CT scan. By imaging the brain simultaneously with
x-rays of two different energies (low and high energy), it became possible to predict
whether the high attenuation was due to contrast staining or hemorrhaging. This is
based on the differences in attenuation of iodine and blood.
The dual-energy data set allows for the creation of a processed image called a
virtual non-contrast scan on which iodine is effectively removed from the image. In
this patient’s case, the high attenuation in the left basal ganglia was not visible on
the virtual non-contrast image, indicating that it was due to contrast staining, and
not a hemorrhage (Fig. 7).

Figure 7. High attenuation is seen in the left basal ganglia on a computed tomography (CT) scan obtained
post-intraarterial thrombectomy after a left middle cerebral artery (MCA) occlusion. Virtual non-contrast scan
showing no high attenuation, which rules out a hemorrhage.
The role of intraarterial thrombolysis or thrombectomy in the treatment of acute

brain infarction with large vessel occlusion is expanding as more hospitals are
offering this service to their patients. Keep in mind that both hemorrhage and
contrast staining can be evident on a post-procedure CT scan.
When there is a question about hemorrhaging, repeat imaging with CT 24 hours later
is helpful since contrast staining resolves more quickly than a hemorrhage. For a
faster diagnosis, however, dual-energy CT can help make this distinction.

Demonstrating the role of CT angiography
and perfusion CT in the acute stroke patient
In this article, we will discuss two intravenous (IV) contrast computed tomography
(CT) imaging techniques: CT angiography (CTA) and CT perfusion. Both CTA and CT
perfusion imaging can help clinicians predict the benefit of intervention for acute
stroke patients.
Computed tomography angiography (CTA) imaging

Computed tomography angiography requires rapid imaging and optimal timing after
the injection of the IV contrast. This is because the CT imaging of the arteries in the
brain must occur when the contrast first appears. This approach provides a surprisingly
accurate rendition of the brain’s arteries and veins when performed properly!
For example, if the left middle cerebral artery (MCA) is occluded by an intravascular
thrombus, the CTA image will show the patient’s normal right MCA opposite of an
absent left MCA.
This example is considered a large vessel occlusion. Depending on the image timing
relative to the onset of symptoms and other clinical factors, the patient could benefit
from intraarterial thrombectomy.
Figure 1. Computed tomography angiography (CTA) showing an absent left middle cerebral artery (MCA),
suggesting occlusion by an intravascular thrombus.

Computed tomography (CT) perfusion imaging
Computed tomography (CT) perfusion is another imaging technique that is dependent
on the timing of arrival and distribution of the IV contrast within the brain. From this
imaging data, calculated brain perfusion maps of regional blood flow and cerebral
blood volume can be determined and displayed on images.
For acute infarcts, critical information about cerebral blood flow and time to maximal
enhancement can be obtained using CT perfusion imaging.
How to use CT perfusion to weigh the benefit of an

intraarterial treatment
Computed tomography (CT) perfusion is frequently used to predict the potential

benefit of intervention based on the completed infarction size and brain tissue
volume that is not yet infarcted (but is at-risk).
At-risk brain tissue (adjacent to the completed infarct) is called the penumbra and is
marginally supplied by blood flow through the collateral arteries. Information about
the infarction size and at-risk brain tissue volume, along with the patient’s history
and physical exam, may be used to determine whether the benefit of an intraarterial
treatment outweigh the risk.
For example, if there is evidence of a completed infarct but no evidence of other

at-risk brain tissue in a patient beyond six hours from the onset of symptoms, it is
unlikely that a catheter intervention will be of substantial benefit to the patient.
Figure 2. Calculated perfusion display in a patient with a left middle cerebral artery (MCA) occlusion showing
the infarction (purple), and the at-risk brain tissue (green). The similarity in the surface area suggests that an
intervention may not provide a substantial benefit to the patient.

On the other hand, if the CT perfusion scan shows a relatively small and completed
infarction compared to a much larger area of at-risk brain tissue, the patient might
benefit from intraarterial treatment.
Figure 3. Calculated perfusion display in a patient with a left middle cerebral artery (MCA) occlusion showing
the infarction (purple), and the at-risk brain tissue (green). The difference in the surface area suggests that an
intervention might provide a substantial benefit to the patient.
Current approach to CT imaging of patients with

acute neurological symptoms
When a patient presents with acute neurological symptoms suggestive of infarction,
the current approach is to obtain a head CT alongside a CTA, and in some cases CT
perfusion. Computed tomography perfusion is suggested for patients who present
beyond the usual treatment time window.
In the case presented next, volume rendering of the patient’s CTA demonstrated a
branch MCA occlusion. In this case, it was proven on digital subtraction angiography
(DSA) and treated through a catheter which resulted in a complete restoration of
flow to the M2 branch.
Figure 4. A middle cerebral artery (MCA) branch occlusion before and after treatment. The volume rendered
computed tomography angiography (CTA) demonstrates the location of the occlusion, which is proven on digital
subtraction angiography (DSA). The treatment resulted in a complete restoration of flow to the M2 branch.


Chapter 4
NONTRAUMATIC
HEMORRHAGE
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Recognizing subarachnoid hemorrhage on CT
Detection of subarachnoid hemorrhages on computed tomography (CT) is critical
to your patient’s care because it can be the first and only imaging sign of a ruptured
aneurysm.
Since subarachnoid hemorrhage findings can be very subtle on a brain CT scan, the
following five tips will help you accurately detect subarachnoid hemorrhages:
• Look at the interpeduncular cistern.

• Look carefully at basilar cisterns and all cortical sulci (including the Sylvian
fissures) and if there is any doubt, you may be able to confirm using magnetic
resonance imaging (MRI).
• Use thin sections for reviewing the CT imaging.
• Use coronal and sagittal view reconstructions.
• Keep in mind that high attenuation in the cortical sulci is not always due to
hemorrhaging.
Tip 1: Look for subarachnoid hemorrhages

at the interpeduncular cistern
A good place to begin detecting subarachnoid hemorrhage—especially when
subarachnoid blood is suspected as the cause of headaches—is the interpeduncular
cistern. This space is at the level of the midbrain and lies between the two cerebral
peduncles. The interpeduncular cistern is normally filled with low attenuation
cerebrospinal fluid, so when the triangular interpeduncular cistern appears white,
that means it’s filled with blood.
Figure 1. Computed tomography (CT) scan of the interpeduncular cistern appearing white, indicating that it’s
filled with blood.

Tip 2: Look carefully for subarachnoid
hemorrhages at the basilar cisterns and all
cortical sulci (including the Sylvian fissures)
Ambient cisterns
The next tip for detecting subarachnoid hemorrhages is to carefully examine the
ambient cisterns lateral to the midbrain. If blood involves the posterior fossa but
extends no higher, the CT scan findings suggest the diagnosis of a perimesencephalic
hemorrhage.
Oftentimes, the bleeding from a perimesencephalic hemorrhage is not due to a

ruptured aneurysm and can be venous in origin. The clinical course of these patients
is usually more benign. However, it is still important to exclude any underlying
aneurysms since a perimesencephalic hemorrhage is a diagnosis by exclusion.
Figure 2. Computed tomography (CT) scans show the posterior fossa of the ambient cisterns appearing white,
suggesting that it is filled with blood. If the blood does not extend higher than the posterior fossa, it may be
from a perimesencephalic hemorrhage or aneurysmal rupture.
Cortical sulci (including the Sylvian fissures)
After assessing the ambient cisterns, carefully look at all the cortical sulci. This
is frequently the site of nontraumatic subarachnoid hemorrhages. Subarachnoid
hemorrhages in a single sulcus can be further confirmed on fluid-attenuated
inversion recovery (FLAIR) magnetic resonance imaging (MRI).

Figure 3. Computed tomography (CT) and fluid-attenuated inversion recovery (FLAIR) magnetic resonance
imaging (MRI) scans highlighting a small single-sulcus subarachnoid hemorrhage.
Tip 3: Use thin-section imaging

Detecting a small subarachnoid hemorrhage can be difficult because its high
attenuation is not always sharply defined on a brain CT. The clarity of the hemorrhage
is dependent on the quality of the CT, the technique used, and the slice thickness of
the image reconstructions. Hemorrhages are usually more apparent on 1–2 mm
reconstructions.
Figure 4. Differences in the clarity of the hemorrhage are due to differences in CT quality, technique, and slice
thickness.

For example, it is often easier to detect a small subarachnoid hemorrhage when
you look at a 1 mm reconstruction. While a 5 mm reconstruction is standard at
many sites, it can make the attenuation of a small subarachnoid hemorrhage less
apparent than thinner sections.
Figure 5. A small subarachnoid hemorrhage on brain computed tomography (CT) images. The high attenuation
is less apparent on a standard 5 mm reconstruction than on a 1 mm reconstruction.
High attenuation (e.g., blood) is more difficult to recognize on thick sections because
it may be offset by low attenuation of the cerebrospinal fluid when they are both
included within a large voxel. The blending of high and low attenuation can make
the voxel resemble the surrounding brain and therefore much less apparent on CT.

Tip 4: Use coronal and sagittal view
reconstructions
Computed tomography is always viewed as axial images. But, when trying to detect
subarachnoid hemorrhages in patients with suspected trauma or other potential
causes of hemorrhaging, reconstructions in coronal and sagittal views are valuable.
These reconstructions can help detect the subarachnoid hemorrhage as well as
assigning it to the correct compartment.
Figure 6. An area of high attenuation in the right cerebellar hemisphere that could be parenchymal is evident
on this axial computed tomography (CT) image. Its location in the subarachnoid space is easier to establish
when the scan is displayed as a coronal reconstruction.
Tip 5: Keep in mind that high attenuation in the

cortical sulci is not always due to hemorrhage
A subarachnoid hemorrhage is usually the only abnormality detected after
aneurysmal rupture. But in a small percentage of cases, aneurysmal rupture can
result in an intraventricular hemorrhage, a subdural hematoma, or a parenchymal
hemorrhage with or without subarachnoid hemorrhage.
Rarely, blood may even be evident in four compartments—the subarachnoid,

subdural, parenchymal, and intraventricular compartments—as seen after this
rupture of a middle cerebral artery aneurysm (Fig. 7).

Figure 7. Brain computed tomography (CT) images showing the rare occurrence of an intraventricular
hemorrhage, a subdural hematoma, and a parenchymal hemorrhage with or without subarachnoid
hemorrhages after a middle cerebral artery (MCA) aneurysmal rupture.
In patients who present with a parenchymal hemorrhage without a subarachnoid

hemorrhage, you should consider the possibility of an underlying arteriovenous
malformation, venous occlusion, cavernoma, or dural fistula.
The enlarged blood vessels that supply an arteriovenous malformation or dural

fistula can be easily mistaken for subarachnoid blood on non-contrast CT scans
because they usually are evident on the surface of the brain.

Sometimes, the area of high attenuation appears linear but extends too deeply into
the brain to be within a normal cortical sulcus. This finding suggests that there are
abnormally enlarged blood vessels associated with a vascular malformation, rather
than an intracranial hemorrhage.
In patients without anemia, keep in mind that normal intravascular blood will have
higher attenuation than normal brain tissue.
Figure 8. Computed tomography (CT) and catheter angiogram of an arteriovenous malformation (AVM). The
CT scan highlights the high linear attenuation extending deeply into the brain. This suggests that there are
abnormally enlarged blood vessels associated with a vascular malformation, rather than an intracranial
hemorrhage. A catheter angiogram confirms a dural fistula with large draining veins.
The presence of a subarachnoid hemorrhage can be a critical finding for the care of
patients with headaches. These five tips will help improve your detection accuracy
for subarachnoid hemorrhages and subsequent patient management!

Identifying common locations for aneurysms
Patient cases can help illustrate the common locations of brain aneurysms, and
help you effectively search for brain aneurysms. First, let’s review the basics of how
aneurysms are named!
How brain aneurysms are named

Saccular versus fusiform aneurysms
Nearly all brain aneurysms are saccular, meaning that they extend off the side of
an artery. This is why these spherical protrusions can be closed off using a spring
clip in surgery, or coils in an angiography suite, without occluding the normal artery.
Less common are fusiform aneurysms; these are characterized by dilation of the
entire circumference of the artery. Since most cannot be clipped or coiled, fusiform
aneurysms are more difficult to treat than saccular aneurysms and sometimes
require occlusion of the affected artery.
Figure 1. Computed tomography angiography (CTA) scans demonstrating a saccular aneurysm and a fusiform
aneurysm.
Originating vessel
Aneurysms are named after the vessel they arise from or the nearest branch artery.
For example, an aneurysm arising from the carotid artery within the cavernous sinus
is called a cavernous carotid aneurysm.

What are the common locations for brain
aneurysms?
There are six common locations of brain aneurysms that may be the cause of a
subarachnoid hemorrhage:
1. Anterior communicating artery (ACoA)
2. Posterior communicating artery (PCoA)
3. Basilar artery
4. Posterior inferior cerebellar artery (PICA)
5. Middle cerebral artery (MCA) bifurcation
6. Distal carotid artery apex
Since the anterior communicating artery and posterior communicating artery are
the most common sites for aneurysm formation, you should start your search there
when looking for a brain aneurysm on CT. Most aneurysms arise near the circle of
Willis, the MCA bifurcation, and PICA origin.
Figure 2. Illustration of the circle of Willis highlighting the common sites for an aneurysm.

Anterior communicating artery (ACoA) aneurysms
Let’s discuss the most common aneurysm site, the ACoA. You may be able to detect
an ACoA aneurysm on a computed tomography angiography (CTA) scan. Volume-
rendered 3D images can be helpful for aneurysm detection when reviewing a CTA scan.
But, remember that volume-rendered CTA scans are displayed as if you were looking from
the top of the head and not from the feet of the patient (as axial CT scans are displayed).
Figure 3. Anterior communicating artery (ACoA) aneurysm on 3D volume-rendered computed tomography
angiography (CTA) images showing the aneurysm projecting inferiorly where the ACoA divides to form the left
and right anterior cerebral (ACA) arteries.
Posterior communicating artery (PCoA) aneurysms

The second location where you’ll commonly find brain aneurysms is the PCoA. You
should be able to locate the posterior communicating arteries that connect the
internal carotid artery with the posterior circulation in patients with a complete circle
of Willis. The posterior cerebral arteries can be seen curving around the midbrain on
CTA and magnetic resonance angiography (MRA).
Figure 4. A magnetic resonance angiography (MRA) scan illustrating the location of the posterior communicating
arteries (PCoA) as they connect the internal carotid arteries, with the posterior cerebral arteries (PCA), seen here
curving around the midbrain.

Let’s take a look at a case
When a 45-year-old patient presented with a severe headache and sensitivity to

bright light (e.g., photophobia), a CT was obtained in the emergency room. The CT
demonstrated a diffuse subarachnoid hemorrhage filling the interpeduncular cistern,
the ambient cisterns, and the Sylvian fissures. Additional imaging was ordered to
determine if a ruptured aneurysm was the source of the hemorrhage.
A volume-rendered CTA scan revealed a saccular aneurysm arising near the patient’s
posterior communicating artery. This was confirmed on the digital subtraction
angiography (DSA) examination.
One way you can be sure on DSA that this is an aneurysm—and not a vascular loop—
is that the aneurysm should have a similar attenuation as the parent blood vessel.
This differs from vascular loops, which should have higher attenuation on DSA. This
effect is due to summation of attenuation of the overlapping contrast-filled arteries.
Figure 5. Computed tomography (CT), volume-rendered computed tomography angiography (CTA), and
digital subtraction angiography (DSA) scans demonstrating diffuse subarachnoid hemorrhaging caused by a
ruptured posterior communicating artery.

Basilar artery aneurysms
The third location that’s important to assess for brain aneurysms is at the basilar
tip. Sometimes, the aneurysm itself is visible on CT! In our next patient case, an
unruptured basilar tip aneurysm was identified on a patient’s non-contrast CT scan.
Based on its size and location at the basilar tip, treatment was suggested and a DSA
was obtained.
When sufficiently large, these aneurysms may be evident on non-contrast CT and

should not be mistaken for a parenchymal hemorrhage.
Figure 6. An unruptured basilar tip aneurysm was visible on non-contrast computed tomography (CT) and
confirmed with digital subtraction angiography (DSA).
Posterior inferior cerebellar artery (PICA) aneurysms
Brain aneurysms can also be commonly found at the origin of the PICA. Our next
case involves a patient who presented with headaches which were found to be
related to a subarachnoid hemorrhage.
A posterior inferior artery aneurysm can be seen on this patient’s CTA scan. However,
you would need the entire stack of images from the CTA to recognize that this is an
aneurysm!
The aneurysm and its relationship with the PICA are better demonstrated on
the maximum intensity projection image from the CTA scan and on a catheter
angiography scan.

Figure 7. The posterior inferior cerebellar artery (PICA) aneurysm is well demonstrated on the maximum
intensity projection image from the computed tomography angiography (CTA) scan and on a catheter
angiography scan.
Middle cerebral artery (MCA) aneurysms

Another common location for brain aneurysms is the MCA. In some patients, you
cannot detect abnormalities by just comparing the patient’s left side to the right
side—since they can be symmetrically abnormal. In this patient, who presented with
a diffuse (but roughly symmetrical) subarachnoid hemorrhage, the CTA revealed an
aneurysm arising from the left MCA that was confirmed on a DSA (Fig. 8).
Despite the aneurysm arising on the patient’s left, the hemorrhage was symmetrical
in the Sylvian fissures on an axial CT scan. While the distribution of a subarachnoid
hemorrhage will occasionally help you find the aneurysm, do not depend on it as
a reliable indicator for the bleeding site in patients with more than one aneurysm.
Figure 8. Computed tomography (CT) scan showing a diffuse subarachnoid hemorrhage that is symmetrical
in the Sylvian fissures from a ruptured left middle cerebral artery (MCA), seen here on computed tomography
angiography (CTA) and confirmed on a digital subtraction angiography (DSA) scan.

Nearly all ruptured aneurysms are found in adults, and the peak age for rupture is 49
years of age. Fusiform aneurysms are frequently secondary to atherosclerosis in adult
patients and usually occur in the basilar artery or cavernous segment of the carotid.
However, you may see MCA fusiform aneurysms in young patients. When middle
cerebral artery fusiform aneurysms occur in young patients, they have been called
dysplastic aneurysms since their etiology and behavior can differ from the usual
adult saccular aneurysm.
Figure 9. A dysplastic aneurysm, known as a middle cerebral artery (MCA) fusiform aneurysm, in a young patient.
Distal carotid artery aneurysms
Brain aneurysms are also commonly found in the distal carotid artery, especially
where it branches into the anterior and middle cerebral arteries, called the carotid
apex. In the case of a patient with an unruptured fusiform aneurysm of the distal
right carotid artery, a volume-rendered image from CTA confirmed that it arose in the
distal internal carotid artery itself.
The aneurysm’s location was just distal to the ophthalmic artery, where the
entire circumference of the carotid was involved. When aneurysms arise distal to
the cavernous segment, the rupture of the aneurysm will result in subarachnoid
hemorrhaging. While cavernous aneurysms can cause symptoms from cranial
nerve compression or dural irritation, they are not the cause of a subarachnoid
hemorrhage.

Figure 10. An unruptured fusiform aneurysm of the distal right carotid artery visible on a computed tomography
angiography (CTA) scan. A volume-rendered CTA demonstrates that the aneurysm arises in the distal internal
carotid artery, just distal to the ophthalmic artery.
Aneurysms rarely arise from the distal segment

of a cerebral artery
Nearly all aneurysms, both fusiform and saccular, appear on the proximal portion
of the cerebral arteries. However, you may eventually encounter a patient with
subarachnoid or parenchymal hemorrhages that are the result of an aneurysm
arising from the distal segment of a cerebral artery.
In our next patient case, the ruptured aneurysm was found beyond the circle of Willis
and was unusual in both shape and location.
Figure 11. A ruptured aneurysm arising from the distal segment of a cerebral artery.

Distal aneurysms may be secondary to an infection caused by trauma, vasculitis,
septic emboli from the heart (also called mycotic aneurysms), or tumor emboli from
the heart. Distal aneurysms require further evaluation to properly determine their
etiology.
So, when assessing a brain scan for aneurysms, start your search at the most
common sites for aneurysm formation, such as the anterior and posterior
communicating artery origins. Remember to search thoroughly, since more than one
aneurysm is detected in up to 20% of cases!

Describing CT features of cavernomas and
arteriovenous malformations
Not all high attenuation in the brain is due to hemorrhaging. When you see high
attenuation on a computed tomography (CT) scan, several other diseases should be
considered—especially if they are more consistent with the patient’s clinical history!
Magnetic resonance imaging (MRI) and computed tomography angiography (CTA)

are valuable when evaluating other possible causes of high attenuation on brain CT,
which may include the following:
• Vascular malformations of the brain

• Sarcoidosis
• Meningiomas and lymphomas
Differentiating vascular malformations from

hemorrhages on brain CT
Case 1: Diagnosing a cavernous angioma
A 27-year-old patient presented to the emergency room with new, severe headaches.
Her CT demonstrated an area of high attenuation in the inferior left frontal lobe. The
patient had a complete work-up for nontraumatic hemorrhaging that included a CTA
(which was normal), followed by MRI.
Figure 1. Computed tomography (CT) scan demonstrating an area of high attenuation in the inferior left frontal
lobe from a cavernous angioma, and a corresponding normal computed tomography angiography (CTA) scan.

Corresponding to the high attenuation seen on CT, the patient’s magnetic resonance
T2-weighted scan revealed a lesion with a dark rim and mixed high and low signal in
the center. This appearance on both CT and MRI is typical for a cavernous angioma.
Cavernous angiomas are vascular malformations of the brain that can occasionally
hemorrhage, but their natural history in any individual patient may be difficult to predict.
Figure 2. Magnetic resonance T2-weighted scan from a 27-year-old patient revealing a lesion with a dark rim
and mixed high and low signal in the center, which is typical of a cavernous angioma.
Case 2: Diagnosing an arteriovenous malformation
In this next case, a 26-year-old woman presented with headaches to the emergency
room. Her CT showed two areas of high attenuation. These were initially thought to
be due to a hemorrhage but proved to be dilated blood vessels from an underlying
arteriovenous malformation (AVM).
Figure 3. CT image showing two areas of high attenuation from dilated blood vessels within an arteriovenous malformation.

You should be aware of the CT findings for an unruptured AVM so that they are not
mistaken for an acute hemorrhage, and appropriate additional imaging is ordered.
Arteriovenous malformations can be distinguished from cavernomas on an MRI, but
digital subtraction angiography (DSA) is the definitive test.
Look for rounded or linear high attenuation caused by dilated blood vessels within
or on the brain CT scan, with or without calcifications.
Normal flowing intravascular blood has a higher attenuation than the normal brain,
which explains why dilated blood vessels can be mistaken for parenchymal or
subarachnoid hemorrhages. Often, you can determine if this high attenuation is due
to blood vessels by how deeply it extends into the brain. But in some cases, an MRI
will be necessary to establish the diagnosis.
Case 3: Confirming an arteriovenous malformation with

catheter angiography
In this case, the patient has a large, clearly evident AVM (Fig. 4). However, it still
could be mistaken for a hemorrhage at first glance!
Figure 4. Computed tomography (CT) from a patient with a large, more evident arteriovenous malformation
that still could be mistaken for a hemorrhage.
The characteristic feature of an AVM on catheter angiography is the early appearance

of veins. This is a sign of the underlying pathology since blood flow is bypassing the
capillaries from direct connections between the small arteries and veins. The nidus
(or core) of the AVM can be seen on an angiogram (Fig. 5).

When an arteriovenous malformation hemorrhages, it can be the result of venous
hypertension. But, you should also consider the possibility of a ruptured intranidal or
supplying artery aneurysm. Aneurysms of vessels supplying the AVM are presumed
to be the result of the chronically elevated blood flow to the AVM. The patient in this
case had an unruptured aneurysm of the anterior communicating artery (ACoA).
Figure 5. Catheter angiography showing the nidus (or core) of the arteriovenous malformation (AVM),
along with dilation of supplying blood vessels. A 3D volume rendered CTA reconstruction demonstrates an
unruptured aneurysm of the anterior communicating artery.
Case 4: High attenuation surrounded by low attenuation is

a sign of an arteriovenous malformation
A 35-year-old patient presented with headaches and no history of trauma or

anticoagulation. The CT revealed a very small area of high attenuation with
surrounding low attenuation. This was the only indication of the patient’s underlying
AVM. The low attenuation indicates abnormal brain tissue near the AVM, due to
vascular shunting or the result of a previous hemorrhage.
Figure 6. Computed tomography (CT) scan showing a very small area of high attenuation with surrounding low
attenuation caused by an arteriovenous malformation (AVM).

Case 5: Calcification near an arteriovenous malformation
A CT from a patient demonstrated a larger AVM that was near the cerebellum (Fig. 7).
Note the multiple dilated blood vessels and a small calcification in this image.
Figure 7. Computed tomography (CT) scan demonstrating a large arteriovenous malformation (AVM) near the
cerebellum with multiple dilated blood vessels and a small calcification.
Case 6: Confirming an arteriovenous malformation using a

digital subtraction angiography
In this case, a patient presented with a new seizure, and on the CT scan you can see
some high attenuation in the patient’s left temporal lobe (Fig. 8). While this could be
mistaken for hemorrhaging, you now know that an AVM and cavernomas can also
appear as high attenuation in the brain on CT.
If there is any question regarding the nature of high attenuation on CT, consider a
follow-up CT, a CTA, or a magnetic resonance angiography (MRA). For this patient,
an MRA showed some subtle flow-related enhancement in the temporal lobe that
was suspicious for an AVM but a diagnosis could not be confirmed. So, a digital
subtraction angiogram was ordered.

Figure 8. Brain computed tomography (CT) image showing high attenuation in the left temporal lobe, and
magnetic resonance angiography (MRA) showing subtle flow-related enhancement in the same region.
The carotid injection on the patient’s DSA confirmed the diagnosis of an AVM based
on the findings of a nidus and the appearance of an early vein. The term early vein
indicates that it appears during the early phases of the angiography when no veins
are visible elsewhere.
Figure 9. Digital subtraction angiography (DSA) from a patient who presented with an arteriovenous malformation
(AVM) showing a nidus and the appearance of an early vein.

Case 7: Digital subtraction angiography confirms an
arteriovenous malformation
Unfortunately, arteriovenous malformations often go unrecognized and many will

present with hemorrhaging as the first clinical symptom. Patients with hemorrhaging
from an AVM tend to be younger on average than those with ruptured aneurysms.
When a large parenchymal hemorrhage was evident on a non-contrast CT from

a 30-year-old patient, a vascular cause was suspected. However, a CTA did not
demonstrate any abnormal blood vessels in the region of the hemorrhage. Since
a vascular cause was suspected (and CTAs may not show a small AVM), a digital
subtraction angiography was ordered.
Figure 10. A large parenchymal hemorrhage in a 30-year-old patient on a non-contrast CT and a CTA.
The DSA from this patient demonstrated a small, peripheral AVM with an abnormal
cluster of blood vessels, a large supplying blood vessel from the anterior cerebral
artery, and early filling of the superior sagittal sinus.

Figure 11. A small, peripheral arteriovenous malformation (AVM) on a digital subtraction angiography (DSA)
with an abnormal cluster of vessels, a large supplying vessel from the anterior cerebral artery (ACA), and early
filling of the superior sagittal sinus.
Differentiating sarcoidosis from a hemorrhage

on brain CT
Computed tomography errors can be divided into errors of detection and errors of
interpretation. We have seen several examples where high attenuation in the brain
from vascular malformations may be mistaken for a hemorrhage. Rarely, you may
also encounter difficulty with the interpretation of high attenuation outside the brain.
In one patient, the CT findings were initially interpreted as consistent with a subdural
hemorrhage (Fig. 12). However, the absence of a typical history in the patient led to
further imaging.
An MRI scan demonstrated homogenous enhancement in the extra-axial space and

additional sites of meningeal involvement—without the characteristic features of
blood products. A biopsy of the dura revealed that the extra-axial high attenuation
was from sarcoidosis rather than the result of a hemorrhage.

Figure 12. Findings from a patient with sarcoidosis. Computed tomography (CT) scan findings were consistent
with a subdural hemorrhage, but the MRI demonstrates homogenous enhancement in the extra-axial space
and additional sites of meningeal involvement without the characteristic features of blood products.
Differentiating meningioma and lymphomas from

a hemorrhage on brain CT
Meningiomas and lymphomas also frequently appear as masses with high
attenuation on CT. This can be due to calcification or dense cell packing, and can be
mistaken for a hemorrhage in the brain, ventricles, or subdural space.
Figure 13. Meningiomas and lymphomas frequently appear as masses with high attenuation on computed
tomography (CT) and can be mistaken for hemorrhages.
So, you can now recognize that not all abnormal high attenuation on CT is due to a
hemorrhage! These other diseases should be considered whenever you see an area
of high attenuation on head CT that is not consistent with the clinical history. MRI
with MRA, CTA, and in some cases DSA exams will be of value in the investigation of
other causes of high attenuation on brain CT.

Diagnosing parenchymal hemorrhage
Identifying a unilateral hemorrhage within the brain on a computed tomography (CT)
scan is not particularly difficult. Determination of the cause is more difficult—but is
essential for planning appropriate treatment and follow-up.
In weighing the probable causes of a unilateral hemorrhage, one should consider

the following factors:
• Medical history
• Hemorrhage location
• Evidence or history of drug use
• Medications
• Symptoms
• Patient’s age
Figure 1. Factors to consider when determining the cause of a unilateral hemorrhage.
When considering the cause of unilateral hemorrhage, a patient’s age is a good

starting point. For example, a basal ganglia hemorrhage in a premature newborn
usually arises from immature vessels in the germinal matrix, while the most common
cause of hemorrhaging in the basal ganglia among middle-aged and older adults is
chronic hypertension.

In patients over 75 years of age, hemorrhaging is frequently due to an underlying
condition common with aging called amyloid angiopathy. Thoughtful use of CT
angiography (CTA), CT venography (CTV), magnetic resonance imaging (MRI),
contrast, and in some cases, digital subtraction angiography (DSA) are typically
used to establish the diagnosis.
Parenchymal hemorrhage case 1: Brain infection

While chronic hypertension may lead to a basal ganglia hemorrhage, you cannot
be certain about the cause of a hemorrhage based only on its location. You should
follow the approach used by Sherlock Holmes—examine all the evidence before
reaching any conclusions!
In our first case, an initial non-contrast CT scan was obtained immediately after
symptom onset in an immunocompromised patient and revealed a hemorrhage
surrounded by low attenuation, suggesting peripheral edema. This finding, along
with the location of the hemorrhage, and the patient’s history led to an investigation
for an underlying cause. The hemorrhage proved to be due to a brain infection with
aspergillus.
But, a hemorrhage surrounded by edema is not a reliable sign of infection. This

finding normally appears in the days after any hemorrhage, as a reaction to the
evolving blood products.
Figure 2. An initial non-contrast computed tomography (CT) scan in an immunocompromised patient with a
hemorrhage due to a brain infection with aspergillus. Note that the hemorrhage on this first scan is already
surrounded by peripheral edema.

Parenchymal hemorrhage case 2 and 3:
Arteriovenous malformation
In our second case, a 30-year-old patient presented with left-sided hemiparesis with
no history of hypertension or drug use. This patient’s CTA demonstrated a cluster
of enhancing blood vessels near the hemorrhage consistent with an arteriovenous
malformation (AVM).
A DSA confirmed this diagnosis on the carotid injection where a large, early draining
vein was demonstrated arising from the dense nidus of the AVM. Notice that no other
veins were visible on this angiogram image taken in the early arterial phase which
established that this is an early vein, characteristic of an abnormal arteriovenous
communication within the AVM.
Figure 3. Computed tomography (CT) from a patient with hemorrhage causing left-sided hemiparesis,
a computed tomography angiography (CTA) demonstrating a cluster of enhancing blood vessels near the
hemorrhage, and digital subtraction angiography (DSA) showing an early vein finding.

After a 42-year-old patient presented with an acute onset of a seizure, their
non-contrast CT in the emergency room (ER) demonstrated a left temporal lobe
hemorrhage. There was no history of trauma or hypertension in this case.
A CTA was also obtained in the ER, which showed abnormal enhancement at the
periphery of the hemorrhage. This finding (although less obvious compared to the
previous case) suggested an AVM as the source of the parenchymal hemorrhage.
The DSA with injection of the left carotid demonstrated an enlarged supplying artery
to a small cluster of vessels (called a nidus), and the early draining vein which is
characteristic for an AVM.
Figure 4. A left temporal lobe hemorrhage on non-contrast computed tomography (CT) and CT angiography
(CTA) showing abnormal enhancement at the periphery of a hemorrhage. A digital subtraction angiography
(DSA) with injection of the left carotid demonstrating an enlarged supplying artery, nidus, and early draining
vein characteristic of an arteriovenous malformation.

Parenchymal hemorrhage case 4:
Links to medication use
The fourth case involves a 20-year-old woman who recently started birth control
pills and presented with new seizures and aphasia. Her CT demonstrated a left
temporal lobe hemorrhage. Based on her age and history, a CTA was ordered.
When examining the CTA, you may be looking for abnormal vessels near the
hemorrhage after the past two cases, but the problem here does not lie in the
arterial system. The patient had a thrombus in the left sigmoid sinus that extended
to involve the left vein of Labbé.
The vein of Labbé drains the lateral temporal lobe. The loss of normal venous
drainage of the left temporal lobe led to venous hypertension with a resultant
parenchymal hemorrhage in this patient.
Figure 5. Computed tomography (CT) demonstrating a left temporal hemorrhage, and computed tomography
angiography (CTA) showing that the cause of the hemorrhage which was a thrombus in the left sigmoid sinus
that extended to involve the left vein of Labbé.

Venous occlusion
In our fifth case, a computed tomography venography (CTV) demonstrated a clot
in the superior sagittal sinus. On enhanced imaging, this is called the empty delta
sign. A CTV is a variation of a CTA where the brain is scanned slightly later to show
enhancement of the veins instead of the arteries.
Figure 6. Computed tomography venography (CTV) demonstrating a clot in the superior sagittal sinus.
Additional testing for suspected venous occlusion
In cases where you suspect venous occlusion based on symptoms or history,

look carefully at the large venous structures on non-contrast CT. Just as we saw
in the arteries, clotted blood has a higher attenuation than normal flowing blood.
However, diffuse venous occlusion is possible, so you cannot rely on comparing the
appearance of veins side to side.
If you measure the attenuation of a venous sinus using picture archiving and
communications system (PACS) tools on a computer and it is above 70 HU, this
suggests a venous occlusion. However, whenever venous occlusion is suspected,
it should be confirmed on an MRI or CTV. This is because values below 70 HU in
the sinuses do not ensure that the veins are normal, and values of 70 HU and above
are possible in patients with polycythemia since attenuation follows the patient’s
hematocrit.

Figure 7. Computed tomography (CT) image showing a venous occlusion. Just as in the arteries, clotted
venous blood has a higher attenuation than normal flowing blood.
In many cases, the cause of a venous occlusion cannot be confidently established.

When the cause of a venous thrombosis can be identified, it is often the result of one
of the following five possibilities:
1. Inherited clotting disorders
2. Drugs (including birth control pills)
3. Dehydration
4. Trauma
5. Hypercoagulation (in patients with cancer)
Figure 8. Common causes of venous thrombosis.

Parenchymal hemorrhage case 6 and 7:
Chronic hypertension
In our sixth case, chronic hypertension was determined to be the cause of a
patient’s left basal ganglia hemorrhage since the patient had a long history of
poorly controlled hypertension. The patient’s high attenuation hemorrhage was not
surrounded by low attenuation edema and appeared uniform. This is typical for a
benign hemorrhage and argues against hemorrhage into an underlying tumor.
Figure 9. Computed tomography (CT) scans from a patient with a left basal ganglia hemorrhage.
The high attenuation hemorrhage is not surrounded by low attenuation edema and
appears uniform, which is typical for a benign hemorrhage.
The next case involves a 68-year-old man who presented to the ER with a sudden
loss of balance and headaches. The CT scan demonstrated a cerebellar hemorrhage
resulting in mass effect. He had a history of hypertension and a systolic blood
pressure of 220 mmHg in the ER.
A susceptibility-weighted MRI was obtained immediately after the CT at the time of

his presentation. It demonstrated multiple areas of signal loss elsewhere in the brain.
This finding indicated the presence of prior hemorrhages (likely subclinical) that were
predominantly in the basal ganglia. This is a typical pattern for microbleeds in patients
with chronic hypertension, which was most likely the cause of his cerebellar hemorrhage.
Be aware that after an acute intracranial hemorrhage, some patients will have
elevated blood pressure. The observation of high blood pressure alone should not
be used to establish the diagnosis of a hypertensive hemorrhage since they are
usually the result of years of poorly controlled hypertension.

Figure 10. Brain computed tomography (CT) scan demonstrating a cerebellar hemorrhage resulting in mass
effect, and magnetic resonance (MR) susceptibility-weighted imaging scan demonstrating multiple areas of
signal loss, which indicates the presence of prior hemorrhages predominantly found in the basal ganglia.

Amyloid angiography
When an 82-year-old patient presented with confusion and headache to the ER,
his CT scan demonstrated a large frontal lobe hemorrhage. An MRI was ordered to
determine whether this was from a hemorrhagic infarction, an underlying tumor, or
an amyloid angiography.
Susceptibility-weighted MRI scans are extremely sensitive to the presence of blood

products within the brain. On this patient’s susceptibility-weighted scan, you can see
innumerable small dots from susceptibility effects of blood products, but with much less
involvement of the basal ganglia than the last patient. This pattern on susceptibility-
weighted imaging in a patient over 70 years of age strongly supports the diagnosis of
amyloid angiography. In this case, it was the most likely cause of the hemorrhage.

Figure 11. Computed tomography (CT) scan demonstrating a large frontal lobe hemorrhage, and magnetic
resonance (MR) susceptibility-weighted scan showing innumerable small dots from susceptibility effects of
blood products.
While the finding of innumerable small dots on an MR susceptibility-weighted scan

indicates amyloid angiopathy in a patient over 75, in a 30-year-old it would suggest
underlying vasculitis.
Always keep the age and clinical context in mind as you review imaging for patients
with parenchymal hemorrhages!
Parenchymal hemorrhage case 9: Drug use

A 50-year-old patient presented with a cortical hemorrhage, a subcortical hemorrhage,
and elevated blood pressure. While a hemorrhagic infarction or cortical vein occlusion
is a possibility with this appearance, his drug screen in the ER was positive for
cocaine and he admitted to using cocaine just before the onset of symptoms. Drugs
like cocaine, methamphetamine, and others may sharply elevate blood pressure and
should be considered in all patients with an acute brain hemorrhage.
Figure 12. Computed tomography (CT) scan showing a cortical and subcortical hemorrhage caused by a
sharply elevated blood pressure due to cocaine use.

Parenchymal hemorrhage case 10: Brain tumor
In our tenth case, a 50-year-old patient presented with a right-sided basal ganglia
hemorrhage and no history of hypertension. His CTA was negative, but an MRI with
contrast demonstrated enhancement at the periphery of a blood clot one day after
symptom onset.
This enhancement was suspicious since benign hemorrhages should not enhance
at all on the acute phase MRI, so a repeat MRI scan was obtained six weeks later.
This exam showed more extensive, inhomogeneous enhancement. A needle biopsy
of this lesion confirmed the diagnosis of an aggressive primary brain tumor (a
glioblastoma), that was undoubtedly the source of the hemorrhage.
Figure 13. A computed tomography (CT) scan showing a right-sided basal ganglia hemorrhage, and a
magnetic resonance imaging (MRI) scan with contrast one day after symptom onset demonstrating suspicious
enhancement at the periphery of the blood clot. A repeat MRI scan 6 weeks later showing more extensive
inhomogeneous enhancement, so further investigations (e.g., needle biopsy) are warranted.

Keep an open mind when considering the cause of a parenchymal nontraumatic
hemorrhage, since it can be the presenting sign of many diseases involving the brain.
Location of the blood, such as the basal ganglia, does not establish the hemorrhagic
cause in all patients.
Reaching the correct diagnosis will require you to consider the age of the patient,
imaging findings, and the patient’s medical history to guide the work-up. Additional
imaging beyond CT and CTA is frequently necessary to establish the cause of
hemorrhaging.

Describing isolated intraventricular
hemorrhage
Intraventricular hemorrhages frequently occur in patients with traumatic and
parenchymal hemorrhages. But, isolated ventricular hemorrhages without a history
of trauma and without subarachnoid or parenchymal hemorrhaging are rare.
Let’s explore several cases where intraventricular hemorrhaging occurred without a

history of trauma. We’ll consider what to look for on computed tomography (CT), as
well as additional testing that can be used to determine the cause of hemorrhaging
for each patient case. Keep in mind that pure intraventricular hemorrhaging (without
evidence of excessive anticoagulation) warrants further evaluation to determine the
source of hemorrhaging!
Five common non-traumatic causes of intraventricular hemorrhage include:
1. Ruptured saccular aneurysm
2. Arteriovenous malformation
3. Cavernous angioma
4. Elevated international normalized ratio (INR)
5. Moyamoya disease
Intraventricular hemorrhage case 1:

Ruptured saccular aneurysm
In our first case, intraventricular high attenuation blood was associated with
a parenchymal hemorrhage on the same side. To determine the source of the
hemorrhages, a digital subtraction angiography (DSA) was ordered.
The source of the parenchymal hemorrhage was a ruptured saccular aneurysm

arising at the origin of the posterior cerebral artery (PCA). While it is not typical for an
aneurysm to present with a parenchymal hemorrhage and without a subarachnoid
hemorrhage, this case illustrates the intraventricular hemorrhage extending from a
parenchymal brain hemorrhage.

Figure 1. Intraventricular high attenuation blood extending from a parenchymal hemorrhage on the same side
due to a ruptured saccular aneurysm arising at the origin of the posterior cerebral artery.

Arteriovenous malformation
In our next case, a 22-year-old patient presented with a sudden onset of severe
headaches. Her CT scan demonstrated high attenuation within the right and left
ventricles with no evidence of any nearby brain abnormalities. Based on the age of
the patient and the absence of any history of anticoagulation, a cerebral DSA was
performed to look for a vascular cause of the bleeding. Her DSA demonstrated an
arteriovenous malformation (AVM); note the diffuse nidus of the AVM and the early
draining vein (Fig. 2).

Figure 2. Computed tomography (CT) scan showing high attenuation within the right and left ventricles and
no evidence of nearby brain abnormalities, and digital subtraction angiography (DSA) demonstrating an
arteriovenous malformation (AVM) with diffuse nidus and an early draining vein.

Cavernous angioma
The CT scan of a 40-year-old man demonstrated an extensive intraventricular
hemorrhage which appeared to expand the fourth ventricle and extend into the
foramina of Luschka. There was no history of trauma or other potential causes of
bleeding.
A DSA was performed since an aneurysm arising from the posterior inferior cerebellar
artery (PICA), AVM, or dural fistula were all possible diagnoses at the time.
Figure 3. Computed tomography (CT) scan of a 40-year-old man demonstrating an extensive intraventricular
hemorrhage expanding the fourth ventricle and extending into the foramina of Luschka.

The DSA was normal in this patient, but because the source of the bleeding remained
unexplained, a magnetic resonance imaging (MRI) scan of the brain and cervical
spine was ordered.
The MRI demonstrated a mass with a dark rim next to the ventricle. This proved
to be a cavernous angioma, also known as a cavernoma, during surgery. This is a
benign vascular malformation that usually causes a parenchymal hemorrhage—but
can also bleed into the ventricle or subarachnoid space (depending on its location).
Figure 4. A normal digital subtraction angiography (DSA), and magnetic resonance imaging (MRI)
demonstrating a mass with a dark rim next to the ventricle—a cavernous angioma.

Elevated international normalized ratio (INR)
A 72-year-old patient presented with headaches, an unsteady gait, and a diminished
level of consciousness. His CT scan demonstrated a cerebrospinal fluid-blood level (a
visible line at the interface between the CSF and blood) in the atrium of the left ventricle.
Remember, that due to gravity, blood will settle to the lowest part of the ventricle.
Figure 5. Computed tomography (CT) scan demonstrating a cerebrospinal fluid-blood level in the atrium of
the left ventricle.

The patient’s lab studies in the emergency room revealed an international normalized
ratio (INR) of 8.0 when the normal at this hospital is below 1.2. This was most likely due
to his treatment with warfarin for atrial fibrillation but with poorly controlled drug levels.
Nevertheless, a computed tomography angiography (CTA) was performed but proved to

be negative. The greatest likelihood was that the patient’s elevated INR was the cause
of the hemorrhage.

Moyamoya disease
A 42-year-old patient’s CT scan showed intraventricular blood with no history of
anticoagulation medications or trauma.
A CTA revealed an unusually small right middle cerebral artery (MCA) that was
substantially smaller than the left middle cerebral artery. A DSA was ordered.
Figure 6. Computed tomography (CT) images showing intraventricular blood, and a computed tomography
angiography (CTA) image revealing an unusually small right middle cerebral artery that was substantially
smaller than the left.

The patient’s DSA revealed an abnormal cluster of collateral vessels near the distal
carotid. This proved to be the result of longstanding stenosis of the proximal middle
cerebral artery.
These enlarged vessels provide blood supply to portions of the brain that would
otherwise have insufficient blood flow. The sudden filling of these collaterals on
DSA accounts for the name of this disease, moyamoya. The word means puff of
smoke in Japanese and describes the vascular blush of these enlarged collateral
vessels. In adults, moyamoya disease can be the cause of hemorrhages and was
likely the explanation for the patient’s intraventricular hemorrhage.
Figure 7. Digital subtraction angiography (DSA) revealing an abnormal cluster of collateral vessels near
the distal carotid that was the result of longstanding stenosis of the proximal middle cerebral artery due to
moyamoya disease.
So, we’ve covered several possible scenarios such as a ruptured saccular

aneurysm, an arteriovenous malformation (AVM), a cavernous angioma, and
moyamoya disease. Keep these in mind as you search for the cause of an isolated
intraventricular hemorrhage. When you encounter a patient with an isolated
nontraumatic intraventricular hemorrhage (and a normal INR), consider additional
imaging since it’s likely that there is an underlying vascular abnormality.

Chapter 5
BRAIN TUMOR IMAGING
www.medmastery.com
Recognizing intra- versus extra-axial
tumors on CT
When examining computed tomography (CT) scans, you will eventually see a scan
with an unexpected intracranial mass causing displacement or compression of the
brain. As you consider the nature of the mass, keep in mind that mass effect alone
does not mean that the patient has a brain tumor; infections, inflammatory diseases,
and demyelinating diseases can also cause displacement of normal structures.
Before you can make any predictions about the composition of the mass, you should
first determine if it resides outside the brain (extra-axial) or within the brain (intra-
axial). This is because the range of possible diagnoses differs in these two spaces.
For example, an extra-axial mass is not due to acute demyelination or a glial tumor.
Deciding whether a mass is intra-axial or extra-axial

When you press your finger deeply into an inflated balloon, the finger may appear to
be inside, but it is still in fact outside the balloon. In the same way, an extra-axial
mass can press on the surface of the brain and may look to be inside, but it is still
outside the brain.
Figure 1. An extra-axial mass resides on the outside of the brain, while an intra-axial mass resides within the
brain itself.
So, be thoughtful about this first step of assigning location! An error in predicting
the location of a mass will very likely result in errors when predicting the tumor’s
histology and expected behavior. And in some cases, it will be difficult or impossible
to be sure about where the tumor resides.
We will also be looking at several magnetic resonance imaging (MRI) scans in this
article, since tumors are better seen on MRI. Once you see common findings on an
MRI, it becomes easier to recognize subtle abnormalities when viewing CT scans.

Review CT images in two perpendicular planes to
distinguish between intra- and extra-axial masses
It’s crucial to begin your search by carefully reviewing the CT images reconstructed
in two perpendicular planes. This is particularly helpful when the mass is along a
fissure or near the surface of the brain.
This approach is especially helpful whenever you see a mass surrounded by brain
tissue. In some cases, it may seem reasonable to conclude that it is arising from
the brain (e.g., intra-axial). Before you leap to that conclusion, keep in mind that you
should look at the tumor in at least two planes before making a decision. Remember,
collect the evidence first!
You will notice on this MRI that the mass is in the interhemispheric fissure (Fig. 2).
In the axial view, the tumor appears to be surrounded by brain tissue. But when you
look at the tumor on the coronal view, you can now see that the tumor is arising from
the dura along the skull base and pressing up into the brain. This tumor proved to be
an extra-axial meningioma.
Figure 2. Axial magnetic resonance imaging (MRI) scan showing a mass that looks to be intra-axial. Coronal
MRI demonstrates that the mass (a meningioma) is clearly extra-axial, arising from the dura along the skull
base and pressing up into the brain.
In the next example, based on the axial view you might predict that the tumor is
intra-axial because this axial section is not close to the surface of the brain (Fig. 3).
As well, the tumor is not near a fissure and nearly reaches the center of the brain.

However, when you view this tumor in the coronal plane (perpendicular to the axial slice),
you can see the broad dural attachment of the tumor and some subtle bone reaction.
This proved to be another meningioma—but even larger than the first example!
Figure 3. Magnetic resonance imaging (MRI) scans of a large meningioma seen here in the axial plane (where
it appears intra-axial) and the coronal plane (where you can see the broad dural attachment and subtle bone
reaction, indicating it is in fact extra-axial).
Next, let’s look at another case of an extra-axial mass that appeared to be within the
brain on axial MRI imaging (Fig. 4). When you look at the mass on the sagittal plane
you can see that the mass arises from the skull base and projects upwards into the
brain substance—like a finger pressing into a balloon.
While MRI scans are used here to illustrate this concept, most current CT scanners can
provide high quality, multiplanar reconstructions that provide comparable information.
Figure 4. Magnetic resonance imaging (MRI) scans of an extra-axial mass that appears intra-axial on the axial
plane. But, the sagittal plane reveals that the mass arises from the skull base and projects upwards into the
brain substance.

When unclear after CT, enhanced MRI may help
to distinguish between intra- and extra-axial
masses
On a 45-year-old patient’s CT scan (Fig. 5), we can see that the fourth ventricle is
displaced by a mass on the patient’s left side. This displacement is more evident
when you compare it with a CT section of a different patient that shows a normal
fourth ventricle.
Notice that the mass itself is difficult to see on CT, and its presence is inferred by
the displacement of the fourth ventricle. This should be a reminder of why the fourth
ventricle is one of the brain structures you should look for on all head CT scans.
Figure 5. Computed tomography (CT) scan showing that the fourth ventricle is displaced by a mass on the
patient’s left side.
Determining the location of the mass is critical! If the mass is extra-axial, it would
most likely be a meningioma or vestibular schwannoma in this location. But, if the
findings suggest that it is intra-axial, metastatic disease, subacute infarction, and
tumefactive multiple sclerosis are all possible diagnoses in adults.
The MRI scan in this case clearly demonstrated that the mass was extra-axial in
origin based on its broad attachment to the petrous apex and enhancement that
extends into the internal auditory canal. Note again the mass effect on the fourth
ventricle, due to the displacement of the brain by the tumor.

Figure 6. Enhanced magnetic resonance imaging (MRI) was used to determine that a mass was an extra-axial
mass based on its broad attachment to the petrous apex and enhancement that extends into the internal
auditory canal.
When determining if a mass is intra-axial or extra-axial, it can be helpful to look for

six findings, which we will demonstrate with case studies:
1. Skull changes
2. Displacement of the brain cortex
3. Displacement of large blood vessels
4. Multi-compartment involvement
5. Location in the midline or along Sylvian fissures
6. Blood supply to the mass
Skull changes can help establish that a mass is extra-axial
Bone changes can help establish that a mass is extra-axial. A contrast-enhanced

CT scan demonstrates another extra-axial mass (Fig. 7). Note the widening of the
left internal auditory canal when compared to the other side.
Skull changes can also support the diagnosis of a vestibular nerve sheath tumor (as
in this case). These tumors arise from the eighth cranial nerve and while they grow
very slowly, they eventually can cause hearing loss and sometimes vertigo.

Figure 7. Contrast-enhanced computed tomography (CT) scan showing a vestibular nerve sheath tumor. Note
the widening of the left internal auditory canal compared to the right.
When unsure after MRI, a CT may help distinguish between

an intra- or extra-axial mass
Even when you have an MRI to review, you should consider obtaining a CT when you
are not sure if a mass is extra-axial. For example, on the MRI from a patient with a
history of breast cancer, a rounded enhancing mass was evident and appeared to
be extra-axial in origin.
A CT was also ordered since the imaging was consistent with a meningioma (which
is usually a benign, slowly growing tumor) and a dural metastasis (which would be of
more immediate concern). The bone-filtered CT image demonstrated bone formation
along the inner table of the skull that corresponded to the mass seen on MRI.
This finding, called hyperostosis, is characteristic of a meningioma rather than

metastatic disease. This information proved to be a great comfort to the patient!

Figure 8. Magnetic resonance imaging (MRI) showing a rounded enhancing mass that appears to be extra-
axial. A computed tomography (CT) scan demonstrated bone formation along the inner table of the skull
(hyperostosis) which is characteristic of a meningioma.
You may have noticed that the tumor appears to be in two different locations when
you look at the MRI and CT images (Fig. 8). This is a common pitfall and is the result
of a discrepancy in the standard plane of reconstruction used for MRI and CT. For
a variety of reasons, the convention with CT is that the images are reconstructed
at an angle while magnetic resonance images are simply displayed in the plane
perpendicular to the long axis of the patient.
Displacement of the brain cortex indicates an extra-axial mass
In our next example, a large enhancing mass was seen on a contrast-enhanced

CT scan. In considering the location of the mass, you should notice that there
is evidence of displacement of the frontal lobe cortex by the mass (Fig. 9). This
displacement is visible because the cortex has a slightly higher attenuation than the
white matter. The finding was confirmed on the MRI scan.
Recall the analogy of a finger pressed into a balloon. Displacement of the brain
cortex argues strongly that the tumor’s origin was extra-axial since it displaced the
outer layer of the brain as it enlarged.
As well, the tumor was associated with skull changes. This finding indicated that the
tumor arose from the skull itself, and proved to be a cavernous hemangioma of the
skull based on surgical pathology.

Figure 9. Contrast-enhanced computed tomography (CT) scan showing a large enhancing mass (cavernous
hemangioma of the skull) with evidence of displacement of the cortex, seen on a magnetic resonance imaging
(MRI) scan with contrast. A bone-filtered CT shows evidence of extensive skull changes consistent with an
extra-axial tumor.
Displacement of large blood vessels
Another finding to look for when trying to determine if a mass is intra- or extra-axial
is the displacement of large blood vessels. In our next case, the vertebral arteries
(which lie on the surface of the brain) are displaced away from the skull base. This
sign indicates that the tumor is extra-axial since a tumor arising from the brainstem
would displace the arteries towards the skull base.

Figure 10. Brain computed tomography (CT) scan showing vertebral arteries displaced away from the skull
base indicating that the tumor is extra-axial in location.
Multi-compartment involvement is common with

extra-axial tumors
The next case illustrates multi-compartment involvement typically seen with

meningiomas. On MRI, the enhancing tumor occupies the sphenoid sinus, the left
cavernous sinus and middle fossa, and the internal auditory canal in the posterior
fossa (Fig. 11).
Figure 11. Magnetic resonance imaging (MRI) scan showing a meningioma with multi-compartment
involvement, occupying the sphenoid sinus, the left cavernous sinus and middle fossa, and the internal
auditory canal in the posterior fossa.

Be careful when the mass is in the midline or along the
Sylvian fissures
In our next case, the mass appears to be surrounded by brain tissue with considerable
edema extending into the left frontal lobe. While both features suggest that this
could be an intra-axial mass, it proved to be an extra-axial mass arising from the
interhemispheric fissure.
Remember that edema can be seen with both intra- and extra-axial tumors. For that
reason, edema is an unreliable sign for the location of a tumor.
Figure 12. Magnetic resonance imaging (MRI) scan showing an extra-axial mass arising from the interhemispheric
fissure surrounded by brain tissue and considerable edema extending into the left frontal lobe.
Tumor blood supply from arteries that supply brain tissue

suggests an intra-axial tumor
Deciding whether a mass is intra- or extra-axial in some cases can be quite difficult.
Every now and then you will encounter a tumor where the location remains uncertain
even with multiplanar reconstructions and the use of contrast CT and MRI.
In our next case, a patient’s non-contrast CT demonstrated a displaced and

compressed fourth ventricle. The mass appears just posterior and to the left of the
fourth ventricle and seems intra-axial since it appears to be surrounded by brain
tissue. However, we have seen that this sign is unreliable when viewed on only one
plane of imaging.

The patient had no history of cancer to support the diagnosis of metastatic disease
(the most common intra-axial tumor in the cerebellum in adults), so more testing
was ordered.
Figure 13. Non-contrast computed tomography (CT) scan showing a displaced, compressed fourth ventricle
and a mass that is just posterior and to the left of the fourth ventricle.
The contrast-enhanced CT image from the same patient shows enhancement of

multiple enlarged blood vessels. In this image, the tumor again appears intra-axial
(Fig. 14). However, an MRI scan in the coronal plane shows the tumor has a broad
attachment along its inferior border suggestive of extra-axial origins.
In this case, because of the tumor’s hypervascularity, a preoperative digital

subtraction angiography (DSA) was performed. The exam demonstrated that the
blood supply to the tumor arose primarily from an artery that supplies the brain—
the posterior inferior cerebellar artery—which favors an intra-axial tumor. The mass
proved to be a primary brain tumor called a hemangioblastoma during surgery.

Figure 14. Contrast-enhanced computed tomography (CT) showing enhancement of multiple enlarged blood
vessels. The coronal magnetic resonance imaging (MRI) shows that the mass has a broad attachment along
its inferior border suggestive of extra-axial origins. The digital subtraction angiography (DSA) revealed that
the blood supply to the tumor arose primarily from the posterior inferior cerebellar arteries (PICA) that supply
the brain, evidence of an intra-axial tumor.
When reviewing imaging scans of a patient with a newly diagnosed brain mass,
before you make any decision regarding its histology, consider whether the tumor
arose from inside the brain or outside the brain.
Multiplanar reconstructions, skull changes, displacement of the cortex, and in some

cases blood supply are helpful findings. Remember to be particularly careful with
your decision when the tumor is in the midline, along the Sylvian fissure, or near the
periphery of the brain.

Distinguishing common adult extra-axial
tumors
Let’s examine several cases which will demonstrate how to distinguish between the
four common types of extra-axial masses in adults using brain computed
tomography (CT) and magnetic resonance imaging (MRI):
1. Vestibular schwannoma
2. Meningioma
3. Epidermoid tumor
4. Arachnoid cyst
Vestibular schwannomas, meningiomas, and epidermoid tumors are the most

common extra-axial tumors found in the posterior fossa (the space below the
tentorium). Elsewhere in the brain, meningiomas remain the most common tumor.
Keep in mind that meningiomas can be hard to distinguish from metastatic tumors
in the dura or bone in patients with cancer. Arachnoid cysts are not strictly tumors
but can also have a mass effect like a solid tumor.
Figure 1. The four common extra-axial masses in adults are vestibular schwannomas, meningiomas, epidermoid
tumors, and arachnoid cysts.

Vestibular schwannoma
In our first case, the patient’s MRI and CT scans demonstrated a small vestibular
schwannoma. These are histologically benign nerve sheath tumors that arise from
the eighth cranial nerve and appear initially within the internal auditory canal.
When they grow larger, vestibular schwannomas can extend into the adjacent cistern
and compress the brainstem while the tumor is still evident in the internal auditory canal.
Figure 2. A small vestibular schwannoma on magnetic resonance imaging (MRI), and computed tomography
(CT), which shows the tumor’s location in the internal auditory canal and extending into the adjacent cistern
to compress the brainstem.

Meningioma
In our second case, a patient’s MRI demonstrated an extra-axial mass that
was largely on the right. The mass crosses the midline and doesn’t involve the
internal auditory canal—findings that argue against the diagnosis of a vestibular
schwannoma!
This mass proved to be a meningioma. All meningiomas and schwannomas enhance

on MRI and both can have cystic areas that do not enhance.
Figure 3. Magnetic resonance imaging (MRI) scan demonstrating an extra-axial mass that was determined to
be a meningioma. The mass crosses the midline and doesn’t involve the internal auditory canal.
Epidermoid tumor
In our third case, a patient had a left-sided extra-axial posterior fossa mass
that can be seen displacing the middle cerebellar peduncle on MRI. This mass
did not enhance, so a diagnosis of meningioma or vestibular schwannoma was not
considered.
While the mass resembles cerebrospinal fluid (CSF) on this image, both arachnoid
cysts and epidermoid tumors can also resemble CSF on both CT and MRI. In this
case, the diffusion-weighted MRI established the diagnosis of an epidermoid tumor
since an arachnoid cyst should be dark and resemble CSF.

Figure 4. Magnetic resonance imaging (MRI) scan showing a left-sided extra-axial epidermoid tumor that
displaces the middle cerebellar peduncle and resembles cerebrospinal fluid (CSF) beside a diffusion-weighted
MRI image showing a tumor that does not resemble CSF.
Usually, the combination of CT and MRI (and the use of intravenous contrast) will
allow you to correctly predict the nature of posterior fossa extra-axial tumors.
Consider our next patient who presented to the emergency room with dizziness.
The CT scan demonstrated a low attenuation mass that was poorly seen on CT. But,
based on the loss of the normal fourth ventricle contour, we know the tumor is there
(Fig. 5). Based on this CT alone, the mass could be intra- or extra-axial in location.
Figure 5. Computed tomography (CT) scan demonstrating a low attenuation mass alongside loss of the
normal fourth ventricle contour in a patient presenting with dizziness.

The T1-weighted MRI of this patient demonstrated a sharp border between the
tumor and the cerebellum. While the mass appears to be surrounded by brain tissue,
be skeptical of this observation when based on a single view, especially with masses
at the periphery of the brain and the midline.
Contrast-enhanced T1-weighted MRI shows that the mass does not enhance. This
observation makes meningioma and vestibular schwannoma tumors unlikely since
they both should enhance with intravenous contrast.
Figure 6. A T1-weighted magnetic resonance imaging (MRI) scan of an epidermoid tumor demonstrating a sharp
border between the tumor and the cerebellum, and a contrast-enhanced T1-weighted MRI scan showing that
the mass does not enhance, which makes the diagnosis of a meningioma or vestibular schwannoma unlikely.
In the same patient, the midline mass has a very high signal intensity on the next
diffusion-weighted MRI image. Considering the tumor’s lack of enhancement, the
location of the tumor in the midline, and high signal intensity on diffusion-weighted
MRI, you can conclude that this tumor is an extra-axial epidermoid tumor, even
though it’s not in a typical location!

Figure 7. A diffusion-weighted magnetic resonance imaging (MRI) scan showing a high signal intensity of an
epidermoid tumor.
Arachnoid cyst
In our final case, the patient showed a cerebellopontine angle (CPA) mass at the level
of the internal auditory canal on a T1-weighted MRI image. In this case, the mass on
the diffusion-weighted MRI has the same signal as CSF. This is an arachnoid cyst—a
collection of CSF that doesn’t usually require treatment.
Figure 8. T1-weighted magnetic resonance imaging (MRI) scan showing a cerebellopontine angle (CPA) mass
at the level of the internal auditory canal, and a diffusion-weighted MRI scan showing that the mass has the
same signal as cerebrospinal fluid (CSF) which is consistent with an arachnoid cyst.
While you will not be able to predict the type of every extra-axial mass, accurate
localization of the mass to the extra-axial space will allow you to limit the possible
diagnoses considerably.

Recognizing intra-axial tumors
Once you have determined that a mass is intra-axial, you should then consider
whether it represents a primary or metastatic brain tumor or something entirely
different! We are going to cover the key findings of intra-axial brain tumors on
computed tomography (CT). We’ll also cover how to rule out other possibilities since
not all intra-axial masses are brain tumors.
Before we get started, it’s important to note that both magnetic resonance imaging
(MRI) and the patient’s history are very helpful in differentiating between all possible
diagnoses. Many brain tumors cannot be seen on CT since they can resemble normal
brain tissue, so obtaining an MRI is often helpful.
For example, a low-grade cerebellar tumor is only faintly visible on CT, but only if you
know where to look based on the MRI results.
Figure 1. Computed tomography (CT) showing a low-grade cerebellar tumor that is only faintly visible. The
magnetic resonance imaging (MRI) scan makes the tumor much more conspicuous.
While there are a variety of primary brain tumors that can occur in the brain, the
histology of the tumor frequently cannot be determined with certainty on CT or MRI
alone. For that reason, most patients will be referred for a biopsy or resection.
Brain tumors can vary substantially in appearance from mostly cystic to mostly
solid, non-enhancing to solidly enhancing, and sharply defined to diffuse. All of
these imaging features weakly correlate with prognosis and tumor behavior.

Ruling out other possibilities when considering
an intra-axial mass
It’s important to rule out the three possible diagnoses when considering whether an
intra-axial mass is a brain tumor:
1. Subacute infarction
2. Brain infection
3. Tumefactive demyelination
You should know about your patient’s history so that you can avoid mistaking brain
infection or demyelination for a neoplasm. The patient’s history may also help you
avoid confusing a subacute infarction for a brain tumor—or the reverse.
Figure 2. When examining computed tomography (CT) images, avoid mistaking brain infarction, infection, or
demyelination for a neoplasm.
In our first case, a 49-year-old patient presented to the emergency room with
intermittent word-finding difficulty. While, in many ways, the CT findings resembled
an infarction with both gray and white matter involvement, it had an unusually round
configuration (Fig. 3). As well, on careful questioning, you learned the patient’s
symptoms were waxing and waning over a week, which would be atypical for an
infarction of this size.
An MRI was obtained based on the combination of the patient’s history and CT scan.
It showed that the patient had a primary brain tumor and not an infarction.

Figure 3. Brain computed tomography (CT) of a primary brain tumor which resembles an infarction with gray
and white matter involvement, except for the unusually round configuration. Magnetic resonance imaging
(MRI) confirmed the tumor.
Ruling out infection or demyelination
Not all intra-axial masses that spare the cortex are neoplasms. Always consider the
possibilities of infection and demyelination since both of them (in the acute phase)
can resemble tumors.
In our next case, a patient’s CT scan demonstrates abnormally low attenuation,

suggesting a brain tumor, with sparing of the overlying cortex (Fig. 4). Because of
the mass effect, an MRI was obtained.
The MRI demonstrated a sharply defined zone of restricted diffusion in the same
region as the brain mass. This finding can be seen with some highly cellular tumors
like lymphoma, but it is typically a sign of pus within a bacterial abscess. The mass
proved to be a brain abscess during surgery.

Figure 4. Computed tomography (CT) scan demonstrating abnormal low attenuation, suggesting a brain
tumor, with sparing of the overlying cortex. Magnetic resonance imaging (MRI) scans showed a sharply
defined zone of restricted diffusion in the same region as the brain mass, which is a finding typical of pus
within a bacterial abscess.
Key findings to make you suspect that an

intra-axial mass may be a brain tumor
There are three imaging findings which should cause you to suspect that an intra-
axial mass may be an underlying brain tumor:
1. Unexplained calcifications in the brain
2. Sparing of the cortex
3. Disproportionate mass effect to the symptoms
Figure 5. The key findings which indicate that an intra-axial mass may be an underlying brain tumor include
unexplained calcifications in the brain, sparing of the cortex, and disproportionate mass effect on computed
tomography (CT) compared to the patient’s symptoms.

Finding 1: Unexplained calcifications
In our next case, a patient presented with intermittent word-finding difficulties. An

intra-axial mass with calcification was noted in the left temporal lobe on CT (Fig. 6).
This also proved to be a primary brain tumor called an oligodendroglioma.
Figure 6. Computed tomography (CT) scan showing an intra-axial mass that was determined to be an
oligodendroglioma with calcification in the left temporal lobe. Notice the air on this CT, which was obtained
immediately after biopsy.
In another case with unexplained calcification, the patient was involved in a car
crash. On CT, the mix of high attenuation and adjacent low attenuation in the frontal
lobe did not extend to the cortex (Fig. 7).
It is always tempting to attribute any imaging findings to the clinical situation, which
was trauma in this case. This error is common and even has a name—confirmation
bias. Always strive to be impartial and analytical if you want to contribute
substantially to patient care as an imager.
As a result of confirmation bias, you might at first consider a hemorrhagic contusion

for this finding in a trauma patient. However, the high attenuation looks more like the
skull than blood products, and the overlying cortex of the brain is normal. Since the
high attenuation might be calcium, the findings should lead you to at least consider
a calcified primary brain tumor, which was the actual diagnosis in this case!

Figure 7. Computed tomography (CT) scan showing a mix of high attenuation and adjacent low attenuation in
the frontal lobe that does not extend to the cortex. The bone-filtered and windowed CT image shows that the
high attenuation is from a calcified primary brain tumor.
Finding 2: Sparing of the cortex
A 47-year-old patient presented with transient left arm weakness that had resolved
by the time he had arrived at the emergency room. A small area of low attenuation
was found on his CT, which was initially called an infarction (Fig. 8). This is an
example of how you can go wrong by making a snap judgment, or what some call
gunslinger radiology. But, it is always better to be accurate than fast in the case of
clinical imaging.

On careful examination of the CT, the preservation of the cortex was distinctly
unusual for an infarct, so an MRI scan was ordered.
The enhanced MRI scan demonstrated that the cause of the low attenuation on CT
was a small subcortical enhancing tumor. This was resected and proven to be a
primary brain tumor.
Figure 8. Computed tomography (CT) showing a small area of low attenuation that was initially called an
infarction, but the preservation of the cortex was distinctly unusual for an infarct. An enhanced magnetic
resonance imaging (MRI) scan demonstrating that the low attenuation was from a small subcortical
enhancing tumor.
Finding 3: Disproportionate mass effect
The CT scan from our next case shows an area of low attenuation along the midline
that conforms to the anterior cerebral artery territory (Fig. 9). There is also some
mass effect with effacement of the sulci and a midline shift.
The mass could be attributed to an evolving, subacute infarction. However, the

patient had no neurological deficits and presented only with headaches.
When you look at the coronal CT reconstruction of the scan, you can see there is
in fact abnormally low attenuation on both sides of the brain. This proved to be a
primary brain tumor. As was the case with this patient, primary brain tumors can be
quite large without causing neurological deficits.

Figure 9. Axial computed tomography (CT) scan showing an area of low attenuation along the midline that
conforms to the anterior cerebral artery territory, some mass effect with effacement of the sulci, and a midline
shift. A coronal CT reconstruction shows low attenuation on both sides of the brain that proved to be from a
primary brain tumor.
Intra-axial tumors may sometimes appear with

high attenuation on CT
Not all brain tumors appear as masses with low attenuation; lymphoma typically
has high attenuation on CT. Our next case features CT images from a patient with
central nervous system (CNS) lymphoma (Fig. 10).
Figure 10. Computed tomography (CT) images from a patient with central nervous system (CNS) lymphoma,
which typically has high attenuation on CT.
But beware! High-grade glial tumors and meningiomas may also appear to have
high attenuation (due to their cellularity) on brain CT. So, high attenuation is not a
specific sign of lymphoma. The high attenuation in our next case proved to be due
to an anaplastic astrocytoma that extended across the corpus callosum, which is
best seen on MRI (Fig. 11).

Figure 11. Computed tomography (CT) and magnetic resonance imaging (MRI) scans from a patient with
anaplastic astrocytoma that extended across the corpus callosum. Due to its high cellularity, this tumor
appears to have high attenuation, which is best seen on MRI.
In our final case, notice that there is high central attenuation within an area of low
attenuation that is associated with mass effect on the ventricle (Fig. 12). The high
attenuation argues against the diagnosis of tumefactive demyelination, which
should appear to have homogeneously low attenuation. Later, the attenuation
proved to be another case of central nervous system lymphoma.
Figure 12. Computed tomography (CT) images from a patient with central nervous system lymphoma showing
central high attenuation within an area of low attenuation and associated mass effect on the ventricle.
So, CT findings of unexplained calcifications, cortical sparing, and mass effect out of
proportion to symptoms should make you consider an underlying intra-axial brain tumor.

Chapter 6
SEIZURES AND
EPILEPSY
www.medmastery.com
Describing CT findings in patients with seizures
Let’s begin by clarifying the difference between the words seizures and epilepsy since
they are not equivalent. When the history for a patient sent from the emergency room
reads seizure, it may indicate that the patient had their first or second seizure. On
the other hand, the term epilepsy indicates that the patient has experienced multiple
seizures for years or even decades. Keep in mind that some patients who are sent
from the emergency room for head computed tomography (CT) with a history of
seizures might have had seizure-like activity that may or may not have been a true
seizure. And, it may never occur again.
Let’s review how to approach CT imaging for patients who present with new seizures.
A CT is usually the first step for patients with new seizures, which ensures that
there is no underlying hemorrhage or tumor. Most of these CT scans will be normal
because there is no lesion, or if there is a lesion it may not be visible on CT.
But, some of the CT scans ordered for patients with new seizures will be abnormal.
So, you need to look carefully at each one, particularly near the cortex of the brain
since most seizures arise from an abnormality in or around the brain cortex—rather
than in the white matter or the cerebellum. Diseases such as neoplasms, vascular
malformations, and infection can all cause seizures.
Figure 1. Potential causes of new seizures include hemorrhages, neoplasms, vascular malformations, and infections.
Keep in mind these three strategies when using CT imaging to assess patients with
new seizures:

Keep in mind these three strategies when using CT imaging to assess patients with
new seizures:
• Carefully examine the cortex

• Look for fluid in the extra-axial space
• Obtain magnetic resonance imaging (MRI) when a focal brain abnormality is likely

Carefully examine the cortex for mass effect

or abnormal attenuation on CT
Case 1: New seizures related to a metastatic tumor
In our first case, an adult, with a history of cancer, presented with new seizures,
and his CT scan demonstrated a rounded mass near the cortex with surrounding
low attenuation edema (Fig. 2). The MRI obtained shortly afterward revealed a rim
enhancing mass that proved to be a metastatic tumor.
Figure 2. Computed tomography (CT) scan demonstrating a rounded mass near the cortex with surrounding
low attenuation edema, and a magnetic resonance imaging (MRI) scan revealing a rim enhancing mass that
proved to be a metastatic tumor.

Case 2: New seizures related to an enhancing meningioma
Some tumors, like the one visible in our next case, resemble brain tissue on non-
contrast CT and can only be detected by their mass effect on the brain or the
ventricles.
The 50-year-old patient presented with new seizures, so the abnormal asymmetry of
the cortical sulci noted on non-contrast CT led to a follow-up enhanced CT because
the patient could not have an MRI (Fig. 3). That CT demonstrated an enhancing
meningioma that was likely the cause of her new seizures.
Figure 3. Non-contrast computed tomography (CT) in an adult patient with a history of seizures revealed
asymmetry of the cortical sulci. An enhanced CT was done and found a meningioma.
Case 3: New seizures related to an arteriovenous malformation
In our next case, a 25-year-old patient with new seizures had a small area of high
attenuation with calcification on their CT scan (Fig. 4). When you see these findings
on CT, you should consider that the patient may have a vascular malformation, since
these can also cause seizures!
Follow-up imaging with MRI or CT angiography (CTA) was warranted in this case. The
MRI demonstrated prominent flow voids that proved to be due to an arteriovenous
malformation (AVM) that was found on CTA.

Figure 4. Computed tomography (CT) of a patient with seizures showing a small area of high attenuation
with calcification beside a magnetic resonance imaging (MRI) scan demonstrating prominent flow voids
that proved to be due to an arteriovenous malformation (AVM) that was found on computed tomography
angiography (CTA).
Cases 4 and 5: New seizures related to herpes encephalitis
When you see an abnormality in the medial temporal lobe in an adult patient with new
seizures, be sure to think of infections such as herpes encephalitis or a neoplasm.
In our next two patient cases, herpes encephalitis was the cause of low attenuation
in the right temporal lobes on both CT scans (Fig. 5).

Figure 5. Herpes encephalitis was suspected as the cause for low attenuation in the right temporal lobes on
computed tomography (CT) scans from two different patients with seizures.
Look for fluid in the extra-axial space on CT since

abscesses can form in the epidural and subdural
spaces
Case 6: New seizures related to an epidural abscess
Our next case involves a patient who presented with seizures, headache, and a fever.
The enhanced CT demonstrated an abnormality on the surface of the brain (Fig. 6).
This proved to be a pus collection in the epidural space (called an epidural abscess)
that can cause seizures.
Figure 6. Enhanced computed tomography (CT) scan highlighting an abnormality on the surface of the brain
which proved to be an epidural abscess (pus collection in the epidural space).

Case 7: New seizures related to an abscess in the
subdural space
The diffusion MRI from our next patient showed abnormally restricted diffusion
outside of the brain (Fig. 7). This is another case of an abscess, but this time in
the subdural space. Magnetic resonance offers greater sensitivity and specificity in
such cases, although blood products can resemble pus on diffusion imaging which
can be misleading in postoperative cases.
Figure 7. A diffusion magnetic resonance imaging (MRI) scan highlighting an abnormally restricted diffusion
outside the brain from an abscess in the subdural space.
Case 8: New seizures and a cortical mass from

a brain abscess
Keep in mind that not all patients with a cortical mass and seizures have a tumor! In our next
example, a right-sided mass with considerable edema proved to be a brain abscess (Fig. 8).
Figure 8. Computed tomography (CT) scan of a right-sided mass with considerable edema which proved to
be a brain abscess.

Use MRI when there is a high likelihood of a focal
brain abnormality
The patient’s history is not usually definitive for establishing the diagnosis of a
brain abscess since the patient may not have the usual features of infection, such
as an elevated white blood cell count or a fever. Magnetic resonance imaging can
be very helpful in establishing the diagnosis since abscesses have a well-defined
enhancing rim alongside centrally restricted diffusion on MRI.
Figure 9. Magnetic resonance imaging (MRI) scans showing typical MRI findings for brain abscesses such as
well-defined enhancing rim and centrally restricted diffusion.
Case 9: New seizures and a hemorrhage related to herpes

encephalitis
From these cases we’ve discussed, you’ll notice that the abnormalities on CT in
patients with new seizures range from the obvious to nearly undetectable. And even
when the findings are visible, they can be easily misinterpreted!
For example, the CT findings in our final case are from a patient with new seizures.
At first, a temporal lobe abnormality was thought to represent an underlying
hemorrhagic tumor (Fig. 10). On additional testing, this proved to be another case of
herpes encephalitis. The hemorrhage, while distracting, is not uncommon with this
particular type of infection.

Figure 10. Computed tomography (CT) findings from a patient with a hemorrhage related to herpes encephalitis
that was at first thought to represent an underlying hemorrhagic tumor.
In all patients with new seizures, you should carefully evaluate the cortex and extra-
axial spaces on CT, and order an MRI if a focal brain abnormality is likely. Keep
in mind that a variety of diseases can present with new-onset seizures in adults,
including hemorrhages, neoplasms, vascular malformations, and infections.

Explaining the role of CT and MRI in patients
with seizures
Let’s review several examples of brain abnormalities that are difficult—if not
impossible—to detect on computed tomography (CT).
Whenever a patient has had multiple seizures, or if there is a strong clinical suspicion
that a seizure is secondary to an underlying brain lesion (and the CT scan is normal),
magnetic resonance imaging (MRI) is usually warranted.
Case 1: A small metastatic lesion is best viewed

on contrast-enhanced MRI
Small metastatic lesions can lead to seizures, but are difficult (or even impossible)
to see on non-contrast MRI. Our first case features two MRI scans with contrast that
demonstrates small metastatic lesions. One of these lesions is within the cortex and
could represent the source of the seizures.
Figure 1. Magnetic resonance imaging (MRI) with contrast demonstrating two small metastatic lesions in a
patient with seizures. The lesion within the cortex could represent the source of the seizures.

Case 2: A cerebellar metastasis is more evident
on enhanced MRI
In the next case, a patient’s cerebellar metastasis is much more evident on an enhanced
MRI scan than on the non-contrast fluid-attenuated inversion recovery (FLAIR) scan.
Figure 2. A cerebellar metastasis is much more evident on the enhanced magnetic resonance imaging (MRI)
scan than on the non-contrast fluid-attenuated inversion recovery (FLAIR) scan.
Case 3: A herpes encephalitis abnormality is

better viewed using FLAIR MRI
Our third case involves a patient with seizures secondary to herpes encephalitis.
The abnormality in the patient’s right temporal lobe is much more apparent on the
FLAIR MRI compared to CT (Fig. 3).
Figure 3. Computed tomography (CT) scan showing an abnormality due to herpes encephalitis in the patient’s
right temporal lobe, and a fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI)
image which more clearly shows the abnormality.

Case 4: A small cavernoma is best viewed with
gradient echo MRI
In our fourth case, the patient had a cavernoma involving the left insular cortex.
In this circumstance, the CT scan might show some high attenuation within the
cavernoma, but the CT appeared normal since the lesion was small and barely
visible on T2-weighted MRI. Small cavernomas are best seen on gradient echo or
susceptibility-weighted MRI images.
Figure 4. A T2-weighted magnetic resonance image (MRI) scan from a patient with a cavernoma involving the
left insular cortex where the lesion is barely visible, and a gradient echo MRI scan where the small cavernoma
is more conspicuous.
Case 5: A cavernoma is much more evident on MRI
Keep in mind the concept of conspicuity when considering the role of CT and MRI in
patients with seizures. In our fifth case, even though the CT demonstrates a small area of
high attenuation in the white matter, the cavernoma is much more conspicuous on MRI.
Figure 5. Computed tomography (CT) demonstrates a small area of high attenuation in the white matter in
a patient with a cavernoma, but the magnetic resonance imaging (MRI) makes it much more conspicuous.

Case 6: Left-sided mesial temporal sclerosis on
MRI in a patient with epilepsy
In our sixth case, the MRI from a patient with epilepsy demonstrated left-sided
mesial temporal sclerosis. The right hippocampus is normal and appears larger
and lower in signal intensity than the left hippocampus. This is a typical finding
with this disease and would be almost impossible to detect on CT. In appropriate
circumstances, the patient may be a candidate for surgery and would have a high
likelihood of improved seizure control afterward.
Figure 6. MRI from a patient with epilepsy demonstrating left-sided mesial temporal sclerosis. The normal
right hippocampus is larger and lower in signal intensity than the left hippocampus, which are typical findings
with this disease and would not be evident on CT.
So, we’ve covered imaging approaches for patients with seizures. In patients with
one or more new seizures, even when the CT scan is normal, consider MRI with
contrast when you have a reasonably high degree of suspicion that the patient has
an underlying brain lesion. But, in patients with epilepsy, there is almost no reason
to start with CT because an MRI is much more likely to demonstrate subtle changes
in the brain that may be the source of the seizures.

Chapter 7
METABOLIC DISORDERS,
INFECTIONS AND
DEMYELINATION
www.medmastery.com
Describing abnormalities in the basal ganglia
Let’s talk about how to recognize abnormalities involving the basal ganglia and
thalami on computed tomography (CT). Generally speaking, bilateral abnormalities
involving the basal ganglia typically occur due to metabolic insults such as
insufficient oxygen delivery or poisoning, while abnormalities of the thalami can be
due to deep venous occlusion or infarcts.
Abnormalities in the basal ganglia on CT

When considering basal ganglia abnormalities on CT, the first step is to recognize
what the normal basal ganglia look like. You should be able to see the lentiform
nucleus (which consists of the globus pallidus and the putamen) on all normal CT
scans because they all have a slightly higher attenuation than the surrounding white
matter.
Figure 1. On normal computed tomography (CT) scans of the basal ganglia, you should be able to see the
lentiform nucleus, which consists of the globus pallidus and the putamen, because they all have a slightly
higher attenuation than the surrounding white matter.
Because of their high metabolic rate, the basal ganglia are particularly sensitive to
metabolic injury from low blood flow, low levels of oxygen, and low glucose that can
result in symmetric injuries of the basal ganglia.

Unilateral and bilateral basal ganglia abnormalities have
different causes
While unilateral basal ganglia abnormalities are common with infarctions, infections,
and brain tumors, bilateral basal ganglia abnormalities are usually the result of lack
of oxygen seen with near-drownings, respiratory failure from a drug overdose, or low
perfusion from cardiac arrest.
You should also consider poisoning as the cause of bilateral basal ganglia
abnormalities, which can happen with carbon monoxide poisoning and toxic
ingestions. For example, methanol ingestion has taken on new significance with
reports of methanol-based hand sanitizer ingestion and skin absorption during the
early days of the COVID-19 pandemic.
Figure 2. Causes of basal ganglia abnormalities on computed tomography (CT). Bilateral basal ganglia
abnormalities are caused by low blood flow, low levels of oxygen, low glucose, and poisoning. Unilateral basal
ganglia abnormalities are common with infarctions, infection, and brain tumors.

Case 1: Bilateral basal ganglia abnormalities due
to methanol poisoning
Now that you know how the basal ganglia should look, you should be able to
recognize the basal ganglia as symmetrically abnormal in our first patient case.
On CT, notice how both sides of the basal ganglia are low in attenuation (Fig. 3).
This patient ingested methanol in a suicide attempt that resulted in a bilateral basal
ganglia injury.
The abnormality is more evident on magnetic resonance imaging (MRI), where mixed
low and high signals due to both edema and hemorrhaging can be seen, which is
typical of methanol poisoning.
Figure 3. A computed tomography (CT) scan from a patient who ingested methanol which shows basal ganglia
that are symmetrically abnormal with low attenuation along with a magnetic resonance imaging (MRI) scan
showing mixed low and high signal due to edema and hemorrhage that is typical with methanol poisoning.
Case 2: Bilateral basal ganglia abnormalities due to carbon

monoxide poisoning
The second case we will examine also demonstrates a symmetrical basal ganglia
abnormality. Here, in a 41-year-old with carbon monoxide poisoning, only the medial
part of the lentiform nucleus is involved. Focal involvement of the globus pallidus
has been reported with carbon monoxide poisoning. But, it is not specific for carbon
monoxide poisoning since it can also be seen in other conditions such as drug
overdose.

Figure 4. Computed tomography (CT) scans of a symmetrical basal ganglia abnormality in a 41-year-old with
carbon monoxide poisoning where only the medial part of the lentiform nucleus is involved (Image courtesy of
Dr S. Mohan. Associate Professor of Radiology, Hospital of the University of Pennsylvania).
Case 3: Bilateral basal ganglia abnormalities due to cardiac

arrest
In clinical practice, basal ganglia abnormalities are often missed because the
changes can be quite subtle on CT, and may be attributed to suboptimal CT scan
quality. For example, a CT of a resuscitated 74-year-old man who was found
unconscious after cardiac arrest shows the blurring of the border of the basal
ganglia—if you are looking for it!
Figure 5. Bilateral basal ganglia abnormality on a computed tomography (CT) scan with a blurring of the
border of the basal ganglia.

Case 4: Bilateral basal ganglia abnormalities after cardiac
arrest in a child
Our fourth case involves a child who experienced cardiac arrest after major trauma.
Her emergency room CT shows the blurring of the basal ganglia as well as at the
gray-white matter interface on both cerebral hemispheres. One of the challenges
of reading head CT is that you must recognize what is missing. When you look at
the child’s CT scan alongside a CT from a patient with normal basal ganglia, the
abnormality is much more evident.
Figure 6. Computed tomography (CT) scan from a child who experienced cardiac arrest after trauma showing
blurring of the basal ganglia and at the gray-white matter interface on both cerebral hemispheres, beside a CT
scan showing normal basal ganglia from a different patient.
The child’s CT scan also demonstrated a diffuse abnormality of the cortex. This is
more evident on the coronal reconstruction of the CT scan where you can see that
the cerebellum has a higher attenuation than the cortex of the hemispheres. This is
called the white cerebellum sign and can help you identify a diffuse, hypoxic insult
to the brain.

Figure 7. Computed tomography (CT) scans demonstrating a diffuse abnormality of the cortex which is
more evident on the coronal reconstruction. The reconstruction shows the white cerebellum sign, where the
cerebellum has a higher attenuation than the cortex of the hemispheres.
Abnormalities in the thalami on CT

Posterior and immediately adjacent to the lateral border of the third ventricle is the
thalami. These structures also have higher attenuation than white matter on CT,
just like the basal ganglia. The lateral borders of the thalami are defined by the low
attenuation posterior limbs of the internal capsule.
The thalamic blood supply arises almost entirely from the posterior circulation
arteries, while the basal ganglia are supplied by perforators from the anterior
circulation arteries arising from the carotids. The basal ganglia and thalami have a
common venous drainage through the midline deep venous system.
Figure 8. The lateral borders of the thalami are defined by the low attenuation posterior limbs of the internal
capsule.

Case 5: Bilateral basal ganglia and thalami abnormalities
due to a deep venous occlusion
In our fifth case, the patient’s CT scan demonstrated low attenuation in the region
of the basal ganglia and thalami. There is also evidence of hemorrhaging (Fig. 9).
When you see this pattern of involvement of both the basal ganglia and thalami,
you should consider the possibility of a deep venous occlusion since an arterial
infarction is unlikely to involve both anterior and posterior perforating arteries.
Figure 9. Computed tomography (CT) scans from a patient with a cerebral deep venous occlusion
demonstrating low attenuation in the region of the basal ganglia and thalami with evidence of a hemorrhage.
The sagittal reconstruction from a CT venography of the patient demonstrated a

thrombus in the vein of Galen and the internal cerebral veins. Because of occlusion
of the venous outflow, while there was continued arterial flow, the signal of the basal
ganglia and thalami are altered due to venous hypertension.
One day later, a bilateral hemorrhage developed. This is another manifestation

of venous hypertension. While the brain changes from venous occlusion in some
patients are reversible, in this case, it resulted in a hemorrhagic infarction.

Figure 10. Sagittal reconstruction of a computed tomography (CT) venography from a patient with a cerebral
deep venous occlusion demonstrating a thrombus in the vein of Galen and the internal cerebral veins beside
a CT showing a bilateral hemorrhage which developed 1 day later.
Case 6: Bilateral thalami abnormalities due to dural fistula
When a 53-year-old was brought to the emergency room for persistent drowsiness,
he received a contrast-enhanced CT scan. On the CT scan, the thalami do not have
their normal high attenuation (Fig. 11).
The symmetrical thalamic abnormalities suggest the possibility of a deep venous

occlusion. But, you can see that there is normal enhancement of both internal
cerebral veins on the contrast-enhanced CT, which argues against thrombosis as
the cause of the bilateral thalamic abnormalities.
Figure 11. Contrast-enhanced CT from a patient with persistent somnolence showing that the thalami do not
have their normal high attenuation. But, both internal cerebral veins show normal enhancement, which argues
against thrombosis as the cause.

The thalamic abnormalities were more apparent on the same patient’s magnetic
resonance fluid-attenuated inversion recovery (FLAIR) scan. Even with the normal
enhancement of the internal cerebral veins, a vascular cause was still suspected as
the source of the patient’s symptoms. So, a digital subtraction angiography (DSA)
was performed.
The DSA revealed the early appearance of the vein of Galen on a vertebral artery
injection, which is a characteristic finding of a dural fistula. With an arteriovenous
fistula (even though the deep venous system was open), the patient may have
venous hypertension from the elevated, arterialized pressure in the venous system.
Figure 12. Magnetic resonance fluid-attenuated inversion recovery (FLAIR) scan from a patient with thalamic
abnormalities beside a digital subtraction angiography (DSA) scan revealing the early appearance of the vein
of Galen on a vertebral artery injection, which is a characteristic finding of a dural fistula.
Cases 7 and 8: Bilateral thalami abnormalities due to neoplasm
Our next cases involve two patients who also have bilateral thalamic abnormalities
on MRI, but in their cases, it is due to neoplasm. Glial tumors can spread widely
throughout the brain, so the tumor can spread from one thalamus to the other through
a normal anatomic structure called the massa intermedia. This structure, also called
the interthalamic adhesion, provides a bridge from one thalamus to the other.

Figure 13. Magnetic resonance imaging (MRI) scans from two different patients highlighting bilateral thalamic
abnormalities due to neoplasm.
Case 9: Bilateral thalamic abnormalities due to an infarction
Bilateral thalami abnormalities can be the result of an infarction due to multiple

emboli in the perforators that arise at the top of the basilar and posterior cerebral
arteries.
Figure 14. Two magnetic resonance imaging (MRI) scans demonstrating bilateral thalami abnormalities due
to infarction.
But, occlusion of the single artery of Percheron, a variation of the normal blood
supply to the thalami, can also account for this appearance since it provides blood
supply to both thalami in some patients.

Figure 15. The artery of Percheron.
Finally, Wernicke’s encephalopathy and osmotic demyelination can involve both

thalami. But, the findings in such cases are almost always inapparent on CT.
A careful review of the history will be of considerable help in patients with bilateral
disease involving the basal ganglia or thalami. When you see abnormalities of the
basal ganglia, consider metabolic insults such as an insufficient supply of oxygen or
poisoning. As well, abnormalities of the thalami on CT are usually due to infarctions
or deep venous occlusions.

Identifying brain abscess and encephalitis
Let’s examine several patient cases with brain abscesses and encephalitis on
computed tomography (CT). Brain abscesses can resemble brain tumors on CT,
but they can usually be distinguished from neoplasms using magnetic resonance
imaging (MRI). When MRI is not sufficient, surgery with biopsy may be necessary
for the diagnosis.
Case 1: Brain abscess with mass effect and

a shift of the midline structures on CT
In our first case, the patient’s CT demonstrated a right frontal mass effect with
an obvious shift of the midline structures. While a brain neoplasm (primary or
metastatic) should be in the differential for this finding, you should at least consider
infection as well.
The MRI demonstrated an abnormal signal on the diffusion-weighted image in the

center of this lesion indicating restricted diffusion in this region. When accompanied
by rim enhancement, this finding is typical for a brain abscess (with pus causing the
diffusion restriction).
Figure 1. Computed tomography (CT) scan from a patient with a brain abscess demonstrating a right frontal
mass effect with an obvious shift of the midline structures and a magnetic resonance imaging (MRI) scan
showing centrally restricted diffusion due to pus in a brain abscess.

Case 2: Brain abscess with mass effect in the
right thalamus on CT
The CT in our second case shows low attenuation with mass effect in the right
thalamus. The contrast-enhanced CT scan in the patient demonstrated rim
enhancement of the mass. This finding can be seen with primary tumors, metastatic
tumors, and brain abscesses.
Figure 2. Computed tomography (CT) showing low attenuation with mass effect in the right thalamus due to
a brain abscess, and contrast-enhanced magnetic resonance imaging (MRI) demonstrating rim enhancement
of the mass.
The diffusion-weighted magnetic resonance imaging (MRI) from the same patient
shows restricted diffusion in the center of an enhancing rim. A high signal on the
trace image of the diffusion-weighted MRI that corresponds with a low signal on the
apparent diffusion coefficient image establishes that there is restricted diffusion of
water in the lesion. This is usually from pus or necrosis. This abscess was drained
during surgery.

Figure 3. High signal on the diffusion-weighted magnetic resonance imaging (MRI) corresponds with low
signal on the apparent diffusion coefficient image to demonstrate that there is restricted diffusion of water in
a patient with an abscess in the right thalamus.
Case 3: Cysticercosis on CT
Our next case presented to the emergency room with headaches that started after
a previous visit to Mexico. Their CT shows a large left-sided mass with ventricular
enlargement. The MRI demonstrated rim enhancement, but the diffusion-weighted
imaging was normal.
These findings were unusual for neoplasm, and MR spectroscopy was consistent
with infection. This proved to be the result of brain infection from cysticercosis,
which regressed spontaneously.
Figure 4. Computed tomography (CT) scan from a patient with a brain infection caused by cysticercosis
showing a large left-sided mass with ventricular enlargement, and a magnetic resonance imaging (MRI) scan
demonstrating rim enhancement.

Cases 4 and 5: Herpes encephalitis on CT
These next two patient cases had mass effect from swelling and hemorrhaging in
the medial temporal lobes secondary to herpes encephalitis. While not all cases of
herpes encephalitis will lead to a hemorrhage, nearly all cases of herpes infection of
the brain involve the medial temporal lobe.
Figure 5. Computed tomography (CT) scans from two different patients who both had mass effect from
swelling and hemorrhaging in the medial temporal lobes that proved to be secondary to herpes encephalitis.
Case 6: Creutzfeldt-Jakob disease on MRI

There are many other brain infections to consider, such as Creutzfeldt-Jakob
disease (e.g., mad cow disease). Our next case demonstrates typical findings of this
prion disease on diffusion-weighted MRI including symmetric restricted diffusion in
the basal ganglia and thalamus. These findings are frequently overlooked because
the symmetry suggests a normal finding even though it is not!
Figure 6. A diffusion-weighted magnetic resonance imaging (MRI) scan with typical findings for Creutzfeldt-
Jakob disease (e.g., mad cow disease).

Case 7: Progressive multifocal
leukoencephalopathy on MRI
Another type of brain infection to consider is progressive multifocal leukoencephalopathy.
This infection is demonstrated in our next case featuring an immunocompromised
patient. Typically we see asymmetric T2 prolongation in the white matter of the brain
without substantial mass effect. Any enhancement is variable, but when present, will
usually be peripheral.
Keep in mind that CT scans for Creutzfeldt-Jakob disease and multifocal

leukoencephalopathy may be normal!
Figure 7. Magnetic resonance imaging (MRI) demonstrating progressive multifocal leukoencephalopathy in

an immunocompromised patient.
Errors of interpretation and incorrect patient management may occur when an

infection is thought to be a tumor on CT. This is precisely why you should be guarded
with your diagnosis in patients with a newly discovered intracranial mass. In many
cases, MRI along with the patient’s medical history will help establish the correct
diagnosis.

Describing the CT findings of demyelination
Computed tomography (CT) is not a regular part of the assessment of the brain
for patients with multiple sclerosis (MS) since magnetic resonance imaging (MRI)
is much more sensitive to changes in the white matter. However, in some cases,
the white matter abnormalities of MS may be first evident on a CT scan before a
definitive diagnosis is made. When you see white matter abnormalities on CT, you
should consider demyelination as a cause, especially when they are homogeneously
low in attenuation and limited to the white matter.
Case 1: Tumefactive demyelination

In our first case, the patient’s MRI scan demonstrated typical imaging findings of
tumefactive demyelination. You should notice that there is less mass effect on
the ventricle in the magnetic resonance (MR) fluid-attenuated inversion recovery
(FLAIR) scan than what you might expect for a mass of this size (Fig. 1). As well, the
enhanced scan shows only a partial ring of enhancement. These two findings are
frequently seen in cases of tumefactive demyelination.

Figure 1. Magnetic resonance (MR) fluid-attenuated inversion recovery (FLAIR) scan showing findings typical
of tumefactive demyelination with less mass effect on the ventricle than expected. The enhanced magnetic
resonance imaging (MRI) scan also shows typical findings of a partial ring of enhancement.
While MRI shows abnormalities associated with tumefactive demyelination very

well, a CT scan can still be helpful because these abnormalities often resemble a
brain tumor. In most patients with tumefactive demyelination, their non-contrast CT
scan will show that the mass has homogenous low attenuation. This differs from
the appearance of neoplasms since they will usually have areas of high attenuation
that are visible on non-contrast CT, which is most likely from the regions of dense
cellularity that are typical for most neoplasms.
Magnetic resonance perfusion can also help distinguish tumefactive demyelination

from neoplasms. High-grade tumors should (at minimum) have elevated cerebral
blood volume, while tumefactive demyelinating lesions (TDLs) usually show low
cerebral blood volume.
Figure 2. A computed tomography (CT) scan showing homogenous low attenuation in the region of the mass
in a patient with tumefactive demyelination.

Keep in mind that you shouldn’t expect to establish a diagnosis of TDL based on the
patient’s prior history of MS, or expect to see other white matter lesions. In most
cases, tumefactive demyelination is the first manifestation of demyelination.
Not all patients with TDLs will go on to develop MS. In many cases, TDLs are part
of a monophasic disease called acute disseminated encephalomyelitis (ADEM).
Fortunately, TDLs will respond to steroids, but follow-up imaging is prudent to
confirm that the lesion regresses over six to eight weeks (as expected).
Case 2: Acute toxic encephalopathy

While confluent white matter lesions can be evident with multiple sclerosis,
sometimes CT will demonstrate diffuse white matter involvement in patients with
no prior neurological deficits. For example, a young patient was brought to the
emergency room (ER) unconscious and his CT demonstrated diffuse white matter
abnormalities (Fig. 3).
His MRI diffusion sequence also demonstrated a corresponding restricted diffusion

throughout the white matter of both hemispheres. Based on the CT and MRI findings,
along with the clinical presentation, MS was an unlikely diagnosis. In fact, these
findings are more consistent with acute demyelination.
The patient had a positive drug screen in the ER, and further history indicated that
the patient had been using heroin. This history suggests the diffuse white matter
changes were a complication of heroin use called acute toxic encephalopathy, and
these changes were not reversible.
Figure 3. A computed tomography (CT) scan demonstrating diffuse white matter abnormalities, and magnetic
resonance imaging (MRI) diffusion sequence scan demonstrating a corresponding finding of restricted
diffusion consistent with acute demyelination of the white matter of both hemispheres. These findings are
typical of acute toxic encephalopathy.

Case 3: Metabolic insult
Diffuse white matter abnormalities in both hemispheres can also occur secondary
to a metabolic insult such as anoxia, shown next on an MRI from a different patient
(Fig. 4). Drug overdose and anoxia frequently occur together.
Figure 4. Magnetic resonance imaging (MRI) scan of white matter abnormalities in both cerebral hemispheres
secondary to anoxia.
Case 4: Multiple sclerosis

The next CT scan shows two homogeneously low attenuation lesions in the brain
without focal high attenuation within or nearby the lesions. While the patient’s CT
scan is not diagnostic for demyelination, it should lead you to strongly consider
MS in your differential, which is the correct diagnosis in this case. But, in nearly all
cases of suspected or evident white matter abnormalities on CT, MRI with contrast
enhancement is usually of value.

Figure 5. Computed tomography (CT) findings of two homogeneously low attenuation lesions, without focal
high attenuation within or nearby the lesions. These findings should lead to further investigation to rule out a
diagnosis of multiple sclerosis (MS).
Compared to CT, MRI is much more sensitive to changes in the white matter.
However, you may see white matter abnormalities on CT first. If these findings are
homogeneously low in attenuation, and limited to the white matter, you should
consider demyelination that could be due to multiple sclerosis, tumefactive
demyelination, or even acute toxic encephalitis.

Chapter 8
SKULL
ABNORMALITIES
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Describing the typical appearance
of skull fractures
A patient’s history will usually alert you to look for skull fractures on computed
tomography (CT). Let’s review the appearance of several types of skull fractures,
including depressed skull fractures, in-plane fractures, and fractures to the skull
base and facial bones.
First, let’s highlight three techniques to use when looking for skull fractures on CT:
1. Review bone filtered images
2. View thin sections
3. Review at least two reconstruction planes

The best approach for finding fractures on CT images is to review bone-filtered
images that are a thinner reconstruction than 5 mm. These should be reviewed in at
least two reconstruction planes, such as the axial and coronal views.
Identifying depressed skull fractures on CT

Some fractures are quite evident on CT, which is often the case with depressed skull
fractures. However, many skull fractures (when linear and non-displaced) can be
quite subtle on CT.
Figure 1. Computed tomography (CT) scans from two patients with depressed skull fractures.

Case 1: Depressed skull fracture with associated
subarachnoid hemorrhage
When you see a depressed skull fracture, look carefully at the underlying brain since
there may be a cortical contusion of the brain or a subarachnoid hemorrhage. This
was the case in this patient who was struck in the head with a hammer.
Figure 2. Computed tomography (CT) scans showing a depressed skull fracture with an associated
subarachnoid hemorrhage.
Case 2: Depressed fracture with soft tissue swelling
You should carefully search the images for evidence of soft tissue swelling overlying
the skull. In our next case, the soft tissue swelling will lead your eyes to a fracture.
After identifying the fracture, look at the other side of the brain; subdural hematomas
and brain contusions are almost always on the opposite side from the fracture.
Figure 3. Computed tomography (CT) scans showing soft tissue swelling overlying a minimally depressed
fracture, which is opposite to a subdural hematoma.

Identifying in-plane fractures on CT
Case 3: Trauma causing an in-plane fracture
When the fracture line runs in the same plane as the CT image reconstruction, it
can be very difficult for the imager to see the fracture. In our next patient case, the
fracture is hard to see on the axial views of a trauma patient, but it is quite evident
on the sagittal reconstruction of the same data.
Figure 4. Computed tomography (CT) scans from a trauma patient with an in-plane fracture that is very
difficult to see on the two axial views, but it is quite evident on the sagittal reconstruction of the same data.
Case 4: Differentiating skull fractures from cranial sutures

Fractures can usually be differentiated from sutures in the skull bones—generally by
their straight course and sharp margins. This is apparent in our next case involving
a child with a skull fracture.
Figure 5. A fracture can usually be differentiated from sutures in the skull bones on computed tomography
a wavy course. (CT). In a child with a skull fracture, notice the fracture’s straight course and sharp margins
while a suture has

Identifying skull base fractures on CT
Case 5: Trauma causing a skull base fracture
In the setting of trauma, whenever you see fluid in the middle ear on CT, you should
search for an associated skull base fracture. While the fracture in our next case is
faintly visible on the axial image, it is much more evident on thin reconstructions in
the coronal plane.
As with all suspected fractures, it will be more evident if you have the images
reconstructed at 1 mm thick sections. If you are looking at 5 mm thick slices, volume
averaging may obscure fine, non-displaced fractures.
Figure 6. An axial computed tomography (CT) scan showing fluid in the middle ear which was associated with
a skull base fracture in a trauma patient. The fracture is much more evident on a 1 mm reconstruction in the
coronal plane.
Identifying fractures to the facial bones on CT

Case 6: Medial blow-out fracture
When reviewing trauma CT images, you should look for air where there should be
soft tissue or fat, and look for soft tissue or fluid attenuation where there should be
air. In our next case, the patient has a fracture of the medial orbital wall after a blow
to the eye.
This type of fracture is called a medial blow-out fracture and can be seen after a
blow from a fist or a ball (such as a squash ball) striking the eye. As a result of this
fracture that involves an air-filled paranasal sinus, some air from the sinus entered
the orbit. This is quite evident on CT (Fig. 7).

Figure 7. Computed tomography (CT) scan of a patient with a medial blow-out fracture. Notice the air in the
patient’s left orbit that entered from the paranasal sinus.
Case 7: Fracture through the mastoid
The presence of intracranial air—even a small amount—is abnormal. This finding in

the setting of trauma should direct you to carefully search for a fracture involving
a paranasal sinus or the mastoid air cells. In our next case, the patient had a skull
base fracture through the mastoid that was visible on thin-section reconstructions
which were obtained after the intracranial air was identified.
Figure 8. Thin-section computed tomography (CT) reconstructions from a patient with a skull base fracture
through the mastoid, which caused the appearance of intracranial air.

Case 8 and 9: Inferior orbital blow-out fracture
Another common facial fracture is the inferior orbital blow-out fracture, which
involves a similar mechanism of trauma, a blow to the eye. These fractures can
be difficult to recognize on axial imaging and are always easier to see on coronal
imaging.
On the CT scan, note the displacement of fat from the orbital cavity into the maxillary
sinus (Fig. 9). You can predict that this particular fracture is chronic because there
are no fluid or blood products in the maxillary sinus.
Figure 9. Axial and coronal computed tomography (CT) images from a patient with an inferior orbital blow-
out fracture. Note the displacement of fat from the orbit into the maxillary sinus and the lack of fluid or blood
products in the maxillary sinus, indicating the fracture is chronic.
Our next patient has an acute left-sided orbital blow-out fracture. Note the displaced
fragment from the inferior orbital cavity and notice that the fracture is much easier to
recognize on the coronal reconstruction. The soft tissue swelling and blood around
the displaced fragment of the orbital floor is typical of an acute fracture.

Figure 10. Axial and coronal computed tomography (CT) scans from a patient with an acute left-sided orbital
blow-out fracture featuring a displaced fragment of the orbital floor with soft tissue or blood around it. The
fracture is easier to recognize on the coronal reconstruction.
Case 10: Fracture of the mandible
In our next case, the coronal reconstruction reveals a fracture of the right mandible.
This resulted in the dislocation of the mandibular condyle out of the condylar fossa
at the skull base, a finding that is frequently missed when only axial images are
reviewed. The unusual location of the mandibular condyle in this patient is a sign of
a fracture, and it’s one that you should look for in all trauma cases.
Figure 11. Coronal and axial computed tomography (CT) scans from a patient with a fracture that is evident
in the right mandible on the coronal reconstruction along with dislocation of the mandibular condyle that is
less evident on the axial image.

Case 11: Fracture of the medial occipital condyle
A fracture of the medial occipital condyle is another commonly missed fracture after
trauma. This type of fracture is important to look for since it implies there may be an
injury to an alar ligament, which may lead to late instability of the upper cervical spine.
Figure 12. Fracture of the medial occipital condyle on axial and coronal computed tomography (CT) images.
Your chances of identifying a skull fracture will be improved by optimizing the way
you review CT scan images. Take the time to review the bone-filtered images, and
when you have a question arise from the axial imaging, review the coronal views
with the same attention that you devote to the axial views. Remember, viewing CT in
two planes is imperative because many traumatic skull and facial injuries can only
be perceived in one plane of reconstruction.

Identifying benign disease and malignant
bone lesions of the skull
It is essential to look carefully at the skull on all head computed tomography
(CT) imaging scans, as well as the brain. Unexpected benign and malignant skull
diseases are common; you should be aware of the appearance of benign lesions so
that unnecessary imaging or procedures are avoided.
Let’s look at identifying features of the following seven types of skull lesions on CT:
1. Sclerotic (osteoblastic) lesions
2. Lytic skull lesions
3. Mixed sclerotic and lytic lesions
4. Arachnoid granulation
5. Osteoma of bone
6. Hemangioma of bone
7. Paget’s disease
Identifying sclerotic (osteoblastic) lesions on CT

Bone lesions can be evident on CT when they are of higher attenuation than the skull
due to excessive bone formation. These are called sclerotic (osteoblastic) lesions.
When the bone appears destroyed, making the lesion appear of lower attenuation
than the normal skull, the lesion is described as osteolytic.

Cases 1 and 2: Osteoblastic lesions
First, let’s examine CT scans from two patients with unsuspected skull abnormalities.
The abnormalities are of higher attenuation than the skull.
One case features a right-sided skull fracture and a well-marginated lesion with
homogeneous dense bone that appears expanded. This appearance of bone is
called ground-glass, and it is typical for a benign process in the bone called fibrous
dysplasia.
The other case involves a 66-year-old man with a sclerotic bone lesion that was
noted along with other similar lesions in the skull. When single, a benign bone
island would be a consideration. But, when you see multiple lesions, you should
consider the diagnosis of osteoblastic metastases. This is the typical appearance of
metastatic bone disease from prostate cancer, but in women, treated breast cancer
metastases can also have this appearance.
Figure 1. Computed tomography (CT) featuring a ground-glass finding in addition to a right-sided skull
fracture beside a CT from another patient showing a sclerotic bone lesion.

Identifying lytic skull lesions on CT
Case 3: Chordoma
Rather than added bone, our next case features a destructive or osteolytic lesion
on CT in the patient’s clivus. At the same level on T2-weighted magnetic resonance
imaging (MRI), a soft tissue abnormality with high-signal intensity extends beyond
the skull.
These findings are typical for a chordoma, which is a primary malignant bone tumor
that frequently involves the clivus (but can also be found in the spine).
Figure 2. Computed tomography (CT) showing an osteolytic lesion in the patient’s clivus, and a T2-weighted
magnetic resonance image (MRI) showing a soft tissue abnormality with high-signal intensity on the T2-
weighted image that extends beyond the skull. These findings are typical for a chordoma tumor.
Case 4: Multiple myeloma
Our next case features a bone-filtered CT image which shows two lytic lesions in the
skull. On CT, there is no evidence of a dense rim around the lesions; they just fade
into the skull at the edges. This appearance is consistent with metastatic disease of
the skull, which will require further evaluation. This patient proved to have multiple
myeloma.

Figure 3. Bone-filtered computed tomography (CT) image from a patient with two lytic lesions in the skull that
proved to be multiple myeloma. Notice the absence of a dense rim around the lesions that favors a benign cause.
Identifying mixed sclerotic and lytic lesions on CT

Case 5: Arrested pneumatization
In our next case, the patient has inhomogeneous bone at the skull base with areas
of both low and high attenuation. Unlike the previous cases, the lesion is not purely
lytic or osteoblastic in character.
This represents a benign finding called arrested pneumatization that is typically

seen in this location. The low attenuation areas are not really lytic since they do not
represent bone destruction; they are regions of fat intermixed with bone. If you have
any questions about the diagnosis, consider a follow-up CT or MRI.
Figure 4. Computed tomography (CT) from a patient with arrested pneumatization. Notice the inhomogeneous
bone at the skull base with areas of both low and high attenuation, highlighting regions of fat intermixed with bone.

Identifying arachnoid granulation on CT
Case 6 and 7: Arachnoid granulations
Keep in mind that not all lytic skull lesions are due to malignancy. In our next case,
a lesion was noted in the skull of a patient with cancer. It resembles a lytic bone
lesion, except that you can see a thin rim of bone around the lesion and the skull is
not expanded. For this reason, an MRI was requested rather than a biopsy.
The T2-weighted MRI, in this case, shows that the skull lesion resembles the
signal of cerebrospinal fluid seen elsewhere in the brain. The post-contrast MRI
demonstrated no enhancement, which would be expected with a metastatic lesion.
These are typical findings for arachnoid granulations and require no follow-up. Note
it is adjacent to a dural sinus.
Figure 5. Computed tomography (CT) showing a lesion with a thin rim of bone around the lesion, T2-weighted
magnetic resonance imaging (MRI) showing that the skull lesion resembles the signal of cerebrospinal fluid,
and post-contrast MRI demonstrating no enhancement. These are typical findings for arachnoid granulations.
Our next case features erosions of the inner table of the skull on either side of the
midline. This is also a manifestation of the bone changes seen with arachnoid
granulations. Note the smooth margin and proximity to the superior sagittal sinus,
and also notice that there is only peripheral enhancement visible on MRI.

Figure 6. Computed tomography (CT) showing erosions of the inner table of the skull with smooth margins
on either side of the midline, and magnetic resonance imaging (MRI) showing only peripheral enhancement
of the arachnoid granulations.
Identifying osteoma of bone on CT

Case 8: Osteoma of the skull
Our next example features a 65-year-old patient. Focal increased attenuation was
noted on the patient’s skull x-ray, and a CT was requested since a malignancy is
always considered in a patient of this age.
The axial bone-filtered CT image showed very dense bone projecting from the outer
table of the skull with the same attenuation as the skull cortex. This is the typical
appearance of an osteoma of the skull and requires no further follow-up.
Figure 7. Focal increased attenuation on the skull x-ray of a patient with an osteoma of the skull, and axial
bone-filtered computed tomography (CT) image showing very dense bone projecting from the outer table of
the skull with the same attenuation as the skull cortex.

Identifying hemangioma of bone on CT
Case 9: Benign capillary hemangioma
An MRI with contrast from another 65-year-old patient demonstrated a single

enhancing skull lesion that was of concern, and the possibility of a metastatic lesion
was mentioned in the imaging report. A CT scan was obtained since bone-filtered CT
images are very helpful whenever characterizing a skull lesion.
The bone-filtered CT demonstrated a fine internal structure at the site of the

abnormality rather than bone destruction, which would be expected with metastatic
disease. This is the typical appearance of a benign capillary hemangioma of bone
and illustrates how CT and MRI findings should be consolidated when considering
skull lesions.
Figure 8. Magnetic resonance imaging (MRI) with contrast showing a single enhancing skull lesion, and
a bone-filtered CT demonstrating that the lesion had a fine internal structure typical of a benign capillary
hemangioma of bone.
Case 10: Cavernous hemangioma
Our next patient also has a hemangioma of the skull. While this hemangioma has an
internal structure on CT, it is more expansive and demonstrates radiating or spoke-
wheel spicules of bone. This is called a cavernous hemangioma and is less common
than capillary hemangiomas. And it is just as well, since these can grow and require
surgery to reduce the mass effect.

Figure 9. Computed tomography (CT) from a patient with a cavernous hemangioma of the skull demonstrat-
ing radiating or spoke-wheel spicules of bone.
Identifying Paget’s disease on CT

Case 11: Paget’s disease
On our next scan, you can see that the patient’s skull is expanded on the left side with
mixed high and low attenuation. While it is reasonable to consider fibrous dysplasia, you
should consider Paget’s disease in an adult when you see skull expansion with both
sclerotic and lucent bone. Magnetic resonance imaging in such cases can be helpful
since it is common to see preserved fatty marrow in the region of the Pagetic bone.
Figure 10. Computed tomography (CT) scan from a patient with Paget’s disease. Notice the skull on the
patient’s left is expanded and shows mixed high and low attenuation.
Integration of the findings on MRI and CT are frequently necessary to characterize a lesion
in the skull. After reviewing this article, you should be better equipped to identify several
types of benign and malignant skull lesions on CT. Of course, you first have to find the lesion
before you can identify what type it is, so look carefully at the skull on all head CT scans.

Text
APPENDIX
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Reference list
Chapter 1: The basics
Guinto, FC Jr, Garrabrant, EC, and Radcliffe, WB. 1972. Radiology of the persistent
stapedial artery. Radiology. 105: 365–369. PMID: 5079662
Kim, YI, Ahn, KJ, Chung, YA, et al. 2009. A new reference line for the brain CT: the
tuberculum sellae-occipital protuberance line is parallel to the anterior/posterior
commissure line. AJNR Am J Neuroradiol. 30: 1704–1708. PMID: 19762457
Chapter 3: Stroke imaging

Albers, GW, Marks, MP, Kemp, S, et al. 2018. Thrombectomy for stroke at 6 to 16
hours with selection by perfusion imaging. N Engl J Med. 378: 708–718.
PMID: 29364767
Barber, PA, Demchuk, AM, Hudon, ME, et al. 2001. Hyperdense sylvian fissure
MCA “dot” sign: A CT marker of acute ischemia. Stroke. 32: 84–88. PMID: 11136919
Jensen-Kondering, U, Riedel, C, and Jansen, O. 2010. Hyperdense artery sign on

computed tomography in acute ischemic stroke. World J Radiol. 2: 354–357.
PMID: 21160697
Chapter 4: Nontraumatic hemorrhage

Mamourian, A. 2015. Learn to Read CT Angiography of the Brain.
Part 1: Aneurysms. Apple Books
Chapter 6: Seizures and epilepsy

Bronen, RA, Fulbright, RK, Spencer, DD, et al. 1996. Refractory epilepsy:
comparison of MR imaging, CT, and histopathologic findings in 117 patients.
Radiology. 201: 97–105. PMID: 8816528
Friedman, E. 2014. Epilepsy imaging in adults: getting it right. AJR Am J Roentgenol.

203: 1093–1103. PMID: 25341150
Salmenpera, TM and Duncan, JS. 2005. Imaging in epilepsy. J Neurol Neurosurg

Psychiatry. 76: iii2–iii10. PMID: 16107387

Chapter 7: Metabolic disorders, infections,
and demyelination
Kim, DS, Na, DG, Kim, KH, et al. 2009. Distinguishing tumefactive demyelinating
lesions from glioma or central nervous system lymphoma: added value of
unenhanced CT compared with conventional contrast-enhanced MR imaging.
Radiology. 251: 467–475. PMID: 19261924
Chapter 8: Skull abnormalities

Goodenough, D, Weaver, K, Davis, D, et al. 1982. Volume averaging limitations of
computed tomography. AJR Am J Roentgenol. 138: 313–316. PMID: 6976736
Wei, SC, Ulmer, S, Lev, MH, et al. 2010. Value of coronal reformations in the CT
evaluation of acute head trauma. AJNR Am J Neuroradiol. 31: 334–339.
PMID: 19797789

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BRAIN CT

Chapter 1: The basics

Chapter 2: Trauma imaging

Chapter 3: Stroke imaging

Chapter 4: Nontraumatic hemorrhage

Chapter 5: Brain tumor imaging

Become an expert at www.medmastery.com 2

Chapter 7: Metabolic disorders, infections,

Chapter 8: Skull abnormalities

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ACoA anterior communicating artery

ADEM acute disseminated encephalomyelitis

AVM arteriovenous malformation

CPA cerebellopontine angle

CSF cerebrospinal fluid

CTA computed tomography angiography

CTV computed tomography venography

DAI diffuse axonal injury

DSA digital subtraction angiogram, or digital subtraction angiography

FLAIR fluid-attenuated inversion recovery

INR international normalized ratio

IPH intraparenchymal hemorrhages

MCA middle cerebral artery

MRI magnetic resonance imaging

MRA magnetic resonance angiogram, or magnetic resonance angiography

PICA posterior inferior cerebellar artery

PCA posterior cerebral artery

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PACS picture archive and communication system

SWI susceptibility weighted magnetic resonance imaging

TBI traumatic brain injury

TDL tumefactive demyelinating lesion

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High and low attenuation on a brain CT scan

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Using CT imaging for clinical diagnoses

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Identifying the fourth ventricle on a brain CT scan

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An absence of a visible ambient cistern can be a sign of a brain herniation. A CT

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Considered in relation to anatomical position, this cerebrospinal fluid (CSF)-filled

Sometimes, soft tissue—rather than fluid attenuation—appears anterior to the

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Identifying the foramen magnum on brain CT

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Identifying the carotid canals on brain CT

Sometimes on vascular imaging, a normal-sized carotid will be evident on one

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Identifying the foramen ovale on brain CT

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Identifying the dorsum sellae on brain CT

On a CT scan, a normal adult sella contains low attenuation cerebrospinal fluid

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