DEPARTMENT OF PAEDIATRICS

G . R . MEDICAL COLLEGE , GWALIOR (M.P)

HOW TO READ CT-SCAN OF BRAIN

Chairperson
Dr. Ajay Gaur
M.D., Ph.D., F.I.A.P.
Professor & Head of Department Guide
Department of Pediatrics
G.R. Medical College, Gwalior Dr. R D Dutt
M.D.,PGDDN,MBA (Hospital
Presented by Administration) Professor
Dr. Sourabh Baghel
P.G. Student
Department of
Pediatrics


G.R. Medical College, Gwalior

MUST FOR EVERY PHYSICIAN

 CT HEAD is an extremely useful diagnostic tool used routinely in care

of Admitted & Emergency patients .
 The treating physician needs to be able to accurately interpret and
act upon certain CT findings without specialist (eg Radiologist)
assistance , because many disease processes are time dependent
and require immediate action .
 It has been shown that even a brief educational intervention can
significantly improve the physician’s ability to interpret cranial CT
scans .
SCHEME OF THE LECTURE

 BASIC PRINCIPLES OF CT SCAN

 NORMAL NEUROANATOMY AS SEEN ON HEAD CT SCAN
 ILLUSTRATION
 PATGHOLOGICAL TOMOGRAPHS
BASIC PRINCIPLES OF
CT SCAN

A
 HISTORY

 Sir Godfrey Hounsfield -1997

 NOBEL PRIZE in 1979
 Original scanner took approximately 6 minute to perform a rotation (one slice)
6 and 20 minutes to reconstruct. Despite many technological advances since
then , the principles remains the same .
 PARTS

 1) Gantry – which houses X ray apparatus

 2) X ray tube –akin to that in a X ray machine
 3) Detectors
 4) Patient Couch
 5) Viewing console
 PRINCIPLE

 Uses X ray applied in sequence of slices across

the organ.
 Images reconstructed from X ray absorption data
 X ray beam moves around the patient in a
circular path
 CT scan provides a 3D display of the intracranial
anatomy builds up from a vertical series of
transverse axial tomograms
 Each tomogram represents a horizontal slice
through the patient’s head
 BASICS….
 Two types of CT commonly available 1)single slice 2) multi slice
 Multi slice uses slip ring working as spiral CT SCAN
 Nowdays The first image Tomograph contains full volume of particular body
part with isometric resolution from which all the different section taken out –
AXIAL;CORONAL;SAGITTAL; OBLIQUE; 3D SCAN .
 By using DICOM (Digital Imaging and Communication in Medicine) which is
an software .
 BASICS….
 X-RAYS ARE ABSORBED TO DIFFERENT DEGREES BY DIFFERENT TISSUE
 Always describe CT findings as densities – ISODENSE / HYPODENSE
/HYPERDENSE
 Higher the density = whiter is the appearance
 Lower the density = darker the appearance
 Brain is the reference density
 Anything of the Density as Brain = Isodense
 Higher density than Brain= Hyperdense( skull is the best
example)
 Anything darker(lower density) than brain = Hypodense (CSF &
Air are classical example)
 HOUNSFIELD UNITS

 Related to composition & nature of tissue

 Represent the density of tissue
 Also called as CT number
 Appearance of various tissues on computed tomography(CT)
brain

TISSUE COLOR ON CT HOUNSFIELD UNIT

SCAN
AIR DARKEST BLACK ---1000
FAT DARK BLACK ---70
WATER BLACK 0
CSF BLACK +8
WHITE MATTER MEDIUM GRAY +30
GRAY MATTER LIGHT GRAY +45
MUSCLE LIGHT GRAY
SUBACUTE BLOOD LIGHT GRAY
ACUTE BLOOD WHITE +70
BONE, CALCIFICATION, METALLIC BRIGHT WHITE +1000
Indications for CT BRAIN & HEAD
ETIOLOGY INTERPRETATIONS
Trauma Followed by IC bleeding appear
Hyperdense
Hypoxic Injury Hypodensity due to gray matter
white matter diferentiation
Infarction Hypodense
Edema Hypodense
Neoplasms Hypodense
Cysts Hypodense (dark)
Calcification Hyperdense (bright) common causes of I/C
calcifications
Neurocysticercosis
TORCH (toxoplasmosis,other
agents,rubella,cytomegalovirus,herpes)
Tuberous sclerosis
Sturge-weber syndrome(tram track cal)

Bone (fracture-intraarticular#, Hyperdense

communited #,bone tumor ,potts
spine)
Indications for CT BRAIN & HEAD
ETIOLOGY INTERPRETATIONS
BLOOD VESSELS Followed by IC bleeding appear
Hyperdense(subacute, acute)
Hypodense (chronic infarct)
Congenital malformation of BV
Cytic fibrosis
Abdomen Metastasis
Abscess
Complications of acute appendicitis
Inflammatory bowel disease
Lungs Complications of pneumonia
Pulmonary Embolism
Diffuse lung disease
Chronic dyspnoea
INTERPRETATION OF BRAIN
 Firstly recognise basic structure on CT brain .
 It is important to identify the cisterns- suprasellar cistern ,
quadrigeminal cistern , ambient cistern and infrapontine
cistern .
 While reading the CT BRAIN it is advisable to follow few steps
for details :
 *Compare the right and left side of brain
 **Midline : look for the midline shift
 ***Look at anatomy
 ****Subdural window : to look for subdural collection .
What to look at anatomy ?

 Braintissue : Gray matter , white matter

and lesions.
 Cerebrospinal fluid (CSF) spaces : Ventricle ,
basal cisterns , sulci ,and fissures.
 Skulland soft tissue : Scalp swelling ,
fractures, sinuses, orbit and intracranial air.
Spinal Cord- the spinal cord is the continuos with medulla oblongata near the
foramen magnum at the base of skull .
VERTEBRAL ARTERY :- HYPODENSE , INTADURAL OR
INTRACRANIAL SEGMENT
-FROM THE DURA AT THE LATERAL EDGE OF THE POST ATLANTO
OCCIPITAL MEMBRANE TO THEIR CONFLUENCE ON THE MEDULLA
OBLONGATA TO FORM BASILAR ARTERY
MEDULLA:- EXTENSION FROM LOWER BORDER OF PONS TO PLANE JUST ABOVE ;1ST CN
ARISES
ANT- CLIVUS & MENINGES
POST- VALLECULA OF CEREBELLUM
PONS:- EXTEND – FROM CRANIAL END OF MEDULLA TO CEREBRAL PEDUCLE OF
MIDBRAIN
ANT – CLIVUS SEPERATED BY BASILAR ARTERY
LAT- MIDDLE CEREBELLAR PEDUNCLE
POST- FOURTH VENTRICLE
OCCIPITAL LOBE:- SMALLEST OF ALL FOUR LOBE
POST TO TEMPORAL LOBE RESTS ON TENTORIUM CEREBELII
UNCUS :- HOOK SHAPED INNERMOST PART OF THE TEMPORAL LOBE
(COMMON ORIGIN OF TEMPORAL LOBE SEIZURES, UNCLE HERNIATION )
MIDBRAIN:- ANT- INTERPEDUNCULAR STRUCTURE
POST- SPLENIUM OF CARPUS CALLOSUM ; THE GREAT CEREBRAL VEIN;PINEAL
BODY;POST ENDS OF RT & LT THALAMI
INSULA:- a small region of the cerebral cortex located deep within the lateral sulcus,
which is a large fissure that separates the frontal and parietal lobes from the temporal
lobe.
SIGNIFICANCE:- “Loss of insular ribbon" sign denotes loss of grey-white interface in
the insular cortex secondary to edema due to an ischemic insult. This is an early sign of
acute MCA infarction.
THIRD VENTRICLE :- LAT WALL- THALAMUS / HYPOTHALAMUS
ANT- FORNIX/LAMINA /ANT COMMISSURE
POST- PINEAL BODY
INTERNAL CAPSULE :- V SHAPED LARGE BAND OF FIBRES
ANT LIMB – SANDWICHED B/W – LATERAL: LENTIFORM NUCLEUS & MEDIAL:
CAUDATE NUCLEUS
POST LIMB-SANDWICHED B/W – LATERAL: LENTIFORM NUCLEUS & MEDIAL:
THALAMUS
 BASAL GANGLIA :- COMPRISES OF- CAUDATE NUCLEUS;PUTAMEN;GLOBUS
PALLIDUS; AMYGDALOID NUCLEUS (HYPODENSE IN COMPARE TO INTERNAL
CAPSULE )

THALAMUS :- SITUATED IN THE LATERAL WALL OF THIRD VENTRICLE & IN

FLOOR OF THE CENTRAL PART OF LATERAL VENTRICLE.
CEREBRUM:- FALX CEREBRI – THE FALX IS INFOLDING OF MENINGES
WHICH LIES IN MIDLINE AND SEPERATES THE LEFT & RIGHT CEREBRAL
HEMISPHERE
CETRAL SULCUS –RUNS ANTEROINFERIORLY, SEPERATES FRONTAL LOBE IN
FRONT & PARIETAL LOBE POSTERIORLY
LATERAL SULCUS-SEPERATES TEMPORAL INFERIORALY FROM FRONTAL
PARIETAL LOBE
 PATHOLOGICAL TOMOGRAPHS

 HEMORRHAGE (SDH EDH ICH)

 INFARCTION
 EMBOLISM
 CALCIFICATION
 TUBERCULOMA
 ENCEPHALITIS
 HYDROCEPHALUS
SUBDURAL HEMORRHAGE:- Chronic (low density Hypodense)
Subdural hematoma with concavoconvex tomograph results from venous
bleeding , from torn cerebral vein where they enter the superior sagittal
vein.
EXTRADURAL HEMORRHAGE :- Hyperdense biconvex
tomograph showing an extradural haemorrhage is caused by tearing of
branches of middle meningeal artery , typically occure in pterion region blood
collects between the periosteal layer of dura and the calvaria )
INFARCTION :- WEDGE SHAPED HYPODENSE INFARCT NOTED IN
RIGHT FRONTO-PARIETAL REGION
TUBERCULOMA:- AXIAL NONCONTRAST CT
IMAGES SHOWS TWO CALCIFIED LESIONS IN RIGHT
FRONTAL LOBE WITHOUT EDEMA OR MASS EFFECT
CALCIFICATION:- HYPERDENSE FOCII NOTED IN
BILATERAL CHOROID PLEXUS SUGGESTING CALICIFIED
LESIONS
ENCEPHALITIS :- Figure 1 is a computed tomography (CT)
scan of a normal brain. Figure 2 is a CT scan that shows an
accumulation of contrast material in infected areas and around the
brain from encephalitis.
NEUROCYSTICERCOSIS:-post contrast CT demonstrates
numerous calcified 3-7mm lesions some of which demonstrate
surrounding oedema. These lesions also demonstrate surrounding contrast
enhancement.
THROMBOSIS :- Hyperdense right transverse, straight and
superior sagittal sinuses. VENOUS THROMBOSIS
HYDROCEPHALUS:- the abnormal accumulation of CSF in the
ventricles of the brain showing Hypodense Area. An early sign of
hydrocephalus on a CT head is dilation of the temporal horns.
 Reference
 Clinical Approach to Pediatric Neurology Author Jaya Shankar Kaushik ; Piyush Gupta

 Dr Anil Kumar MD Radiodiagnosis Ex SR PGI Chandigarh Consultant Radiologist Vidya Health

Imaging .
 Gray’s Anatomy for HEAD ,NECK AND BRAIN .
 Dr Kunal Mahajan Assistant Professor Cardiology at IGMC Shimla .
 ATLAS of HUMAN ANATOMY 7TH Edition FRANK H. NETTER, MD
 BD Chaurasiya Human Anatomy Brain Neuroanatomy
Thankyou…