Langkah-langkah membaca hasil CT scan kepala:

1 .Membaca CT scan dari lapisan luar kepala menuju ke lapisan dalam,Scalp,Tulang,parenkim.

2. Pada pembacaan scalp, mencari adanya sefal hematom, dan tentukan dengan tepat bagian mana yang terkena.

3. Pada pembacaan tulang, mencari adanya tanda fraktur, bedakan dengan garis sutura yang ada.

4. Pada pembacaan parenkim, evaluasi differensiasi white and grey matter, sulcus dan girus, edema serebri,

ventrikel, dan mencari adanya perdarahan intracranial. Pada pengukuran perdarahan, yang diperhatikan adalah

ketebalan hematom pada slice yang paling tebal, pengukuran volume = (jumlah slice x tebal x panjang) : 2,

semua ukuran dalam cm, yang di foto CTscan biasanya mm, dikonversi menjadi cm, Pergeseran/

midlineshifting dapat dihitung dengan menarik garis lurus dari crista galli

ke protuberamtia occipitalis interna, tegak lurus dengan septum pellucidum (pada foto CT scan potongan axial t

erlihat ventrikel tertius).

5. Mencari tanda patah basis crania.

6. Menentukan ada tidaknya tanda edem.

7. Kesimpulan hasil pembacaan, disebutkan dari yang paling memiliki arti klinis penting diikuti oleh hal yang

lain.

Sumber: Snoek J, Jennett B, Adams JH, et al: Computerized tomography after recentsevere head injury in

patients with acute intracranial hematoma. J Neurol Neurosurg Psychiatry 42:215-225, 1979

Method for interpretation.

Underlying principles and
terminology
Computed tomography (CT) scanning involves the use of X-rays to take cross-sectional images of
the body. This is possible as different tissues interact with X-rays in different ways. Some tissues will
allow the passage of X-rays without influencing them much, whilst other tissues will exert a more
significant effect. The extent to which a material can be penetrated by an X-ray beam is described in
terms of an attenuation coefficient which assesses how much a beam is weakened by passing through
a voxel of tissue (voxel = volumetric pixel).

These values are frequently expressed as Hounsfield units (HU). Distilled water at standard
temperature and pressure has 0 HU, whereas air under the same conditions has -1000 HU.
Approximate values for various tissues are outlined in table 1 (these are not set in stone – only rough
estimates).

Table 1 ¹

Tissue Hounsfield units

Air -1000

Water 0

Cerebrospinal fluid +15

White matter +20 to +30

 Grey matter +37 to +45

Coagulated blood +50 to +75

Bone +200 to +3000

Windowing
This gives rise to a dilemma. An article published in 2007 concluded that although a human observer
could distinguish between up to 900 shades of grey, most scan viewing platforms show images in
256 shades ². If we are trying to visualise a range of units from -1000 to +3000 in terms of 256
shades of grey, for every incremental change in the greyscale there will be a difference of
approximately 15 HU. In short, there will not be enough contrast to reliably discern between
structures. This problem is negotiated with windowing.

Windowing (also known as grey-level mapping) is the process of changing the location and width of
the available greyscale in order to optimise discrimination between tissues. This is best explained
visually.

Below we can see a greyscale (from white to black) being assigned to the whole range of HU (from
air to cortical bone). We can imagine that this may not provide sufficient contrast to differentiate
between grey and white matter, and coagulated blood.

A
greyscale assigned the whole range of HU
Changing the width of the greyscale
Here we have changed the width (w value) of the greyscale – we are now visualising 200 HU in 256
shades. This gives us a much better contrast between CSF, brain matter and blood. However,
everything above blood will appear as white and everything below CSF will appear as black.

200
HU in 256 shades

Changing the centre of the greyscale

Now we have changed the centre (c or l value) of the greyscale – we are getting the same contrast but
at a different range of Hounsfield units. This process of changing the centre and width of the
greyscale is windowing.

An
example of changing the centre of the greyscale
This business of windowing may seem unnecessary to discuss. However, almost everyone will find
themselves fiddling with the windowing on a scan at some point. Hopefully, some understanding of
what this is actually doing will help you achieve the best contrast in an image.
Confirm details
As with the interpretation of all studies, the first step is to confirm you have the correct patient and
scan.

Check the following details:

Patient name, hospital number and date of birth

Date and time the scan was acquired
Previous scans (if available) for comparison

The appearance of tissues on a CT scan is described in terms of ‘density’. Darker structures are
‘hypodense or low density’; brighter structures are ‘hyperdense or high density’.

Blood Can Be Very Bad is a mnemonic that can be used when faced with interpreting a CT head
scan:

Blood
Cisterns
Brain
Ventricles
Bone

Think of this approach as a framework for a quick review of a scan – it won’t turn you into an
experienced radiologist! It’s important to recognise that more subtle signs might still be overlooked.
Furthermore, you should work through the entire system even if you spot something obvious early on
(e.g. if you see a large extradural haematoma, still check the cisterns, brain, ventricles and bone for
any other abnormalities).

Blood
Inspect for evidence of bleeding which may include:

Extradural haematoma (extra-axial)

Subdural haematoma (extra-axial)
Subarachnoid haemorrhage (SAH): may be very subtle. Remember a SAH can extend into
the ventricular system so always look at the posterior horns as blood may collect in the
dependant portion.
Intracerebral haemorrhage (intra-axial): this may be intraventricular (within the ventricles)
and/or intraparenchymal (within the brain tissue).
Bear in mind that blood will have varying appearances depending on the age of the collection, with a
more acute haematoma appearing hyperdense compared to a chronic bleed. Some bleeds may also be
very subtle and difficult to spot unless you look closely and this is one of the reasons why windowing
is so important.

Extradural haematoma
An extradural haematoma is a collection of blood which forms between the dura mater and skull
(they can also occur in the spine although this is much rarer). Extradural haemorrhage is often
preceded by a clear history of trauma, therefore you should look carefully for evidence of an
associated fracture.

The majority of cases of extradural haematoma result from trauma to the middle meningeal artery.
Extradural haematomas need to be identified and managed without delay, as they cannot cross skull
sutures and hence expand inwards towards the brain tissue. As a result, intracranial pressure can rise
rapidly and without prompt evacuation of the haematoma, brainstem herniation can occur.

Ext
3
radural haematoma 

Subdural haematoma
A subdural haematoma forms between the dura and the arachnoid mater and typically develops
secondary to trauma (as a result of tearing of bridging veins). In elderly patients who have
experienced a fall, the inciting traumatic event may be less obvious.
 

Su
4
bdural haematoma with midline shift 

Subarachnoid haemorrhage
A subarachnoid haemorrhage involves bleeding into the subarachnoid space (between the arachnoid
and pia mater). This space normally contains CSF and the vasculature of the brain. The most
common cause of subarachnoid haemorrhage is trauma, however, they can also develop
spontaneously (e.g. aneurysmal rupture).
 Su
barachnoid haemorrhage 5

Intracerebral haemorrhage
Intracerebral haemorrhage involves bleeding within the brain secondary to a ruptured blood
vessel. Intracerebral haemorrhages can be intraparenchymal (within the brain tissue) and/or
intraventricular (within the ventricles).
 Intr
acerebral haemorrhage (intraventricular and intraparenchymal)

Cisterns
There are four key cisterns that which should be assessed for effacement, the presence
of blood and asymmetry:

Ambient cistern: surrounding the midbrain.

Suprasellar cistern: superior to the sella turcica.
Quadrigeminal cistern: adjacent to the corpora quadrigemina.
Sylvian cistern: across the insular surface and within the Sylvian fissure.
 An
example of some of the subarachnoid cisterns made more visible due to the presence of blood
from subarachnoid haemorrhage 5

Brain
Sulcal effacement
Sulcal effacement is the term used to describe the loss of the normal gyral-sulcal pattern of the brain,
which is typically associated with raised intracranial pressure.

Grey-white matter differentiation

On a normal CT head scan, the grey and white matter should be clearly differentiated. Loss of this
differentiation suggests the presence of oedema which may develop secondary to a hypoxic brain
injury, infarction (e.g. ischaemic stroke), tumour or cerebral abscess.
 Hy
poxic brain injury 6

Abnormal shifts of brain tissue

Look for abnormal shifts of brain tissue and/or herniation:

Subfalcine: beneath the falx cerebri

Uncal: inferomedial displacement of the uncus
Transcalvarial: brain shift through the calvarium
Transtentorial: may be superior or inferior
Tonsillar: downward displacement of the cerebellar tonsils into the foramen magnum

Hypo/hyperdense foci

Hypodense foci
Hypodensity on a CT head may be due to the presence of air, oedema or fat:

Oedema is often seen surrounding intracerebral bleeds, tumours and abscesses.

Pneumocephalus (air within the cranial vault) may be noted after neurosurgery or adjacent to
the inner table in cases of calvarial fractures.
Pneumocephalus 7

Cerebral metastases with oedema 8

Hyperdense foci
Hyperdensity on a CT head may be due to the presence of blood, thrombus or calcification:

A hyperdense middle cerebral artery (MCA) is sometimes noted in total anterior circulation
strokes (TACS) and indicates the presence of a large thrombus within the vessel.
 Hy
perdense right middle cerebral artery (MCA) 9

Tumour

Radiological features
The radiological features of a tumour will vary depending on the histological diagnosis.

Any of the following may be noted in our around a tumour:

Surrounding haemorrhage: may be hyperdense, isodense or hypodense depending on the

maturity of the bleed.
Calcification: hyperdense on CT and typically associated with meningiomas.
Mass effect: displacement of tissue due to the tumour or associated bleeding/oedema.
Oedema (hypodense): may be present in the brain tissue surrounding the tumour.

Contrast administration
Following intravenous administration of a contrast medium, lesions may show no change, or
demonstrate some form of contrast enhancement (e.g. homogenous enhancement, ring-enhancement
etc):

Homogenous enhancement occurs in a number of lesions including meningiomas and highly

vascular tumours.
 Ring-enhancement is typically associated with cerebral abscesses and some types of cerebral
metastases (e.g. melanoma).

Cerebral metastases with oedema 8

Meningioma 10

 
Ventricles
Intraventricular haemorrhage and the choroid plexus
Intraventricular haemorrhage appears on a CT head as hyperdensity within the ventricular system.

However, not all hyperdensity in the ventricles represents acute bleeding: the choroid plexus is
frequently calcified and often appears bright on CT. Remember that blood is fluid and hence will be
dependent within the ventricles, therefore if you note a high-density signal within the lateral walls of
the ventricles it is likely to represent the choroid plexus.

Intracerebral haemorrhage (intraventricular and intraparenchymal)

Choroid plexus 11

Hydrocephalus
Hydrocephalus is a term that describes the abnormal accumulation of CSF in the ventricles of the
brain. It can be broadly divided into communicating (i.e. non-obstructive) and non-communicating
(i.e. obstructive). An early sign of hydrocephalus on a CT head is dilation of the temporal horns.
 Hy
drocephalus: enlarged ventricles (ventriculomegaly) 12

Ventricular effacement
Ventricular effacement describes a thinning in the appearance of the ventricles. This may result from
cerebral oedema secondary to a mass or an intracranial haemorrhage. The shift in CSF that occurs in
these cases follows the Monro-Kellie doctrine.
 Ve
ntricular effacement secondary to cerebral metastases 8
Monro-Kellie doctrine

The cranium, enclosing the brain, forms a fixed space comprising three components: blood,
cerebrospinal fluid, and brain tissue. These components remain in a state of dynamic equilibrium,
therefore any increase in any one of them results in a compensatory decrease of the other two. Once
the other compartments have reached their point of maximum compensation, any further increase in
the size of one results in increased intracranial pressure.

Other intraventricular pathology

Cysts
Tumours
Infective lesions

Bone
Assess the bones of the skull using the appropriate windowing.
Look for fractures of the calvarium and skull base. Subtle areas of low density within the inner table
of the skull may represent small locules of air in the soft tissue windows. Careful evaluation to look
for subtle fractures here is essential.

Superficial soft tissue injury may be associated with underlying fractures.

Sk
13
ull fracture (note the use of bone windowing)