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Intracranial Hemorrhage: Bleeding inside the skull. All acute (i.e.

new) hemorrhages
appear dense (i.e. white) on computed tomography (CT). The primary imaging features that
help Radiologists determine the presence, type of hemorrhage are the location, shape and
proximity to other structures.
Challenge: Determine the presence, type of hemorrhage
Intracranial Hemorrhage:

Extra Axial Hemorrhage: Intra Axial Hemorrhage:


Bleeding occur inside the skull but outside the brain Bleeding occur within the brain tissue.
tissue. 1) Intraparenchymal
1) Epidural or Extradural Hemorrhage (EDH) 2) Intraventricular
2) Subdural Hemorrhage (SDH)
3) Subarachnoid Hemorrhage (SAH)

 Pia mater covers the brain.


 Blood is bright white on CT images. Other things that occurs bright white in CT are
bone, IV Contrast
 Ventricles : The ventricular system is a set of four interconnected ventricles in
the brain, where the cerebrospinal fluid (CSF) is produced.
 Arteries: Arteries are blood vessels responsible for carrying oxygen-rich blood away
from the heart to the body.
 Veins: Veins are blood vessels that carry blood low in oxygen from the body back to
the heart for reoxygenation.
Name of Computed Tomography (CT), Images Sympompts Reasons
Hemorrhage
Epidural:
Loss of
Clotting of blood consciousness
between skull and and then
dura matter. regain
consciousness
(Lucid Phase)
Headache
Vomiting

In Non contrast CT it looks like biconvex


disk.
Source: Artery breakage
Skull fracture is there.
It requires rapid surgical evacuation as it
rapidly expands with arterial blood.
It can push brain substance to one side
It doesn’t cross suture lines.
Acute presentation
Other things can be done is MRI, CSF with
the help of Lumbar puncture (it appears
clear in it)
Subdural: It’s typically
Clotting of blood High BP the result of
between dura Low Pulse your head
matter and Headache moving rapidly
arachnoid. Vomiting forward and
stopping, such
as in a car
accident. This
is the same type
In CT it looks like crescent shape. of movement a
Source: Bridging Vein breakage child
It can push brain substance a lot which in experiences
terms can shift mid line of brain. when being
It does require rapid surgical evacuation shaken.
until and unless its size is very big such that
it cause midline shift. A subdural
It can cross suture lines. hematoma is
Acute (<3 days) crescent shape Hyperdense more common
o Sub-Acute (3-14 days) Isodence than other ICHs
o Chronic (>14 week) Hypodense in older people
Other things can be done is MRI, CSF with and people with
the help of Lumbar puncture (it appears history of
bloody in it) heavy alcohol
use
Subarachnoid Worst
Headache
Clotting of blood Vomiting
between arachnoid Pain in neck
matter and pia Light
matter. (i.e. Sensitivity
subarachnoid
space containing
CSF)

In CT it looks like spider shape.


Source: Cerebral Artery breakage
If we want to know that from which vessel
blood has come then investigation of choice
is Angiography
o MRA >CTA>DSA (In order of
Power)
Other things can be done is MRI, CSF with
the help of Lumbar puncture (it appears
bloody in it)
MRI actually has edge over CT scan as MRI is more sensitive in picking up the haemorrhage within brain
Intraparenchymal: High BP The
Weakness in most
Blood that is located one part of common
completely within the the body cause is
brain itself. Difficulty High
inspeaking blood
Tiny arteries bring blood Headache pressure.
to areas deep inside the Vomiting
brain. High blood
pressure (hypertension)
can cause these thin-
walled arteries to rupture,
releasing blood into the
brain tissue. As blood
spills into the brain, the
area that artery supplied
is now deprived of
oxygen-rich blood –
called a stroke. As blood
cells within the clot die, In CT oftenly it looks round shape
toxins are released that Source: Can be Artery breakage or Vein
further damage brain breakage
cells in the area It is the second most common cause of
surrounding the stroke
hematoma.
Intraventricular Slow Heart It is not
Blood that has leaked into rate clear why
ventricles. It is most Breathing IVH
common in premature Problem occurs.
babies.

There are 4 grades of IVH

Grade 1. Bleeding near


ventricles.

Grade 2. Bleeding inside


the ventricles.

Grade3. Ventricles are


enlarged by the blood.
Grade 4. Enlarge
ventricle + Blood in Brain In CT it looks like Shape of Artery
Tissue Source: Can be Artery breakage or Vein
breakage
Grades 1 and 2 are most
common. Grades 3 and 4
are the most serious
CT: Blood Can be Very Bad
Blood B Blood
Can C Cisterns
be B Brain
Very V Ventricles
Bad B Bones

 If no blood is seen
 All cisterns are present and open
 The brain is symmetric with normal grey white differentiation
 Ventricles are symmetric without dilation
 No bone fractures
Then there is no emergent diagnosis from CT scan
Unit of Tissue density for CT images is known as Hounsfield Unit.

Tissue window is the combination of Window (Range of HU) and Level (where is the
window centred).
If tissue density < L-W/2 then that tissue is displayed as black.
If tissue density>L+W/2 then that tissue is displayed as white.

W= 90, L=68.
W=70, L=40.
Dence Blood has Density approx. 80 and Bone
Dence Blood has Density approx. 80 and
has density 400. Therefore, bone will be
Bone has density 400. Therefore, both
displayed whiter whereas blood will be not that
will be displayed white. Therefore, we
much white. Therefore, we can distinguish
cannot distinguish between Bone and
between Bone and Subdural Hemorrhage.
Subdural Hemorrhage.

Select the window and level wisely.

There are at least 5 windows that a radiologist goes through for each scan
1) Brain Matter window: W:80 L:40
2) Blood/subdural window: W:130-300 L:50-100
3) Soft tissue window: W:350–400 L:20–60
4) Bone window: W:2800 L:600
5) Grey-white differentiation window: W:8 L:32 or W:40 L:40

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