Dr Hj Asmah Yusuf Sp.

Rad
Dr Evo Elidar Hrp Sp.Rad

The Skull
The standard projections
are :
1. The lateral view
2. The PA view

Routine method of study of Skull X

ray
Examine : the inner and outer table
Examine trabeculasi and densitas
bone
Examine: Sutures
Examine :Vascular markings
Examine : sella
Examine : intracranial kalsifikasi

Normal intracranial
kalsifikasi
1.Pineal
2.Habenula
3.Choroid plexus
4.Dura (falx,tentorium).
5.Ligaments (petroclinoid and interclinoid)
6.Pacchionian bodies
7.Basal ganglia and dentate nuclei
8.Pituitary gland
9.Lens

Normal Skull Films

AP Skull-X Ray

Lateral Skull-X Ray

AP view

Lateral view

Abnormal
Skull
1.Fracture.
2.Metastasis
3.Congenital disorders
4.Kalsifikasi
5.Raised intracranial
pressure

Metastasis

Lesi lytik

Lesi lytik luas

Multiple Myeloma

Congenital disorders

Scaphocephaly

Scaphocephaly

Scaphocephaly

Raised intracranial pressure

Hydrocephalus

Raised intracranial pressure

Computed tomography

CT schematic

INDICATION

1.HEAD INJURY
2.CEBROVASLULAR DISEASES (CVD)
3.BRAIN TUMOR
4.CEREBRAL INFECTION
5.CONGENITAL DISORDER
6.CEREBRAL ATROPHY OR
7.DEGENERATIVE DISEASES

THE BRAIN LAYER ANATOMY

SKIN
BONE
EPIDURAL
DURAMATER
SUBDURAL
ARACHNOID
SUBARACHNOID
PIAMATER

T
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B
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L
A
Y
E
R
A
N
A
T
O
M
Y

ANATOMY BRAIN

HEAD Scan NORMAL

High density (hiperdens) : densitas lesi

lebih tinggi dari jaringan normal.
Isodens :densitas lesi sama dengan
jaringan sekitarnya
Low density(hipodens): densitas lesi
lebihrendah dari jaringan normal

Skull Fractures
-Associated with pneumocephaly
(air in head) rarely can develop
tension pneumocephalus
-Only significant if open to
air,cosmetically disfiguring(greater
than full thickness displacement)
or

associate with air sinus

(for risk of infection) or
underlying bleed
(epidural hematom)
-Treatment ONLY for
cosmetic orprevention of
infection ( if open
to air or to an air sinus

Fracture

Intracranial Hemorrhage
Intracranial hemorrhage can be
classified according to the space
occupied by the blood:
Epidural Hemorrhage
Subdural Hemorrhage
Subarachnoid Hemorrhage
Intraparenchymal Hemorrhage
Intraventricular Hemorrhage

Intracranial Hemorrhage:
Types

Epidural Hemorrhage
Between skull and dura, limited by
periosteal layer so stops at sutures of
skull and thus biconvex (lens) shaped
Due to middle meningeal artery
tear,often associated with skull
fracture

E
P
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H
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O
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Subdural Hematoma
Occur in the 4 As : alcoholic,anticoagulant-treated,aged and abuse victims
(shaken baby syndrome)
Between dura and archnoid of brain
Follow contour of brain so Crescent
Shape.
Due to cortical bridging vein tear as
hemoglobin broken down,blood changes
color on CT scan and can be easily mised
(see sub acute )

Usually patients with

subdural hematoma have
worse Brain injury than
epidural hematoma
Small size bleeds can be
spontaneusly absorbed by
the body,but if midline
shift is presentSurgical
evacuation

Subdural Hemorrhage

ACUTE

SUB ACUTE

CHRONIC

Subarachnoid
Hemorrhage

Subarachnoid
hemorrhage is generally
feathery in appearance
on CT scan, as itsmixed
in with cerebrospinal fluid

The MOST COMMON cause of

subarachnoid haemorrhage is
1.Trauma
2.The 2 nd and 3 rd most
common causes are
aneurysms or arteriovenous
malformations
No intervention is generally
performed for subarachnoid
hemorrhage alone.

However ,subarachnoid

hemorrhage can cause

hydrocephalus (due to
obstruction of CSF flow)
or vasospasm (due to ?
blood product irritating a
vessel) in delayed fashion

S
A
H

S
A
H

Intraparenchymal
Hemorrhage
Called Contusions in trauma
bruising of the brain
Coup ( direct injury of brain impact)
or contrecoup (injury due to brain
hitting skull opposite side as skull
decelerates but brain doesnt)-usualy
temporal/frontal.

-Can develop extreme amount

of edema or blossom,so must
follow closely with repeat CT
scans
-Can be caused by
hypertensive hemorrhage in
characteristic locations
(basal ganglia,thalamus pons,
cerebellum) or arteriovenous
malformations

-In older patients (> 60 )

can be caused by
cerebral amyloid
angiopathy, usually in
a lobar location
-Surgical evacuation if
excessive mass effect

Intraparenchymal
hemorrhage

Intraventricular
Hemorrhage
-Usually due to extension of
intraparenchymal bleed (most
Commonly from hypertension
-Treatment depends on whether
hydrocephalus develops then
patients may need ventriculostomy
placement

Intraventricular
hemorrhage

STROKE
Stroke is disease
cerebrovasculer (venous of
brain) which marked with
death tissue brain (infarct
cerebral) happened because
the less of oxygen and blood
strem to brain.

Stroke divided to become two

type
1.Stroke ischaemi blood
stream to brain is desisted by
artherosclerotic (heaping of
cholesterol at venous wall) or
blood clot which have corking
an vein to brain
2.Stroke hemorrhage venous
broken causing pursue normal
blood stream and blood seep
into area brain in the

Cerebral infarct

Infarct pons

Cerebral hemorrhage

Hydrocephalus
Normal CSF flow is from lateral
ventricles to third ventricle, via
aquaduct silvii to fourth V, then
through foramina of
magendieand luschka to
subarachnoid space,then
absorption via arachnoid
granulations into the superior
sagittal sinus

-Any obstruction on this pathway

can cause hydrocephalus
-Treatment is temporarily by
diverting spinal fluid via
ventriculostomy catheter
permanently,a shunt ( e.g.
ventriculoperitoneal , or VP
shunt)

H
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BRAIN TUMOURS

BRAIN TUMOURS

Brain Tu (pylocytic
astrocytoma)

Brain tumors

Cerebral abscess

Pada kontras tampak ring enhancement

Encephalitis

 OLEH : Dr Hj. Asmah Yusuf

Sp.Rad
Dr. Elidar Hrp
Sp.Rad

MRI
Beda CT scan VS MRI
CT MRI
Biaya
mahal
P.Rad
Prinsip

Mahal
sedang - tinggi
X-ray

Waktu
Biasa +/- 5 mnt
Soft tissue
tidak baik
Tulang
Baik
Perub-imag
(-)
beberapa
potongan

Sangat
(-)
Magnet &
gel radio
+/- 30 mnt
sangat baik
tidak baik
images
potongan

MRI : Normal brain (axial)

MRI : Normal brain (sagital)

MRI : normal brain (coronal)

MRI ( T 1 and T2)

MRI VS CT
Encephalitis :11(MRI)
Infarct Acute : 82 %

3 (CT)
58 %

CT : -Beberpa jam pertama normal

pada : 60 % pasien walau klinis
sdh ada
-Scan ulang 48 jam setelah stroke
area hypodense ( dark)

MRI lebih sensitif dibanding CT,

Beberaoa menit setelah klinis /
sympton Gambaran MRI (+)

Cerebral
Infarct

CT

T1 MRI

T2 MRI

Cerebral infract

Encephalitis

Encephalitis

Subarachnoid hemorrhage

Brain tumor (sagital)

MRI : Brain tumor

Dandy Walker malformation

Chiari Malformation type II