How to Read a Head CT

(or “How I learned to stop worrying

and love computed tomography”)
Andrew D. Perron, MD, FACEP
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 Andrew D. Perron, MD, FACEP
EM Residency Program Director

Department of Emergency Medicine

Maine Medical Center
Portland, ME

Andrew D. Perron, MD, FACEP

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 Head CT
• Has assumed a critical role in the daily
practice of Emergency Medicine for
evaluating intracranial emergencies. (e.g.
Trauma, Stroke, SAH, ICH).
• Most practitioners have limited experience
with interpretation.
• In many situations, the Emergency
Physician must initially interpret and act
on the CT without specialist assistance.

Andrew D. Perron, MD, FACEP

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 Head CT
• Most EM training programs have no
formalized training process to meet
this need.
• Many Emergency Physicians are
uncomfortable interpreting CTs.
• Studies have shown that EPs have a
significant “miss rate” on cranial
CT interpretation.

Andrew D. Perron, MD, FACEP

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 Head CT
• In medical school, we are taught a
systematic technique to interpret
ECGs (rate, rhythm, axis, etc.) so that
all aspects are reviewed, and no
findings are missed.

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 Head CT
• The intent of this session is to
introduce a similar systematic
method of cranial CT interpretation,
based on the mnemonic…

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 Head CT

“Blood Can Be Very Bad”

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 Blood Can Be Very Bad

• Blood
• Cisterns
• Brain
• Ventricles
• Bone
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 Blood Can Be Very Bad

• Blood
• Cisterns
• Brain
• Ventricles
• Bone
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 Blood Can Be Very Bad

• Blood
• Cisterns
• Brain
• Ventricles
• Bone
Andrew D. Perron, MD, FACEP
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 Blood Can Be Very Bad

• Blood
• Cisterns
• Brain
• Ventricles
• Bone
Andrew D. Perron, MD, FACEP
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 Blood Can Be Very Bad

• Blood
• Cisterns
• Brain
• Ventricles
• Bone
Andrew D. Perron, MD, FACEP
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 CT Scan Basics
• A CT image is a computer-generated
picture based on multiple x-ray
exposures taken around the periphery
of the subject.
• X-rays are passed through the subject,
and a scanning device measures the
transmitted radiation.
• The denser the object, the more the
beam is attenuated, and hence fewer x-
rays make it to the sensor.
Andrew D. Perron, MD, FACEP
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 CT Scan Basics
• The denser the object, the whiter it is on CT
– Bone is most dense = + 1000 Hounsfield U.
– Air is the least dense = - 1000H Hounsfield U.

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 CT Scan Basics: Windowing

Focuses the spectrum of gray-scale used on a particular image.

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2 Sheet Head CT
 Posterior Fossa
•Brainstem
•Cerebellum
•Skull Base
–Clinoids
–Petrosal bone
–Sphenoid bone
–Sella turcica
–Sinuses

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 CT Scan

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CT Scan
Sagittal View

C Circummesencephalic Cistern
 CT Diagnostics

Where is the most sensitive area

to examine the CT for
increased ICP?
A. Lateral Ventricles
B. IVth ventricle
C. Basilar Cisterns
D. Gyral pattern
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 Cisterns

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 CT Scan

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 Brainstem Lateral View

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 2nd Key Level
2nd Key Level Sagittal View

Circummesencephalic Cistern

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 Cisterns at Cerebral Peduncles
Level

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 CT Scan

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 Suprasellar Cistern

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 CT Diagnostics

Where is the most sensitive area

to examine the CT for
ventricular dilation?
A. IIIrd ventricle
B. IVth ventricle
C. Temporal horns of lateral
ventricles
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 CT Scan

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 3rd Key Level Sagittal View

Circummesencephalic Cistern

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 Cisterns at High Mid-Brain Level

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CT Scan
 Ventricles

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 CSF Production
• Produced in choroid plexus in the lateral
ventricles  Foramen of Monroe  IIIrd
Ventricle  Acqueduct of Sylvius  IVth
Ventricle  Lushka/Magendie
• 0.5-1 cc/min
• Adult CSF volume is approx. 150 cc’s.
• Adult CSF production is approx. 500-700
cc’s per day.
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 CT Scans

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 A Few Kid-Specific Thoughts

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 A Few Kid-Specific Thoughts
• Premature Infants (30-34 weeks):
Larger sylvian, basilar (circummesencephalic) cisterns.
Larger subarachnoid spaces
Thin cerebral cortex (Gray matter)
Prominent white matter (with higher water content)
Limited cortical gyral pattern
Ventricles are variable: slit-like to well-developed
• Term Infant (36-41 weeks):
Small, slit-like lateral ventricles
Continued white-matter prominence
More prominent sulcal pattern
Temporal horns unlikely to be seen
• 1st & 2nd years of Life:
Marked growth of all lobes of the brain (proportionally greatest in frontal lobes)
Wide variation in lateral ventricle size (3rd and 4th fairly constant)
Temporal horns unlikely to be seen.

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 1 day 1 year 2 years

40 Andrew D. Perron, MD, FACEP

Trauma Pictures
 B is for Blood
• 1st decision: Is blood present?
• 2nd decision: If so, where is it?
• 3rd decision: If so, what effect is it
having?

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 CT Diagnostics

At what point does blood become

isodense with brain?
A. About 48 hours
B. About 1 week
C. About 2 weeks
D. After 1 month

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 B is for Blood
• Acute blood is bright white
on CT (once it clots).

•Blood becomes isodense

at approximately 1 week.

• Blood becomes
hypodense at
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approximately 2 weeks. Andrew D. Perron, MD, FACEP
 B is for Blood
• Acute blood is bright white
on CT (once it clots).

• Blood becomes isodense

at approximately 1 week.

• Blood becomes
hypodense at
approximately 2 weeks. Andrew D. Perron, MD, FACEP
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 B is for Blood
• Acute blood is bright white
on CT (once it clots).

• Blood becomes isodense

at approximately 1 week.

• Blood becomes
hypodense at
approximately 2 weeks. Andrew D. Perron, MD, FACEP
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 Epidural Hematoma
• Lens shaped
• Does not cross sutures
• Classically described
with injury to middle
meningeal artery
• Low mortality if treated
prior to unconsciousness
( < 20%)

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 CT Scans

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 Subdural Hematoma
• Typically falx or sickle-
shaped.
• Crosses sutures, but does
not cross midline.
• Acute subdural is a marker
for severe head injury.
(Mortality approaches 80%)
• Chronic subdural usually
slow venous bleed and
well tolerated.
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 CT Scan

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 Subarachnoid Hemorrhage

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 Subarachnoid Hemorrhage
• Blood in the cisterns/cortical gyral surface
– Aneurysms responsible for 75-80% of SAH
– AVM’s responsible for 4-5%
– Vasculitis accounts for small proportion (<1%)
– No cause is found in 10-15%
– 20% will have associated acute hydrocephalus

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 CT Diagnostics

What is the sensitivity of CT for

SAH?
A. 100%
B. 95%
C. 80%
D. Depends…I need a lot more
information to answer.
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 CT Scan Sensitivity for SAH
• 98-99% at 0-12 hours

• 90-95% at 24 hours

• 80% at 3 days

• 50% at 1 week

• 30% at 2 weeks
Depends on generation of scanner and who is reading scan and
how much blood there is.

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 CT Scan

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 CT Scan

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 Intraventricular/
Intraparenchymal Hemorrhage

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 CT Scan

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 C is for CISTERNS
(Blood Can Be Very Bad)
• 4 key cisterns
– Circummesencephalic
– Suprasellar
– Quadrigeminal
– Sylvian
Circummesencephalic

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 Cisterns
• 2 Key questions to answer regarding
cisterns:
– Is there blood?
– Are the cisterns open?

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 B is for BRAIN
(Blood Can Be Very Bad)

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 Tumor

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 Atrophy

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 CT Diagnostics

What percentage of mass lesions

will require IV contrast to be
identified?
A. 100%
B. 50%
C. 30-40%
D. 10-20%
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 Abscess

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 Hemorrhagic Contusion

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 Mass Effect

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 Stroke

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 Intracranial Air

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 Intracranial Air

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 Intracranial Air

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 V is for VENTRICLES
(Blood Can Be Very Bad)

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 Ex-Vacuo Phenomenon

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 BONE

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 Blood Can Be Very Bad
If no blood is seen, all cisterns
are present and open, the brain
is symmetric with normal gray-
white differentiation, the
ventricles are symmetric without
dilation, and there is no fracture,
then there is no emergent
diagnosis from the CT scan.
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RIP
 Questions
www.ferne.org
ferne@ferne.org

Andrew D. Perron, MD, FACEP

perroa@mmc.org
(207) 662-7015
ferne_acep_2005_peds_perron_ich_bcbvb_fshow.ppt 01/07/21 07:20
Andrew D. Perron, MD, FACEP
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