CT Scan Basics

LEARNING OBJECTIVES
Upon completion of this discussion, students

will be able to:
• Understand the basics of head CT imaging
• Identify and describe basic cerebral
anatomy
• Develop an approach to head CT
interpretation
• Identify pathologic lesions found on head
CT
CT BASICS
• CT uses x-rays
• Provides axial brain view
• CT scan measures density of the
.The
tissue being studied
standard reconstruction
for CT is axial reconstruction.
CT Brain Axial View
▪ CT uses x-rays to
make cross-sectional
axial images
▪ Right is on left
and left is on the
right
▪ Patient lying on a
stretcher with feet
coming toward you
and is slid through a
large open ring (CT • Lateral view of skull is shown with imaging planes indicated by
lines. The true horizontal plane is approximated by the
machine) orbitomeatal line, while the typical CT imaging plane is angled
slightly upward anteriorly
CT BASICS-DENSITY
Black
Structure/ Tissue Hounsfield units
Air -1000 to -600

Fat -100 to -60
Water 0
CSF +8 to 18
White matter +30 to 41
Gray matter +37 to 41
Acute blood +50 to 100
Calcification +140 to 200
Bone +600 to 2000
White
Hyperdense things on CT
ocular lens bone contrast (dye)
calcifications acute blood metal (bullets w/

streak artifact)
Isodense things on CT
• Note that white matter is

less dense than gray
matter and therefore:
white matter is darker
than gray matter
Gray matter (cerebral

cortex)
Gray matter (basal

ganglia)
White matter
Hypodense things on CT
fat
air
CSF
(water)
Normal Brain Anatomy
Eye Sella turcica

Optic nerve (contains pituitary
gland)
Sphenoid bone Petrous bone

Temporal lobe
Mastoid air cells
Pons
4th ventricle
Cerebellum
Frontal lobe
Interhemispheric fissure
Sylvian fissure
Middle cerebral artery
Temporal lobe
Lateral ventricle (temporal horn)
Suprasellar cistern
Perimesencephalic cistern
Midbrain
Quadrigeminal plate cistern
Cerebellum (vermis)
Occipital lobe
Frontal lobe
Lateral ventricle (frontal horn)
Caudate nucleus (head)
Sylvian fissure
Insula (cortex)
Lentiform nucleus
Internal capsule (post. limb)
Thalamus
Pineal gland (calcified)
Choroid plexus (calcified)

Occipital lobe
B- Bones
B- Bones
Approach to Reading a CT Scan- ABBBC
• A- Air-filled structures (sinuses, mastoid air cells)
• B- Bones (fractures)
• B- Blood (subarachnoid, intracerebral, subdural,
epidural hematoma)
• B- Brain tissue (infarction, edema, masses, brain
shift
• C- CSF spaces (sulci, ventricles, cisterns,
hydrocephalus, atrophy)
A- Air-filled Structures
• Normal air spaces are black both on bone and brain
window (frontal, maxillary, ethmoid, and sphenoid
sinuses)
• Mastoids are spongy bone filled with tiny pockets of air
When these pockets are opacified you will see a (gray or
white) shade
• Air-fluid levels in the setting of trauma suggest a fracture
• Mastoid opacification without trauma indicates
mastoiditis
B- Bones
• Useful when trauma is suspected
• Window your image for bone reading
• Recognize normal suture structures (usually
visible on both sides)
• If fracture suspected, inspect the opposite
side for similar finding
– If not present then look for abnormalities
associated with the fracture (air/pneumocephalus,
black spots within the hemorrhage)
B- Blood
Types of Intracranial Hemorrhage
Location and shape of the blood
• Epidural hematoma: over brain convexity,
not crossing suture line, lens shaped
(biconvex).
• Subdural hematoma: over brain convexity,
interhemispheric, along the tentorium, SDH
will cross suture lines & it’s crescent shaped.
• Intraparenchymal/Intracerebral hemorrhage:
within the brain matter, sizes/shape varies
dependent on etiology can be regular or
irregular.
• Interventricular hemorrhage- inside
ventricles, can be isolated and or secondary
to SAH, ICH.
• Subarachnoid hemorrhage- blood within the
subarachnoid spaces (sulci, sylvian fissure,
cisterns). Usually assumes shape of the
surrounding cerebral structure
Epidural Hematoma
• 20% will have a lucid
period before clinical
worsening
• Note the soft tissue
swelling adjacent to the
hematoma explaining the E
mechanism of the injury
Epidural Hematoma
• Arterial injury
following head
trauma
– Lens shaped
• Confined between the
sutures
– Most commonly
middle meningeal
artery
Subdural Hematoma (SDH)
• Differentiate between acute, subacute,
chronic, or acute on chronic
– Acute SDH
• Bright white on CT
• Can only be removed with a craniotomy
• Doesn’t always require surgery, depends on the
patient’s neurological examination and
comorbidities
• Usually related to shearing of bridging veins
between the dura and brain
Acute Subdural Hematoma
Acute and Chronic Subdural Hematoma
• Patient may be
asymptomatic until
the event leading to
the acute component
• Chronic component
can be drained using
a bedside burr hole
device such as the
Subdural Evacuation
Port System (SEPS)
ICH: Sites of Spontaneous ICH
Traumatic Intracerebral hemorrhage
• Occurs at the time of
impact
– Diffuse axonal injury
• Inertial forces cause
deformation of the white
matter, aka shear injuries
• Most commonly leads to
acute coma
• CT (not very sensitive) may
reveal petechial
hemorrhages in the central
1/3 of the brain
(subcortical white matter,
corpus collosum, basal
ganglia, brainstem,
cerebellum)
• MRI to evaluate extent of
injury
Traumatic Intracerebral hemorrhage
• Focal parenchymal
contusions
– Coup, contra coup,
intermediate coup
– CT: hemorrhagic core
surrounded by low
density edema
– Variable CBF in and
around contusion
Intraventricular Hemorrhage
• Variety of etiologies
– Anticoagulation
– Hypertension
– Aneurysm
– Substance abuse
– Trauma (less likely)
• Often will need an
external ventricular
drain with or without
intraventricular tPA
Subarachnoid Hemorrhage
• Always exclude an aneurysm
even when head trauma is
obvious
• Aneurysmal SAH has a poorer
prognosis than traumatic
subarachnoid hemorrhage
• Traumatic subarachnoid
hemorrhage
– Rarely required surgical
intervention
– Usually has a good
prognosis
Practice Reading CT Scans-ABBBC
Brain Tissue
A. In 1st few hours to day, A B

CT usually normal
(though may show
blurring of gray-white
junction & sulcal
effacement)
B. By day 2, CT shows
dark area with mass
effect (compression of
surrounding Day 1 Day 3
structures) Acute infarction Subacute infarction
Practice Reading CT scans-ABBBC
Air filled structures
A
A B C
B
A: Left parietoocipital pneumocephalus post-op

B: Left temporal ICH
C: Left sinus air fluid level with associated sinus fracture

CT Scan Basics

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LEARNING OBJECTIVES

Upon completion of this discussion, students

Air -1000 to -600

calcifications acute blood metal (bullets w/

• Note that white matter is

Gray matter (cerebral

Gray matter (basal

Eye Sella turcica

Sphenoid bone Petrous bone

Pineal gland (calcified)

Choroid plexus (calcified)

A. In 1st few hours to day, A B

A: Left parietoocipital pneumocephalus post-op

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