DR YAHYA KHAN

About this presentation

This presentation will give you a systematic approach
to head CT
By the end you should be familiar with normal
anatomy and be able to identify classic abnormalities
on CT
You can test your knowledge with the short cases at
the end
Types of head CT’s
Non-contrast

Contrast
IV contrast is given to better evaluate:
 Vascular structures
 Tumors
 Sites of infection

Relative contraindications:
 Allergy, renal failure
Common Indications for Head CT
Cranial-facial trauma
Acute stroke
Suspected subarachnoid or intracranial hemorrhage
Evaluation of headache
Evaluation of sensory or motor function loss
Evaluation of sinus cavities
CT basics
Before we begin, there are key concepts you should
be familiar with:

Hounsfield units
Windowing & leveling
Planes
What’s a Hounsfield Unit?
Named after the inventor of CT
CT scanners record the attenuation (brightness) of each
pixel in Hounsfield Units (HU)
This number represents the relative density of the
scanned substance
Ranges from -1000 to +1000
Hounsfield Unit (HU)
Different substances have different relative densities and
thus, different Hounsfield units
 Air: -1000 HU
 Fat: -50 HU
 Water: 0 HU
 Soft tissue: +40 HU
 Blood: +40-80 HU
 Stones: +100 to +400 HU
 Bone: +1000 HU

Therefore, if you’re not sure what you’re looking at, measure

its Hounsfield Unit!
How to measure
In EFILM, you can
HU
measure the HU using
the oval ROI tool:

On the right, you can

see sample
measurements of
different structures
Note how bone, CSF,
brain tissue, and air all
have different mean
HUs
Windowing
The human eye can only perceive ~ 16 shades of
gray

The CT scanner records levels of gray far beyond

what the eye can see
Therefore, to interpret images, we have to limit
the number of Hounsfield units shown
(windowing)
The computer then converts this set range of HU
into shades of gray we can see
Windows & levels
Window width:
The range of HU of all tissues of interest
Tissues in this range will be displayed in various shades
of gray
Tissues with HU outside the range are displayed as
black or white
Window level:
The central HU of all the numbers in the window width
Windowing
Wide Hounsfield Units Narrow
Window Window
+400
+300
+200
+100
0
-100
-200
-300
-400
Window examples
In head CT, 3 windows are commonly used

BRAIN window BONE window SUBDURAL window

W:80 L:40 W:2500 L:480 W:350 L:90
 Plane
 Plane refers to how the picture slices are orientated

Transaxial plane
 used most often for head CT’s
Coronal plane
 good for evaluation of
pituitary/sella and sinuses
Saggital plane
 rarely used (more common in
MRI)
Plane examples

Axial plane Coronal plane Saggital plane

Identification
 Now we can begin our basic approach to the head CT

Start with the easy stuff:

PATIENT NAME (make sure you have the right patient !!)
MEDICAL RECORD # (MRN)
AGE
DATE OF EXAM
Previous studies
Always check for any previous scans for comparison
Findings can be very subtle
A good way to spot them is to look for changes between
the current and previous scans
Even old chest and abdominal films can give you clues to
possible brain pathology
 ie. Brain mets from lung cancer
Study parameters
Make note of the study technique:
Anatomic region of scan: head, neck, spine
Slice thickness (mm)
Window level & width
Plane: Transaxial, coronal, saggital
Use of contrast?
 Look for the Circle of Willis. It will be enhanced on studies using
contrast
Image analysis
Now that you have noted all the basic information
about the scan, it’s time to look at the scan itself
Use a systematic order & approach to what you look
at
Use the same approach for all scans to ensure that you
don’t miss anything
Regions to inspect
We will start from the inside and move outwards:

1. Midline structures & 5. Sulci

symmetry 6. Sinuses
2. Ventricles 7. Bones
3. Brain parenchyma 8. Skin/soft tissue
1. Midline structures
Identify:

 Fornix
Falx Cerebri

 Pineal gland
(usually calcified)

 Great vein of Galen

Midline shift
Evaluate for midline shift:

The septum
between the
lateral ventricles
should not deviate
more than 5mm
from the midline

Find a slice where the 2 Draw a vertical line down

lateral ventricles are the middle joining the falx
prominent cerebri anteriorly &
posteriorly
Midline shift examples

R L R L

A right-sided abscess is causing a A left-sided tumor is causing a

midline shift to the left midline shift to the right
2. Ventricles
 Identify:

Lateral ventricles x 2

 Third ventricle
 Cerebral aqueduct
 Fourth ventricle
Ventricles
Evaluate for any changes in
Symmetry
Size
Shape
Density
A displaced ventricle is often the product of mass
effect or atrophy
 Ventricles
Common pathology:

 Mass effect
 Atrophy
 Hydrocephalus
 Intra-ventricular Hemorrhage
3. Cisterns
 Identify:

 Supracellar cistern
 Ambient cistern
 Prepontine cistern
 Cisterna magna
Cisterns
Evaluate for any changes in
Symmetry
Size
Density

Cisterns often contain blood with subarachnoid

hemorrhage
Cisterns can fill with pus in the setting of meningitis
4. Brain parenchyma – Lobes
First, identify the major lobes:

 Frontal lobe
 Temporal lobe
 Parietal lobe
 Occipital lobe
 Brain Parenchyma - Brainstem
Then identify:

 Midbrain
 Pons
 Medulla
 Cerebellum
Brain parenchyma – Deep structures
Lastly, identify the deep structures:

 Corpus Callosum
 Caudate
 Thalamus
 Lentiform Nucleus
 Internal capsule
 External capsule
 Parenchymal masses
Look for mass lesions

 Abscess

 Neoplasm

Note how thethe

Note tumor
ring becomes
enhancingbright
lesionwith contrast
consistent
with that of
Also note the surrounding an area
dark abscess
of edema
Acute Infarct
 Look for signs of acute infarction
 Hyperdense MCA sign  Loss of gray-white
differentiation

Click
The middle me to
cerebral see(MCA)
artery The usualClick
borderme to seegrey and white
between
becomes hyperdense due to occlusion matter is lost due to vasogenic edema
Chronic Infarct
 Then, look for signs of chronic infarction:

Retractment of parenchyma
from skull due to atrophy

Focal area of
hypodensity

Mild midline shift to the

right due to atrophy
Infarction locations
Microangiopathic change
You may encounter the term
“microangiopathic change” in reports
and wonder what it is

Microangiopathic change refers to

age-related white matter ischemia due Normal

to microvessel disease

Very commonly seen in the elderly

Its clinical significance is still not

known
Microangiopathic change
Types

of Hematoma
Look for evidence of a bleed:

Subdural Hematoma
Due to tear of bridging veins
Look for crescentic shape along brain surface
Crosses suture lines

Epidural Hematoma
Due to rupture of middle meningeal artery
Associated with skull fractures
Look for biconvex, lenticular shape
Does not cross suture lines
Subdural vs. Epidural

Note the cresentic shape Note the lenticular shape

SUBDURAL EPIDURAL
 Subarachnoid Hemorrhage
Look for a subarachnoid hemorrhage
 Due to aneurysm rupture, trauma, or AVM
 Blood in the subarachnoid space and/or ventricles
 Blood can often first be seen in the inter-peduncular cistern

Blood in
subarachnoid
space

(Normal)

Blood in
sulci
Blood in ventricle
Intraparenchymal Hemorrhage
Look for intraparenchymal
hemorrhage:
blood (acute, subacute, or
chronic) located in brain
parenchyma
surrounding area of edema
may also be seen
Usually caused by
hypertension
 Hemorrhage timeline
If you see a bleed, try to assess if its new or old:

ACUTE bleed (< 3 days)

 Hyperdense (80-100 HU) relative to brain
 Caused by protein-Hb component
 Can be hard to spot if hemoglobin is low (<80)

SUBACUTE bleed (3-14 days)

 Hyperdense, isodense, or hypodense relative to brain
 Density loss starts from periphery and goes to centre

CHRONIC bleed (>2 weeks)

 Hypodense (<40 HU) relative to brain
 Density of blood over time in a
subdural hematoma

Hypodense
Hyperdense Isodense blood
blood blood

Acute Sub-acute Chronic

(<3 days) (3-14 days) (>14 days)
5.

Sulci
Identify:

 Sulci
 Sylvian fissures
 Central sulcus
 Precentral sulcus
 Postcentral sulcus
 Sulci
Remember that sulci will become deeper and more prominent
with age
Look for blood in the sulci & Sylvian Fissure which are
indications of a sub-arachnoid bleed

Acute blood in
Sylvian fissure

Acute blood in
sulci
 6. Sinuses
Switch to Bone Window to better evaluate the sinuses
Identify:
 Superior Saggital Sinus
 Frontal Sinus
 Ethmoid Sinus
 Sphenoid Sinus
 Maxillary Sinus
Sinuses
Evaluate for any sinusitis:

fluid in sinuses
(notice the air/fluid level)

sinusitis normal
Sinuses
Also look for any:
Mucosal thickening
Blood in sinuses (especially with history of trauma)
Polyps or mucous retention cysts
 7. Bone
Stay on the Bone Window and look at the bones now
Identify:

 Skull
 Sutures
 Mastoid air cells
Bone
Evaluate for any:

 Fractures
 Surgical changes
(ie. craniotomies)
 8. Skin & Soft tissue
Evaluate for any:

 Sub-galeal hematoma
 Foreign body
 Surgical changes
Thank you……………
Recap
Begin with the basic identification
Remember to check for previous scans
Check the technique
Look at each region of the brain systematically
We started from the middle and worked out:

1. Midline structures 5. Sulci

2. Ventricles 6. Sinuses
3. Cisterns 7. Bones
4. Brain parenchyma 8. Skin/soft tissue
Recap
In each area, identify the major anatomy
Then look for findings
Below is a list of important things not to miss:

 Midline: midline shift

 Ventricles: blood and mass effect
 Cisterns: blood and pus
 Parenchyma: signs of ischemia and/or bleeding
 Sulci: for blood
 Sinuses: signs of sinusitis
 Bones: fractures
 Soft tissue: hematoma
Recap
Remember to use the same approach every time so
that you don’t miss anything!

Try out the cases in the next slides to test your

knowledge
Case #1
Mr A is an 80 y/o female presenting with:
Expressive aphasia/apraxia
Mild right facial droop
Atrial fibrillation
A non-contrast CT scan of her brain is performed
Your analysis
What are your findings?
What is your impression?
What would be your top diagnosis?
Normal
Case #1 - Answer
Mr A had an infarction of her Left
Parietal Lobe
The location is consistent with
MCA infarction
The cause was emboli related to
her atrial fibrillation
Case #2
Mr. B is a 56 y/o male presenting with:
A sudden onset 10/10 headache while running
Photophobia, nausea & vomiting
No history of trauma or LOC
Otherwise well

A non-contrast CT scan of his brain is performed

Your analysis
What are your findings?
What is your impression?
What would be your top diagnosis?
Is this pathology acute, subacute, or chronic
Case #2 - Answer
Mr. B had a large subarachnoid
hemorrhage
The bleed was acute
This was caused by rupture of an
ACA aneurysm
He was admitted to ICU where
his condition deteriorated
rapidly
He passed away shortly after
admission
Case #3
Mr C is a 66 y/o female who slipped down the stairs
yesterday and hit the back of her head.
She presents with
Generalized left sided weakness
Light headache
A non-contrast CT scan of her brain is performed
R L
Your analysis
What are your findings?
What is your impression?
What would be your top diagnosis?
Is this pathology acute, subacute, or chronic
Case #3 - Answer
Mr C had a large right-
sided subdural hematoma
The hematoma is acute
This was caused by
rupture of bridging veins
when she hit her head
A craniotomy was
performed and the bleed
was drained
Bonus case
Mr. X is a 80 y/o male presenting with:
3 month history of delirium
Recent fall from bed
Large scalp laceration
No focal neurological findings
An non-contrast CT scan of his brain is performed
 Hint? Look closely at the midline structures

Subdural
Analysis
Can you spot the abnormalities?
What is your impression?
What would be your top diagnosis?
 Bonus case - Answer
 Mr. X had a tiny right-sided
subdural hematoma
 Blood is seen along the left
subdural space as well as in the
falx cerebri anteriorly (arrows)
 The hematoma is acute
 Because of its small size, no
immediate treatment was
required
 Follow-up CT scans showed
resolution of the subdural
hematoma
Normal scan for comparison