CT

:

CT
CT

BCBVB
CT

Canthomeatal line
-
(150) (red line)


For
facial bones,
paranasal sinuses,
sella
 CT of Brain
Brain parenchyma ()
frontal lobe, temporal lobe, parietal lobe, occipital lobe,
cerebellum, basal ganglia, brainstem, corpus callosum
Subarachnoid spaces (, CSF spaces)
Ventricles ()--- lateral, 3rd, 4th ventricles
Cisterns ()--- suprasellar, quadrigeminal cisterns.
Fissures ()--- Sylvian, interhemispheric fissures
Sulci ()
parietal lobe

F
s
d T
P

4th V
Ce

F: frontal lobe P: pons()

T: temporal lobe
s: suprasellar cistern ()
Ce: cerebellum d: dorsum sella
parietal lobe

s
T
Temporal lobe
Mb

Ce

F: frontal lobe Mb: midbrain

T: temporal lobe
s: suprasellar cistern ()
Ce: cerebellum
parietal lobe
F lv
CC
Sy

T 3v
Mb

Qc
O

F: frontal lobe Sy: Sylvian fissure

T: temporal lobe O: occipital lobe
Mb: midbrain 3v: 3rd ventricle
lv: lateral ventricle()
CC: corpus callosum (,genu)
Qc: quadrigeminal cistern ()
parietal lobe

F
CC
s
lv
Sp s
P
O

F: frontal lobe CC: corpus callosum

P: parietal lobe Sp: splenium of CC
O:occipital lobe lv: lateral ventricle
s: sulcus
parietal lobe

F If

Ci cs
CS

F: frontal lobe If: interhemispheric

P: parietal lobe fissure
Ci: cingulum cs: central sulcus
CS: centrum semioval
 Basal Ganglia
Genu of corpus callosum
Head of caudate nucleus
Putamen
Anterior limb
Lentiform genu
nucleus posterior limb
----of internal capsule
Globus
pallidus

Thalamus
Tail of caudate nucleus

Splenium of corpus callosum

 Basal ganglia

c
p g
i t

c: caudate nucleus p: putamen

g: globus pallidus t: thalamus
i: internal capsule

sc: suprasellar cistern lv
Sf sf
aq: aqueduct
th: temporal horn of lateral ventricle 3v

lv qc

3v th

sc
th
lv: lateral ventricle, frontal horn
3v: 3rd ventricle
qc: quadrigeminal cistern aq
Sf: Sylvian fissure


X-ray X-ray attenuation
(X- )
 Gray scale (Hounsfield scale)
Tissue & pathology Hu(attenuation) density
Metallic material artifact

Bone 600-1000 white

Calcification 100-500 white
Fresh blood clot 60-90 white
Fibrotic tissue 50-70 gray
Soft tissue 35-45 gray
Soft tissue edema 15-25 gray-dark
Encephalomalacia 10-20 dark
Thick tissue fluid 10-16 dark
Tissue fluid (CSF) 4-6 dark
Pure water 0 dark
Fat -20~ -120 black
Air -1000 black


Gray matter 40 Hu
White matter 35Hu

Bone 1000Hu
CSF 4Hu
subcutaneous fat
air -1000Hu

fat -20 ~ -120Hu

mastoid air


f m: muscle, soft tissue
g f 35-45Hu
4
l: liver, 50Hu
5 3
l g: gall bladder, 10Hu
b
2 b: bone, 1000Hu
m f: fat, -20 ~ -120Hu

1.
2.
3.
4.
5. (aorta)


fresh blood clot 70-90Hu



Soft tissue edema

15-25Hu
A case of hyperparathyroidism with
big calcifications in the
bil. basal ganglia(),
Thalami(),
caudate nuclei()

Calcification: 100-500 Hu


Abscess: pus, 10-16Hu
CSF: tissue fluid, 4-6Hu
ab
e: white matter edema, 25Hu
ab

CSF
e
 Mass Effect
CTMRI, , ,
,

, :
1. , , ,

2., , (septum pellucidum)
3.foramen of Monro, CSF,

4., ,
(hydrocephalus)
5.,
6. (herniation),
(subfalcial herniation), (uncal herniation),
(transtentorial herniation), (tonsilar herniation)
 Mass Effect
 Hematoma
s
s

Mass effect: hematoma more enlarged

1. The ipsilateral ventricle, sulci, fissures are mass effect is stronger
compressed and obliterated, disappeared.
2. Midline is shifted.
3. The contra-lateral ventricle is dilated. (case : X)
 Acute epidural hematoma (EDH),
Hematoma causes strong mass effect with
uncal/transtentorial herniation(yellow arrow)
---obliteration of the suprasellar cistern (red arrow)
and the quadrigeminal cistern (green arrow)
 Strong mass effect
subfalcine herniation
Hematoma

uncal/transtentorial (obliteration of the suprasellar

herniation cistern/quadrigeminal cistern)

Before surgery, a big GBM

in the left temporal lobe with
uncal herniation.()
After surgery, the GBM was
removed, the suprasellar
cistern and quadrigeminal
cisterns are normal.()
 CVA with
ICH
s

Mass effect:
1. The ipsilateral ventricle, sulci, fissures are compressed
and obliterated, disappeared.
2. Midline is shifted.
3. The contra-lateral ventricle is dilated.
Severe mass effect:
Uncal/transtentorial herniation---- obliteration of the
suprasellar cistern(s) and quadrigeminal cistern(q)
 Brain edema
Early
edema
(25Hu)

Density decreased (16-25Hu)

with mass effect

Edema in MCA &

PCA territory (16Hu)
 Severe
mass
s effect
q

Acute infarction 4th day

1st day
Severe mass effect:
Uncal/transtentorial herniation---- obliteration of the
suprasellar cistern(s) and quadrigeminal cistern(q)
Complication of uncal/transtentorial herniation

Posterior cerebral artery (PCA

) is compressed, causing
infarction.Sometime, middle
cerebral artery(MCA),
or other small artery supplying the
basal ganglia are compressed and
causing infarction().
 strong
mass
effect

Acute infarction of right posterior artery (PCA),

this is a complication of uncal/transtentorial
herniation, because the PCA was compressed
by brain herniation.

Big acute subdural hematoma(SDH) caused strong mass effect

with uncal/transtentorial herniation.
Subfalcial herniation may compressing the
anterior cerebral artery (ACA), causing infarction
SDH

ACA infarction
Subfalcial
herniation

Intravenous contrast enhancement by iodinized contrast medium

Normal structures: Pathological conditions

1. Vascularity Tumors
arteries Vascular diseases (aneurysm, AVM)
veins
Capsule of brain abscess, empyema
veinous sinuses
2. Non-brain structures Capsule of chronic SDH
tentorium The margin of an subacute hematoma
falx The area of infarction
choroid plexus of Margin of radiation necrosis
ventricles
Normal brain tissue is not
enhanced due to BBB
IV contrast enhancement by iodinized contrast medium

W: Willis circle
t: tentorium
IV contrast enhancement by iodinized contrast medium

cp cv cp

ss v

sss

v: internal cerebral vein, cp: choroid plexus

ss: straight sinus, sss: superior sagittal sinus
cv: cortical veins


4 5
3
5 33 5 5
1 1

2 2

CTCT
1.
2. ()
3.
4.
5.


Plain CT Contrast CT
Contrast medium enhancement
Brain tumors---breast ca. with right occipital
bone metastasis


before contrast after iv contrast

Contrast medium enhancement

Brain abscess-- ring enhancement
enhancement of the capsule of abscess

: CT

:
CT

(AVM)
White matter edema()
Perifocal white matter edema, caused by
Brain tumors
Brain abscess
Subacute hematoma (hematoma in resorption)
Other causes of white matter edema
Radiation injury
Encephalitis
Once white matter edema is seen, intravenous
contrast medium is indicated

Falx meningioma

Perifocal
(peritumoral)
No contrast
white matter
edema

Post-IV contrast

Two brain abscess, with perifocal white matter edema


brain metastasis (ring-like enhancement)

Once white matter edema is found, intravenous contrast medium
must be given to enhance the focal lesion
 (Hydrocephalus)
Classifications:
Obstructive hydrocephalus
Communicating hydrocephalus
CSF overproduction hydrocephalus

Signs of hydrocephalus
Ventriculomegaly
Temporal horns of bilateral lateral ventricles and
3rd ventricle, are very sensitive for mild hydrocephalus
 Obstructive hydrocephalus

LV

3V 3V
LV

Congenital aqueduct stenosis causing severe hydrocephalus

3V: 3rd ventricle
LV: lateral ventricle
 Obstructive hydrocephalus

CVA due to cerebellar hemorrhage, (case:X)

compressing the 4th ventricle,
causing obstructive hydrocephalus, and IVH
Communicating Hydrocephalus

LV LV
3V
3V
4V

4V

3V: 3rd ventricle

4V: 4th ventricle
LV: lateral ventricle
 Communicating Hydrocephalus

lv
lv
3v 4v
3v

Meningitis with subdural Sequel of meningitis with

effusion communicating hydrocephalus

Bacterial meningitis causing severe communicating

hydrocephalus
 (mild hydrocephalus)

3rd ventricle
temporal horn

Temporal horn

(temporal horns)
;,
 Mild hydrocephalus
3rd ventricle
temporal horn

Temporal horns of bilateral lateral ventricles

and the 3rd ventricle are the most sensitive
for the diagnosis of mild hydrocephalus

3rd ventricle
temporal horn
 (Brain Atrophy)
Brain atrophy Signs of Brain atrophy
Generalized brain atrophy Dilatation of sulci, cisterns
Focal brain atrophy Dilatation of ipsilateral ventricle
Cerebral hemiatrophy The brain volume is decreased
Cerebellar atrophy

,
,

Generalized brain atrophy

Normal brain

Complication of meningitis

Diffuse brain atrophy with

dilatation of cortical sulci
and ventricles
Diffuse brain atrophy

Aged brain with brain atrophy

 Cerebral hemiatrophy

Cerebral hemiatrophy, Cerebral hemiatrophy, left side

right side, due to sequela possible is sequel due to prematurity
of shaken baby syndrome with perinatal injury
 Focal brain atrophy

May, 1996 Aug, 1997

Contusion hematomas Sequel lesion of previous brain contusion
----encephalomalacia with
focal brain atrophy


Old infarction of right MCA, with

encephalomalacia and adjacent
brain atrophy, causing dilatation
of the right lateral ventricle

,
,
 A 14 y/o girl with severe cerebellar atrophy

Cerebellar atrophy Decreased cerebellar volume

(widening of sulci)
(Wallerian degeneration)
corticospinal tract(motor cortex)
(corona radiata), (axon)
(demyelination)(gliosis),
Wallerian degeneration (WD)

CT,
MRI, (pyramid), T2WI
corticospinal tract,
WD, ,
(axons)
(demyelination), (lipid), lipidMRI long TR
, , , corticospinal
tract, WD


Porencephaly in left frontal lobe, due to previous ICH,

with Wallerian degeneration.
Note: atrophy of the left cerebral peduncle(arrow).
 Head CT
mnemonic to remember

Blood Can Be
Very Bad
 Head CT
Blood Can Be Very Bad

B= blood
C=cisterns
B=brain
V=ventricles
B=bone
 Overview
B=blood (SAH, parenchymal, extraaxial)
C=cisterns (suprasellar, sylvian,
circumesencephalic, quadrigeminal)
B=brain (density and symmetry)
V=ventricles (symmetry and size)
B=bone (fracture, sinuses for fluid, air
cells)
 Head CT
blood
Sub-arachnoid(SAH)
Parenchymal(in the substance of the barin)
Deep bleed ?
Ventricular rupture ? (with subsequent
hydrocephalus)
Extraaxial(outside the substance of the brain)
Evidence of compression ?
 Head CT
Types of blood

Extra-cranial
Epi-dural
Sub-dural
Sub-arachnoid
Intra-parenchymal(intracerebral , ICH)
Intra-ventricular(IVH)
 Head CT
Cisterns

Examine each cistern carefully

Blood in cistern SAH
evaluate for hydrocephalus NS
consultation
Cistern effaced (squished shut)
consider IICP with unstable
compartments (impending
herniation)
 Head CT
Brain
Air (black) = skull fracture, dural tear.
Assymetric brain density =
stroke.(brainstem, cerebellum, basal
ganglia, both hemispheres
Symmetric brain hypodensity =
massive ischemia or venous
thrombosis
Look for shift mass lesion
Look at sulci obliteration (in the
adult) may mean tight brain
 Head CT
Ventricles
Examine for hydrocephalus. If
very acute see trans-ependymal
flow of CSF(periventricular
lucency)
Enlargement of temporal horns =
loss of comma shape.
Enlargement of frontal horns =
Mickey Mouse ears
Consider age, alcohol, AIDS as
chronic cause
 Head CT
Bone
Look for fracture (soft tissue
swelling)
Look at the sinuses air/fluid
level blood (unless sinusitis).
Examine mastoid, frontal
maxillary, and ethmoid sinuses.
Petrous bone.
 Head CT
Blood Can Be Very Bad

If there is no gross blood, the cisterns are

black and open, the brain is symmetric with
normal density, the skull and sinuses are
normal, and there is no evidence for
hydrocephalus then there is no emergent
diagnosis from the CT scan.