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Understanding CT Scans in Neurology : Part 1

Learning Objectives: Part 1

To understand how computerised tomography works

To understand the Indications for brain CT scans


The appreciate the Advantages and Disadvantages of CT scans To become familiar with a Normal Scan of the brain To begin to Interpretation abnormalities on CT scans and look at what neurological pathologies may prevail

How does computerised tomography work?

Instead of sending out a single X-ray through your body as with ordinary X-rays, several beams are sent simultaneously from different angles. The pictures produced by CT scans are called tomograms. CT produces a volume of data which can be manipulated, through a process known as windowing, in order to demonstrate various structures based on their ability to block the X-ray/Rntgen beam.

For example; Beams that have passed through less dense tissue such as the lungs will be stronger, whereas beams that have passed through denser tissue such as bone will be weaker.

Although historically the images generated were in the axial or transverse plane (orthogonal to the long axis of the body), modern scanners allow this volume of data to be reformatted in various planes or even as volumetric (3D) representations of structures.

CT scanning of the brain will look at the densities of grey and white matter, CSF, blood and bone can be distinguished, as can abnormal tissue such as haemorrhage, tumour, oedema and abscess.

Because of the artifact from the surrounding bone, CT scanning is not ideal for the examination of the posterior fossa and the spinal cord.

Enhancement of the images, produced by the intravenous injection of a contrast medium, may add precision to the diagnosis. This is often helpful in identifying pathologies such AVMs, acoustic neuromas or intracerebral abscess. Intravenous contrast can show areas of increased vascularity or impairment of the blood brain barrier.

Indications for Brain CT

Stroke Ischaemic / haemorrhagic TIA Subarachnoid haemorrhage Head Injuries Subdural, Extradural, Intracerebral contusions, fractures Tumour primary / secondary Abscess Meningitis (pre lumbar puncture to rule out raised pressure Sometimes MS (MRI better for showing subtle lesions/ plaques

Evaluation of ventriculo-peritoneal shunts Seizures (if suspected to be due another pathology such as a tumour) Neuro psychiatric disorders evaluation of dementia to categories between vascular dementia and Alzheimers Collapse with no cardiac cause

Advantages and Disadvantages of CT scans

Advantages

Cheaper investigation Quicker than MRI Less contraindications than MRI Able to scan ventilated patients The option for contrast

Disadvantages

Radiation dose Difficult to spot pathologies in the posterior fossa due to the amount of bone artefact The older CT scanners images are generated in the axial or transverse plane only Doesnt always pick up some white matter diseases such as MS

A Normal Brain CT Scan

It is worth spending a few minutes familiarising yourself with the appearances of a normal CT scan. It is much easier to detect abnormalities once you are accustomed to normal appearances. You should imagine that you are viewing it as if looking up from the patient's feet. Therefore, the patient's left is to the right of the screen.

Interpretation of CT scans

Contrast Agents

The first question you should ask yourself is;

Has contrast been used?

Contrast agents are often used to illuminate certain details of anatomy more clearly. It will make any vascular areas appear much whiter. It is important to know whether contrast has been added before analysing the scan as you may misinterpret the pathology. For example; you may think youve identified a fresh bleed when actually its caused by a tumour.

*Note the following points 1-6 before contrast enhancement;

Appearance is Dependent on Age

Atrophy can be generalized, which means that all of the brain has shrunk; or it can be focal, affecting only a limited area of the brain and resulting in a decrease of the functions that area of the brain controls.

So when looking at an older brain on a CT, it often appears to have more space than that of a younger brain. This explains why pathologies can present atypically and it can take time for the symptoms to develop.

Tissue Density

CT scanning of the brain will look at the densities of grey and white matter, CSF, blood and bone can be distinguished, as can abnormal tissue such as haemorrhage, tumour, oedema and abscess.

Exercise 1

Put the following structures/tissues in the columns below; Then put them in order of density within each column ie; least dense to most dense
Low Attenuatio n

High Mixed Attenuatio Density n

High Attenuation
Dense Structures / areas Calcification / Bone Fresh Blood (Up to 7 days) Masses (eg. tumours, abscess) Adding contrast will enhance these suspected areas of abnormalities AVMs/ Aneurysms (Calcification of the pineal gland, choroids plexus, basal ganglia and falx may occur in normal scans).

Mixed Density
Tumour Abscess AVMs Contusion Haemorrhagic

Low Attenuation
Less Dense structures/ areas Infarcted tissue Fluid Oedema (as has water in it) Old blood resolving haematoma Abscess Encephalitis Air / Fat ( you can not tell the difference between the two on CT) Fat is found behind the eyes in the orbits

infarct

When looking at abnormal tissue density you can start by identifying the site of the lesion and whether it lies within or without the brain substance.

Note the MASS EFFECT Midline shift Ventricular compression Obliteration of the basal cisterns, sulci

Ventricular System

Size Position Compression of one or more horns ie. frontal temporal or occipital Diseases of the ventricular system include abnormal enlargement (hydrocephalus) and inflammation of the CSF spaces (meningitis, ventriculitis) caused by infection or introduction of blood following trauma or hemorrhage.

Midline shift to the R effacement of the third ventricle with dilatation of both lateral ventricles

Hydrocephalus
Hydrocephalus can be due to many reasons such as haemorrhage, abscess, aqueduct stenosis and infection. The pattern of the ventricular enlargement on a CT can help determine the cause. Lateral and 3rd ventricular dilation with a normal 4th ventricle may suggest aqueduct stenosis. Lateral and 3rd ventricular dilation with deviated or absent 4th ventricle suggest a posterior fossa mass. Generalised dilation suggests a communicating hydrocephalus.

Width of the Cortical Sulci and the Sylvian Fissures

Lesions and mass effect can cause obliteration of the sulci and sylian fissures.

Skull Base and Vault


Hyperostosis Osteolytic lesion (Soft spot or hole in bone caused by cancer cells). Remodelling Depressed Fracture Comminuted Depressed Fracture of the left parietal bone contusion and air in it

Multiple Lesions

May result from; Tumours metastases, lymphoma Abscesses Granuloma Infarctions Trauma contusions axonal injuries

Multiple Lesions

multiple 2-3 cm diameter loculated cystic lesions consistent with multiple abscesses (dark areas with rims of enhancement).

***After contrast enhancement;

Vessels in the circle of willis appear in the basal slices. You should look at the extent and pattern of the contrast uptake in any abnormal region.

Some lesions may only appear after contrast enhancement.

Windowing

Bone window
Open anterior fontanelle is noted at the top of the both images. Large right parietal scalp swelling Large right parietal fracture and smaller left parietal fracture Occipital fractures

WASH CT examples Case Examples

Consider:

Has contrast be added Age Density of tissues Ventricular system Width of cortical sulci and Sylvian Fissure Skull base and vault Windowing

Example 1

82 year old female. Found by relative in bed unable to move. Complete R sided weakness with facial drop. Aphasic

Example 1 Report; Without Contrast

Large subacute infarct within the left middle cerebral artery territory. No haemorrhage or haematoma. No mass lesion or hydrocephalus

Example 2

84 year old female history of falls found collapsed with decreased GCS and confusion.

Example 2 Report; Non Contrast

There is a large left sided acute on chronic subdural haematoma which has acute blood layered within it

It extends over the left frontal and parietal lobe up to the vertex. Its maximum depth is 3.3cm and there is underlying sulci effacement.
There is associated midline shift of 11mm to the right, with distortion and displacement of the adjacent left lateral ventricle. There is ventricular dilatation with dilated temporal horns in particular. At present the basal cisterns are still patent. No underlying fracture. Conclusion: Large left acute on chronic subdural haematoma with midline shift and developing hydrocephalus. The images were sent to Hurstwood Park.

Example 3

51 year old male. Sudden onset severe headache, collapse L sided paralysis with acute confusion. L visual neglect

Example 3 Report; Without Contrast

There is a large temporal lobe haematoma with intraventricular subarachnoid extension Some slices suggest that there may be a more organised component of this mass- that is a giant aneurysm. There is also noticeable hydrocephalus

Example 4

30 year old male fell down a flight of stairs whilst under the influence of alcohol. Loss of consciousness. When admitted decreased GCS disorientated and non compliant and moving all four limbs.

Example 4 Report; Without Contrast

There is a fracture of the left parieto-temporal bone extending through the mastoid air cells and mastoid process and a further fracture of the left occipital bone extending down to the skull base. There are pockets of air around the fracture sites and an associated extradural haematoma measuring up to 2cm in depth. There is also a subdural component tracking along the left cerebral convexity. Multiple contusions are noted in the right temporal lobe (contrecoup injury) and the frontal lobes bilaterally. There is also subarachnoid blood throughout both cerebral hemispheres with significant cerebral oedema, effacement of sulci and some compression of the left midbrain. The CSF spaces around the foramen magnum appear patent. Blood is also noted in the sphenoid sinuses. Conclusion: Left parieto-temporal and occipital fractures with an associated extradural haematoma and multiple contusions. Subdural and subarachnoiod blood is also noted and there is significant cerebral oedema.

Example 5

65 year old man, known alcoholic fell down a flight of stairs. Loss of consciousness. Found after 12 hours with complete L sided weakness with R sided upper limb weakness.

Example 5 Report; Without Contrast

There is evidence of a large, acute on chronic right subdural collection which approaches 3 cm in maximal thickness. It extends from the right temporal fossa to the vertex and is associated with marked local mass effect with compression of the ipsilateral lateral ventricle and approximately 2.5 cm of midline shift towards the left. There is evidence of soft tissue scalp swelling over the right temporoparietal region but the underlying bony vault is intact. Conclusion : Large acute on chronic right subdural collection associated with significant midline shift. Urg ent neurosurgical referral recommended.

Example 6
82 year old male with gradual onset of decreased mobility and increased confusion over several weeks. When arrived in hospital completely immobile L sided weakness with increased tone L upper limb

Example 6 Report;
Without and With Contrast

Within the right frontal lobe there is an enhancing lesion. This has marked surrounding oedema causing effacement of the right lateral ventricle with associated midline shift. No intra or extra axial bleed Post MRI and biopsy diagnosis given ; Meningioma

Example 7
60 year old man during surgical procedure to coil a cerebral aneurysm unfortunately went into vasospasm and presented with complete L sided weakness

Example 7 Report; Without Contrast

There is an extensive subarachnoid blood and early ventricular dilation

Nearly 85% of non-traumatic SAH is caused by ruptured aneurysms Intracranial aneurysms that lead to SAH typically occur at branch points of intracranial blood vessels near the Circle of Willis, a ring of connected blood vessels that supply the majority of the cerebral circulation

Example 8

58 year old male with sudden onset of neck pain and severe headache for 2 hours followed by a new onset of seizures.

Example 8 Report;
Without and With Contrast
There are vascular tangles which are serpiginous and hyperdense with and without contrast. They are further enhanced with contrast. These vascular tangles present as Arteriovenous Malformations in the temporal-occipital region

Subarachnoid Haemorrhage
Cisterns
Blood in the Intrahemispheric space Ventricle Size Blood? Hydrocephalus?

Blood in the Insular Space (Sulci) Increased attenuation is seen in the CSF spaces - blood may be widely spread over the cerebral hemispheres (look closely at the Sylvian fissure and interhemispheric fissures), in the basal cisterns or in the ventricular system.

Extradural Haemorrhage
Temporal Fracture

Contralateral ventricular dilation

Biconvex shape limited by attachments of dura to skull Mass effect

Midline shift

Acute Subdural

High attenuation May spread more widely in the subdural space, Crescentic appearance More irregular inner margin.

A subacute subdural hematoma is approximately 5-7 days in age

Consequently often hypodense crescentic collections, can cause mass effect. The collection may be more complex with layering of more dense material posteriorly and a gradual transition. Expansion due to osmosis may tear further veins leading to recurrent bleeds;.

Isodense collections may be better demonstrated after contrast as the density will then be less than that of the brain. However this is rarely a problem with more modern scanners.

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