How to Read a Head CT

(or How I learned to stop

worrying and love computed
tomography)

Andrew D. Perron, MD, FACEP

EM Residency Program Director
Department of Emergency Medicine
Maine Medical Center
Portland, ME
Andrew D. Perron, MD, FACEP

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

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

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.

Andrew D. Perron, MD, FACEP

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

Andrew D. Perron, MD, FACEP

Head CT

Blood Can Be Very Bad

Andrew D. Perron, MD, FACEP

Blood Can Be Very Bad

Blood
Cisterns
Brain
Ventricles
Bone
Andrew D. Perron, MD, FACEP

Blood Can Be Very Bad

Blood
Cisterns
Brain
Ventricles
Bone
Andrew D. Perron, MD, FACEP

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
Introduced in 1974 by Sir Jeffrey Hounsfield.
The original Siretom Circa 1974

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 xrays 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.

Andrew D. Perron, MD, FACEP

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CT Scan Basics: Windowing

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

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Andrew D. Perron, MD, FACEP

2 Sheet Head CT

Posterior Fossa
Brainstem
Cerebellum
Skull Base
Clinoids
Petrosal bone
Sphenoid bone
Sella turcica
Sinuses

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CT Scan

Andrew D. Perron, MD, FACEP

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CT Scan

Sagittal
View

Cisterns

Andrew D. Perron, MD, FACEP

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CT Scan

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Brainstem Lateral View

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nd

Key

nd
2
Key
Level
Level Sagittal

View

Andrew D. Perron, MD, FACEP

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Cisterns at Cerebral
Peduncles Level

Andrew D. Perron, MD, FACEP

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CT Scan

Andrew D. Perron, MD, FACEP

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Suprasellar Cistern

Andrew D. Perron, MD, FACEP

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CT Scan

3 Key Level Sagittal View

rd

Andrew D. Perron, MD, FACEP

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Cisterns at High Mid-Brain

Level

Andrew D. Perron, MD, FACEP

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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 ccs.
Adult CSF production is approx. 500700 ccs per day.
Andrew D. Perron, MD, FACEP

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CT Scans

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Andrew D. Perron, MD, FACEP

Trauma
Pictures

PATHOLOGY

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?

Andrew D. Perron, MD, FACEP

39

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.

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.

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.

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

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CT Scan

CT Scans

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Subdural Hematoma
Typically falx or sickleshaped.
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.
Andrew D. Perron, MD, FACEP

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CT Scan

47

Andrew D. Perron, MD, FACEP

CT Scan

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Andrew D. Perron, MD, FACEP

Subarachnoid Hemorrhage

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

Andrew D. Perron, MD, FACEP

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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
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CT Scan

52

Andrew D. Perron, MD, FACEP

CT Scan

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Andrew D. Perron, MD, FACEP

Intraventricular/
Intraparenchymal Hemorrhage

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Andrew D. Perron, MD, FACEP

CT Scan

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Andrew D. Perron, MD, FACEP

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

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

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Andrew D. Perron, MD, FACEP

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Andrew D. Perron, MD, FACEP

B is for BRAIN
(Blood Can Be Very Bad)

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Andrew D. Perron, MD, FACEP

Tumor

63

Andrew D. Perron, MD, FACEP

Atrophy

64

Andrew D. Perron, MD, FACEP

Abscess

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Andrew D. Perron, MD, FACEP

Hemorrhagic Contusion

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Andrew D. Perron, MD, FACEP

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Andrew D. Perron, MD, FACEP

Mass Effect

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Andrew D. Perron, MD, FACEP

Stroke

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Andrew D. Perron, MD, FACEP

Intracranial Air

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Intracranial Air

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Andrew D. Perron, MD, FACEP

Intracranial Air

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Andrew D. Perron, MD, FACEP

V is for VENTRICLES
(Blood Can Be Very Bad)

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Andrew D. Perron, MD, FACEP

Ex-Vacuo Phenomenon

79

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Andrew D. Perron, MD, FACEP

BONE

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Andrew D. Perron, MD, FACEP

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Andrew D. Perron, MD, FACEP

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Andrew D. Perron, MD, FACEP

Three Stooges

Blood Can Be Very Bad

If no blood is seen, all cisterns
are present and open, the brain
is symmetric with normal graywhite differentiation, the
ventricles are symmetric without
dilation, and there is no fracture,
then there is no emergent
diagnosis from the CT scan.
Andrew D. Perron, MD, FACEP

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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_spring_perron_ich_bcbvb.ppt

07/19/15 12:02

Andrew D. Perron, MD, FACEP