Basic 101 on CT

Neuroimaging
(from neurology point of view)

Dr Ahmad Shahir Mawardi

Neurology Department
Hospital Kuala Lumpur
25th May 2016
Content
• Basics of CT Neuroimaging
• Neuro anatomy on CT
• Common neurological conditions
Expectation(s)

• Able to
– do on-call confidently
– intreprete important CT findings
What not to expect(s)

• interprets CT scan like a 'pro'

• pass medical examination with flying colours
The Eyes Don't See
What the Mind Don't
Know
CT scan Intrepretation (Abnormal)

1. Lesion(s) (hyperdense/Hypodense)
2. Location
3. Age of lesion (acute/subcute/chronic)
4. + Cause, + complications

e.g
• Acute infact at the left internal capsule
• Acute communicating hydrocephalus
Pitfalls

• Pt name (make sure you have the right

pt!)
• Age
• Date
• CT (brain)
• Plane/View
• Plain vs contrast
• Findings
Part I

Basic of CT Neuroimaging
Basics of CT Neuroimaging

• Orientation
• Region/Planes
• Windows
• Density
• Slice thickness
• Contrast enhancement
Basics of CT Neuroimaging: Orientation
Basics of CT Neuroimaging: Orientation
Basics of CT Neuroimaging:
SYMMETRY
MIRROR IMAGE
CT brain – 2 identical half
Basics of CT Neuroimaging: Planes
Basics of CT Neuroimaging: Planes

C
S
Basics of CT Neuroimaging: Window
Basics of CT Neuroimaging: Density

• Hypodense
• Hyperdense
• Isodense
Basics of CT Neuroimaging: Density
HYPERDENSITIES
Left temporal
Most common: epidural haematoma
•Blood
•Calcification
•Exception to
the rule:
– Pineal gland
– Choroid plexus
HYPODENSITY

Most common:

•Infarction
•Fluid
– edema, infection,
tumour
•Hydrocephalus
•Air
Basics of CT Neuroimaging: Density

The Density of Blood Changes with Time!

Basics of CT Neuroimaging: slice thickness

• Scanogram
– Plane used for
scanning
– Anatomic extent of
series of scans

• Slice thickness may vary

(5-10 mm)
CT brain: Contract vs non-contrast

• Contrast: • CTA (stenosis)

– Vascular lesion • CTV (CVT)
– Tumor • Leptomenigeal
– Sites of infection enhancement
(meningitis)
• Ring enhancing lesion
Ring enhancing lesion

• Tumour • Resolving hematoma (10-21

– Primary (GBM, lymphoma) days)
– Metastasis • Radiation necrosis
• Postoperative change
• Aneurysm
• Infections: • Multiple sclerosis/ADEM (MRI)
– Abscess
– HIV associated:
toxoplasma, crytococcus
– TB/ tuberculoma
– Neurocysticercosis
Ring enhancing
lesion
Part II

NeuroAnatomy
Identification of structures
Lateral View of Brain
Ventricular System
Cross-sectional Anatomy

• Grey/White interface, Subcortical white matter

Cross-sectional Anatomy

• Paired of crescent-shape = Twin bananas

Cross-sectional Anatomy
Basal ganglia
 Cross-sectional Anatomy

• Third ventricle, Basal ganglia, Superior cerebellar cistern

Physiologic Calcification
Brain Anatomy
Cross-sectional Anatomy

• Third ventricle, Smiley face

Cross-sectional Anatomy

• Midbrain, Interpeduncular cistern

Cross-sectional Anatomy

• Star shape ~ Circle of Willis,

• Fourth ventricle, Temporal horn ~ slit
Cross-sectional Anatomy

• Base of skull, Midline bony prominence,

• Prepontine cistern, Pretrous bone, Frontal sinus
Cross-sectional Anatomy

• Orbits, Ethmoid air cell

Part III

Common neuropathological findings

Common neuropathological findings
• Stroke
• Haemorrhage
• Hydrocephalus
• Leptomeningeal enhancement
• CNS infections
Ischemic stroke

• Location:
– Cortical infarction
– Lacunar infarction
– Watershed / Borderzone infarction

• Timing:
– Hyperacute changes
– Early changes
– Established changes

• Complications:
– Haemorrhagic transformation
– Cerebral oedema
Cortical signs
• Aphasia
• Neglect (may be spatial, sensory, visual, auditory)
• Alteration of consciousness
• Visual field cut
Stroke: Cortical Infarction

• Follows vascular territory

– ACA
– MCA
– PCA
– Mixed
• Wedge shape
• May have complications
– Haemorrhagic
transformation
– Cerebral oedema
• Usually embolic aetiology
Lacunar Infarction

• Sites (BITCP)
– Basal Ganglia (Caudate, Putamen)
– Internal capsule
– Thalamus
– Pons
– Cerebellum
• 3-15 mm in diameter
• Distal distribution of penetrating arteries
– Lenticulostriate
– Thalamoperforators
– Pontine perforators
– Recurrent artery of Heubner
• Fibrinoid degeneration
 Lacunar Infarction

Penetrating arteries/
perforators
Lacunar Infarction
Borderzone Infarction

• Cortical Borderzone

• Internal Borderzone

• Pathology / Occlusion of
proximal vessels – ICA
Hyperacute changes

• Dense MCA sign

• Dot sign
• Loss of gray-white
differentiation
• Loss of sulcation
• NORMAL

• As early as 2-6 hours

from onset
6 hours 24 hours 40 hours
ASPECTS score
What ASPECTS tell us

• Functional Outcome
• Risk of bleeding
 Intracerebral
Haemorhage
• Typical hypertensive sites:
– Lenticulostriate vessels
• Basal Ganglia (Caudate, Putamen)
• Internal capsule
• Thalamus (a/w intravent. Ext)
• Pons
• Cerebellum
– Complications:
• Mass effect
• Obstructive hydrocephalus
Intracerebral
Haemorrhage
• Atypical sites!!!:
– Cerebral Amyloid Angiopathy
• 15% of ICH in pts > 60 yrs old

– AVMs
• Intracerebral haemorrhage or SAH

• Ix: CTA
Venous Infarction

• Thrombosis of cerebral veins

– Evidence of thrombosis – Dense cord sign,
Delta / Empty delta sign
– Complications of CVT – SAH, Atypical infarcts.
Haemorrhage
Haemorrhage
 Epidural Haematoma
• Biconvex
• restricted by dural tethering at
the cranial sutures
Subdural Haematoma
• Crescent-shaped
• They do not cross the midline
because of the meningeal
reflections
Subarachnoid haemorrhage
Subarachnoid haemorrhage
Hydrocephalus

Ventriculomegaly a/w raised ICP

•Communicating/Non-obstructive:
– Impaired reabsorption of CSF fulid in the absence of any CSF flow
obstruction

•Non-Communicating/Obstructive:
– CSF-flow obstruction
• Foramen of Monro
• Aqueduct of Sylvius
• Fourth Ventricle obstruction
Hydrocephalus
• Acute
- “Ballooned” ventricles with
periventricular low density “
halo”
- 3rd ventricle - rounded

• Chronic
– “Ballooned” ventricles
without periventricular halo
- 3rd ventricle – normal app

• Obstructive:
– Basal cisterns, sulci compressed /
obliterated
Hydrocephalus Hydrocephalus ex-vacuo
Tuberculous Meningitis
1.Meningeal enhancement:

2. Infarction (20.5 – 30.8%):

- thalamus, basal ganglia, internal capsule

3. Hydrocephalus

4. Tuberculomas
-Infrequently seen except in miliary TB

5. Vascular changes
-uniform narrowing of large segments
-small segmental narrowing
-irregular beaded appearance
-complete occlusion.

Postgrad Med J 1999;75:133 140 doi:10.1136/pgmj.75.881.133

TB Meningitis: Tuberculomas

Contrast-enhanced CT
•showing multiple
tuberculomas in a patient
with tuberculous meningitis

Postgrad Med J 1999;75:133 140 doi:10.1136/pgmj.75.881.133

Meningioma
Right Temporal Glioblastoma
High grade glioma –
usually Glioblastoma
Brain Abscess
 Herpes Encephalitis

• Predilection for limbic system:

– Temporal lobes
– Insular cortex
– sub frontal area
– cingulate gyri.

• Initially unilateral --> "sequential

bilaterality" is highly suggestive of
HSE1.
Toxoplasmosis Primary CNS Lymphoma
Thank You
Hydrocephalous
Subarachnoid hemorrhage