CT imaging for making treatment decisions

Presenters Name
Date
CT imaging - recap
X-ray attenuation of any given tissue
type is relatively constant
Attenuation coefficient is measured in
Hounsfield Units (HU)
Viewing software converts a range of
HU values to shades of grey
CT imaging - recap
The range of HU values is defined by
the level (centre) and window (width)
Different ranges are commonly used
for different body parts
Common ranges are also often referred
to as windows e.g. “bone window” or
“lung window”
BONE HIGH
L750 CONTRAST
W3500 BRAIN L32 W20
L40 W80

Note: All images in this presentation have a level of 40 HU and window of 80 HU unless otherwise stated
CT imaging - recap
TISSUE TYPICAL HU VALUE

CSF 8

WHITE MATTER 30

GREY MATTER 45

FRESH BLOOD 60

CALCIFICATIONS 100+

BONE 1000+

When looking for a clot (Hyper dense artery sign) > 45 HU

Calcifications > 100 HU
CT acquisition coverage
CORRECT INCORRECT
CT acquisition coverage → result
CORRECT INCORRECT
CT acquisition coverage → consequences
MISSED BLEED
Quality of the acquisition
CORRECT INCORRECT
Keep a level head
We need to be able to compare similar BAD
structures in both hemispheres to
identify ischaemic damage
If the patient’s head is not in line with
the scanner, the scan may be hard to
interpret GOOD

If the patient cannot hold their head

straight, use the CT scanner software or
e‑ASPECTS to straighten the image after
acquisition

Identify early ischaemic damage

Side alignment of the scan
Scanner artefacts
Metal objects reflect X-rays and cause METAL
OBJECT
bright and dark lines on the scan
Movement during acquisition may
result in a blurred image or cause
discontinuities between slices
Images can be noisy (grainy),
particularly when viewing thin slices

Identify early ischaemic damage

3 ways to improve image interpretation
SET THE CORRECT WINDOWING
(Windowing)

KNOW WHAT YOU ARE LOOKING

FOR AND WHERE TO FIND IT
(Scrolling)

CONSIDER HOUNSFIELD UNITS

(HU’s)
 EXCLUDE BLEEDING

ASSESS STROKE SEVERITY

 WINDOWING SCROLLING CONSIDER HU

1. Bleeds are much easier to see in Brain window than Ischemia window
BRAIN WINDOW ISCHEMIA WINDOW
 WINDOWING SCROLLING CONSIDER HU

2. Look for signs of bleeding

To make sure you cover the whole
brain, divide the image into 4 quadrants
Scroll through the image, analysing
each quadrant and looking for bleeding
 WINDOWING SCROLLING CONSIDER HU

Intra-cerebral haemorrhage
This scan shows an intra-cerebral
haemorrhage (ICH)
The “bright” area measures 60-70 HU
Blood was visible on other slices
covering >40 mm axially
 WINDOWING SCROLLING CONSIDER HU

Intra-cerebral haemorrhage
This scan shows a much smaller ICH
This haemorrhage was visible on other
slices covering ≈20 mm axially
 WINDOWING SCROLLING CONSIDER HU

Sub-arachnoid haemorrhage
This scan shows a sub-arachnoid
haemorrhage (SAH)
SAHs can be less obvious than ICHs due
to their location within the
subarachnoid space, especially when
close to the skull
Beam-hardening artefacts can further
obscure blood, especially in the
posterior fossa
 WINDOWING SCROLLING CONSIDER HU

3. Use Hounsfield units to differentiate

TISSUE TYPICAL HU VALUE

CSF 8

WHITE MATTER 30

GREY MATTER 45

FRESH BLOOD 60

CALCIFICATIONS 100+

BONE 1000+

When looking for a clot (Hyper dense artery sign) > 45 HU

Blood > 60 HU < 100 HU
Calcifications > 100 HU
 WINDOWING SCROLLING CONSIDER HU

Use Hounsfield Units to distinguish between Blood and Calcifications

BRAIN WINDOW ISCHEMIA WINDOW
 WINDOWING SCROLLING CONSIDER HU

Intra-cerebral haemorrhage
Blood in CSF should not be confused MAX
102 HU
MAX
298 HU

with calcifications, which are often

(CALCIFICATION) (CALCIFICATION)

present in the ventricles

Use your viewer’s measurement tools
to check HU values
Beware of partial volume effects
causing edges to reduce in HU value

MAX 70 HU
(BLOOD)
 EXCLUDE BLEEDING

ASSESS STROKE SEVERITY

 WINDOWING SCROLLING CONSIDER HU

1. Ischemia is much easier to see in Ischemia window than Brain window

BRAIN WINDOW ISCHEMIA WINDOW
 WINDOWING SCROLLING CONSIDER HU

Hypodensity using Ischemic window

Hypodensity can be made more visible by reducing the window width to increase contrast
This image uses a window centred on 32 HU, with a width of 20 HU
 WINDOWING SCROLLING CONSIDER HU

2. Cerebral vascular territories

TERRITORIES
ACA – ANTERIOR CEREBRAL ARTERY
ACA
MCA – MIDDLE CEREBRAL ARTERY

PCA – POSTERIOR CEREBRAL ARTERY

MCA MCA

Look for signs of established Hypodensity in the

PCA
MCA region
As ischaemia develops, both white and grey
matter will begin to appear hypodense (darker)
and continue to darken over time
Hypodensity indicates ischaemic core with
irreversible damage
Note: we are not considering strokes in ACA or PCA territories
 WINDOWING SCROLLING CONSIDER HU

>1/3 MCA - Its probably not 2 hours since onset

Only around 30% of stroke patients will
have signs of early ischemic damage in
the first 3 hours after symptom onset.
Established hypo density of > 1/3 of the
MCA region indicates that the stroke
symptoms has probably started > 3
hours ago.

JAMA. 2001;286(22):2830.
 WINDOWING SCROLLING CONSIDER HU

3. Using Hounsfield units can help

TISSUE TYPICAL HU VALUE

CSF 8

WHITE MATTER 30

GREY MATTER 45

FRESH BLOOD 60

CALCIFICATIONS 100+

BONE 1000+

Brain tissue has a HU of < 45 HU

Hypodense tissue has lower HU
 WINDOWING SCROLLING CONSIDER HU

Hypodense tissue has a lower HU

Area of ischemia 25 HU
Surrounding area 36 HU
CT interpretation to guide treatment decisions (Recap)

1. EXCLUDE 2. SEVERITY /
BLEEDING TIME

SET THE CORRECT KNOW WHAT YOU ARE CONSIDER HOUNSFIELD

WINDOWING LOOKING FOR AND WHERE UNITS
(Windowing) TO FIND IT (Scrolling) (HU’s)
Tumours & abscesses
TUMOURS APPEAR AS ILL-DEFINED REGIONS OF EITHER HYPO-
OR HYPERDENSITY

ASSOCIATED OEDEMA IS FINGER-SHAPED

STROKE DAMAGE USUALLY APPEARS
TO BE WEDGE-SHAPED, RADIATING
AWAY FROM
THE OCCLUSION

ABSCESSES APPEAR SIMILAR TO TUMOURS

ON CT

PATIENTS WITH THESE CONDITIONS SHOULD NOT BE GIVEN THROMBOLYSIS DUE TO THE RISK OF BLEEDING
Cerebral atrophy
In older patients, it is common to see
evidence of cerebral atrophy
“Shrinking” of the brain causes the
ventricles and sulci to become larger
Can make it more difficult to identify
structures

Identify early ischaemic damage

Old damage
Patients who have previously had
strokes may show long-standing
hypodensities
Tissue below ≈25 HU is likely to be old
damage
It may be difficult to compare
structures if opposite side is damaged
New damage may be hidden within the
older damage

Identify early ischaemic damage

This is all you need to make treatment decisions in acute stroke

1. EXCLUDE
BLEEDING / 2. SEVERITY /
CONTRAINDICAT TIME
IONS

SET THE CORRECT KNOW WHAT YOU ARE CONSIDER HOUNSFIELD

WINDOWING LOOKING FOR AND WHERE UNITS
(Windowing) TO FIND IT (Scrolling) (HU’s)
But we want you to be very confident in your interpretation
The Angels WOW Study
Improving CT Scan interpretation by using the e-Aspects software

With
or
Without
 The problem with learning how to read a CT scan
Its like learning to play golf in the dark.

It might feel like a good shot but you don’t really know if it The Angels WOW study is like a golf simulator.
when straight or in the wrong direction. Which means the
small adjustments necessary to grow is not possible. By utilizing the e-Aspects software as a training tool you
will to learn to implement a standardized process and
Reading a CT scan is the same, unless you do a follow up MRI grow by seeing the result.
you never really know where you where 100% right and what
you missed.
The WOW study has been proven to increase sensitivity and specificity
of identifying early signs of ischemic damage by as much as 50%
How the Angels WOW study will work
Every user registers and logs in using their own credentials.
Everyone scores the first 10 cases on the online tool to 10 cases (without)
establish their baseline.

After that , participants receive training on how to identify

signs of ischemic damage using a standardized process. Training

60 Cases WOW

To practice using the steps all users will now have the
opportunity to score 60 scans that will be presented
randomly with or without the e-Aspects interpretation.

After practicing with the 60 WOW scans each participant will

use the same tool to score the first 10 cases again (in a 10 cases (without)
different order) to see if their skill level has improved.
Cerebral vascular territories - superior lateral ventricle level
TERRITORIES

ACA – ANTERIOR CEREBRAL ARTERY ACA

MCA – MIDDLE CEREBRAL ARTERY

MCA MCA
PCA – POSTERIOR CEREBRAL ARTERY
PCA

Note: we are not considering strokes in ACA or PCA territories

ASPECTS regions
ASPECTS DIVIDES THE MCA-SUPPLIED CEREBRAL TERRITORIES
INTO TEN REGIONS

SEVEN AT THE LEVEL OF THE BASAL GANGLIA

M1 C
C - HEAD OF CAUDATE NUCLEUS

I - INSULA
M2 I L IC
IC - INTERNAL CAPSULE
M3
L - LENTIFORM NUCLEUS
(PUTAMEN + GLOBUS PALLIDUS)

CORTICAL REGIONS M1, M2 AND M3

Quantify damage using ASPECTS

ASPECTS regions
THREE ABOVE THE LEVEL OF THE
BASAL GANGLIA

CORTICAL REGIONS M4, M5 AND M6

M4

M5

M6

Quantify damage using ASPECTS

The WOW Tool - Start with the first 10 cases
IDENTIFY SIGNS OF EARLY
ISCHAEMIC DAMAGE

HYPERDENSE ARTERY SIGN

INTERNAL CAPSULE

BASAL GANGLIA

INSULAR RIBBON
The vast majority of strokes are in the MCA region so it could make
sense to start a standardised procedure by looking there first
Stroke distribution1

8%

ACA

24%
MCA MCA

PCA
68%

MCA PCA ACA

1. J Clin Neurol. 2013 Apr; 9(2): 97–102.

What do CT scans have in common with Frogs and Boomerangs?
 HYPERDENSE ARTERY SIGN

Step 1. Hyperdense artery sign

Thrombus within the MCA vessel
100% sensitivity
Only 30% specificity as calcification,
blood flow and haematocrit can affect
appearance
Unaffected side must appear normal
Expect density of >43 HU
Step 1. Hyperdense artery sign
Scroll down until you find the frog
The Mid Cerebral Artery (MCA) is represented by the arms of the frog
 WINDOWING SCROLLING CONSIDER HU

3. Use Hounsfield units to differentiate

TISSUE TYPICAL HU VALUE

CSF 8

WHITE MATTER 30

GREY MATTER 45

FRESH BLOOD 60

CALCIFICATIONS 100+

BONE 1000+

When looking for a clot (Hyper dense artery sign) > 45 HU

 HYPERDENSE ARTERY SIGN

Hyperdense artery sign

Hyperdense MCA
measures around 50 HU in
this scan
Surrounding tissue is
around 30 HU
 HYPERDENSE ARTERY SIGN

Hyperdense artery sign

This example is more subtle
The hyperdense part is around 45 HU
The relevance of a Hyperdense artery
IVT has a very low potential to
recanalize occluded vessels if
thrombus length exceeds 8 mm
It gives a clue that Mechanical
Thrombectomy could be indicated.
The position of the clot should be
confirmed with CT Angio

Stroke. 2011;42:1775–1777
Identifying signs of early ischemic damage
- direction of process

INTERNAL CAPSULE

BASAL GANGLIA

INSULAR RIBBON

Look for loss of grey/white differentiation

Checking grey/white differentiation
There should be a clear boundary between the grey and white matter
Find the same structure on both sides of the brain
If one side is damaged then it will be less clearly delineated than its opposite
Consider the insular ribbons below
DAMAGED HEALTHY
INSULA INSULA
Checking grey/white differentiation
It can be difficult to see the differences when using a standard
level and window in your viewer
Reducing the window width will increase contrast and make the comparison easier
This image uses a level of 32 HU and window of 20 HU

DAMAGED HEALTHY
INSULA INSULA
Checking grey/white differentiation

We can also see a loss of grey/white matter

differentiation affecting the cerebral cortex on the
outside of the Sylvian fissure in this example

DAMAGED HEALTHY
CORTEX CORTEX
Follow a standardised “Step-wise” approach
From the Frog, Scroll up until you find
slices showing the insular ribbon
It appears as a thin line of grey matter
next to a darker grey subcortical area
(white matter)
 INTERNAL CAPSULE

Internal capsule
Once you can see the Insular ribbon scroll up or down one or two slices until you
can see a clear Internal capsule on the “Healthy Side”
The Internal capsule is visible as a curved dark line that looks like a Boomerang
 INTERNAL CAPSULE

Internal capsule
If there is damage in the Internal
capsule there will be a less well defined
“Boomerang” on the affected side
compared to the “Healthy side”
 BASAL GANGLIA

Basal ganglia
From the Internal capsule you now
move outwards
The Basal ganglia situated between the
internal capsule and the insular ribbon
 INSULAR RIBBON

Insular ribbon sign

The insular ribbon is often one of the
first structures to be affected
When grey/white differentiation is lost,
the insular ribbon itself is lost
The insular cortex is more susceptible to
ischemia following MCA occlusion than
other portions of the MCA territory
because it has the least potential for
collateral supply from the anterior
cerebral and posterior cerebral arteries
Once you are done with analysing the MCA region you could now focus
on finding ischemic signs in the PCA and ACA regions
Stroke distribution1

8%

ACA

24%
MCA MCA

PCA
68%

MCA PCA ACA

1. J Clin Neurol. 2013 Apr; 9(2): 97–102.

 SWELLING
(SULCI / MIDLINE SHIFT)

Swelling
SWELLING MAY BE PART OF BOTH THE ISCHAEMIC CORE AND PENUMBRA,
SO DAMAGE MAY BE REVERSIBLE

SWELLING MAY APPEAR IN SEVERAL DIFFERENT WAYS

COMPRESSED VENTRICLES
EFFACED SULCI
MID-LINE SHIFT

SWELLING GENERALLY TAKES SOME TIME TO DEVELOP SO IT IS OFTEN NOT VISIBLE DURING
THE EARLY TIME WINDOW FOR THROMBOLYSIS

IF THERE IS SIGNIFICANT, VISIBLE SWELLING, THE PATIENT MAY BE AT INCREASED RISK

OF HAEMORRHAGE FOLLOWING THROMBOLYSIS
Swelling - compressed ventricles
THE LEFT ANTERIOR HORN OF THE LATERAL VENTRICLE
IS COMPRESSED COMPARED TO THE RIGHT HYPODENSE
SWELLING
TISSUE
IN THIS SCAN

THERE IS ALSO EXTENSIVE HYPODENSITY

AND LOSS OF GREY/WHITE MATTER
DIFFERENTIATION

BEWARE
A TILTED SCAN CAN MAKE VENTRICLES APPEAR TO BE
SMALLER ON ONE SIDE
 SWELLING
(SULCI / MIDLINE SHIFT)

Swelling - effaced sulci

SULCI IN THE CEREBRAL CORTEX SHOULD APPEAR
ROUGHLY SYMMETRICAL
IN A HEALTHY BRAIN

WHEN SWOLLEN, SULCI ON ONE SIDE WILL APPEAR

SMALLER AND LESS WELL DEFINED

ESPECIALLY WHEN COMBINED WITH A LOSS OF

GREY/WHITE MATTER DIFFERENTIATION
 SWELLING
(SULCI / MIDLINE SHIFT)

Swelling - effaced sulci

Ensure the scan is level
so you can compare HEALTHY
SULCI
EFFACED
SULCI
similar sulci
Scroll up and down
through slices to check
the appearance of sulci
as they change
direction
Beware - partial
volume effects can
cause blurring of sulci
 SWELLING
(SULCI / MIDLINE SHIFT)

Swelling - mid-line shift

Mid-line shift rarely
occurs within 4 hours
of stroke onset (age NO LONGER
dependent) ON THE
MID-LINE

Below is a comparison
of the same patient
within 4 hours of
onset (left) and over
24 hours later (right)
IDENTIFY SIGNS OF EARLY
ISCHAEMIC DAMAGE

HYPERDENSE ARTERY SIGN Scroll down to Find the frog. Look to find the
Hyperdense artery (HU>45)

INTERNAL CAPSULE
Scroll to the Insula ribbon. Once you find it scroll up
or down to find the Boomerang (Internal Capsule).
Work your way outwards from the Internal Capsule
BASAL GANGLIA
to the Basal Ganglia.
Next is the Insular Ribbon.
INSULAR RIBBON
After this you could analyze the PCA and ACA regions.
SWELLING Swelling is normally found in patients with advanced
(SULCI / MIDLINE SHIFT) ischemia.
Lets try and apply these steps on some example cases

HYPERDENSE ARTERY SIGN

INTERNAL CAPSULE

BASAL GANGLIA

INSULAR RIBBON

SWELLING
(SULCI / MIDLINE SHIFT)
The WOW Tool - Now practice using these steps on the
60 WOW cases