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How to read brain CT? Teach you hand in hand, full of dry goods! As a neurologist, brain CT is often the first examination item that needs to be done to judge the condition, especially in emergency situations.
So, how can brain CT make an efficient and accurate interpretation? Xiaobian will take you to study together! The first step is to search for possible hemorrhage and cerebral hemorrhage.
The first choice is head CT.
When interpreting brain CT, the first step is to look for possible hemorrhage problems.
Cerebral hemorrhage is often secondary to hypertension, aneurysm, vascular malformation, amyloid cerebrovascular disease, anticoagulant or thrombolytic therapy, blood disease, tumor and stroke.
CT can accurately display the location, size, brain edema and whether it has penetrated into the ventricle, etc.
, which can help guide treatment and determine prognosis.
1 Hypertensive intracerebral hemorrhage Location: Basal ganglia-the outer capsule is the most common, followed by the thalamus, brainstem and cerebellum, and a few are located in the brain lobe.
Form: Sudden round or round-like high-density clumps, generally single shot, ranging in size from dots to several centimeters.
Other manifestations: cerebral edema, intraventricular hemorrhage, space-occupying effect, etc.
Figure 1: Imaging manifestations of hypertensive intracerebral hemorrhage.
A.
Axial schematic diagram shows a typical acute hypertensive basal ganglia/external cyst hematoma.
The hematoma breaks into the lateral ventricle and reaches the third ventricle through the interventricular foramen.
B.
Axial CT showed a typical hematoma of the left basal ganglia, involving the putamen and outer capsule (intrastriatal capsule).
Low-density shadows can be seen in the white matter around the ventricle, which may be due to local chronic small vessel ischemia.
2 Amyloid cerebrovascular disease (CAA) in the acute phase is manifested by high-density brain lobes, surrounded by edema of varying degrees.
For CAA microhemorrhages, CT diagnosis is more difficult, and more sensitive SWI and T2* sequences are often required.
Figure 2: CAA imaging appearance A.
The schematic diagram of the CAA axis shows the "blood-liquid level" of acute cerebral hematoma, accompanied by multiple microhemorrhages and old lobe hemorrhage.
B.
CT axial view shows acute cerebral hemorrhage in the right occipital lobe.
3 Subdural hematoma Morphology: crescent-shaped or half-moon-shaped high-density shadow under the cranial plate in the acute phase.
Location: Diffusely extend along the convex surface of the brain or the sickle or tentorium.
Others: Can pass through the cranial suture, but cannot cross the dural attachment point.
Figure 3: Imaging manifestations of subdural hematoma.
A.
Schematic diagram showing that acute subdural hematoma compresses the left cerebral hemisphere and lateral ventricle, causing the midline to shift.
There are cortical contusions and axonal injuries at the same time.
B.
Axial CT plain scan showed a typical acute subdural hematoma extending along the convex surface of the left side of the brain and compressing the subarachnoid space below.
Small punctate low-density foci in a high-density acute subdural hematoma suggest that the acute hematoma has a risk of rapid expansion.
4 Cavernous vascular malformation Cavernous vascular malformation is a kind of benign vascular hamartoma, which consists of tightly arranged immature "cavernous" vascular masses, which may contain thrombus and hemorrhage in the lesion.
CT generally manifests as round or round-like with clear borders to slightly higher density shadows, which may be combined with spot-like calcification, generally without edema around, and larger lesions may have mild edema.
Figure 4: Imaging manifestations of cavernous hemangioma A.
Axial schematic diagram showing cavernous vascular malformations at different stages: typical "popcorn"-like lesions with multi-chamber hemorrhage, surrounded by hemosiderin rings, and multifocal scattered " Black spots".
B.
CT plain scan showed mixed density masses of right thalamus with mild edema and liquid level.
5 Subarachnoid hemorrhage is most often manifested as diffuse high-density shadow of the basal cistern.
In severe cases, the blood can extend to the sylvian fissure, the anterior and posterior longitudinal fissure cistern, the ventricular system or the convex surface of the brain.
The distribution of blood can indicate the location of a ruptured aneurysm: if the aneurysm is located in the internal carotid artery segment, it often shows asymmetrical hemorrhage in the suprasellar cistern; it is more common in the middle cerebral artery segment with lateral hemorrhage; it is in the anterior communicating artery segment.
Hemorrhage at the base of the anterior longitudinal fissure. Figure 5: Imaging manifestations of subarachnoid hemorrhage A.
CT plain scan showed diffuse subarachnoid hemorrhage in the basal cistern.
Note the enlargement of the temporal horns on both sides of the lateral ventricle, which is consistent with the early ventricular obstructive hydrocephalus.
B.
Coronary CTA shows that the saccular aneurysm protrudes upward from the anterior communicating artery.
6 Intraventricular hemorrhage is often secondary to deep intracerebral hematoma rupture into the ventricle or ventricular penetrating injury or retrograde subarachnoid hemorrhage from the fourth ventricle.
Blood clots can cause obstructive hydrocephalus.
Figure 6: The second step of the imaging manifestation of intraventricular hemorrhage, to determine whether there are morphological and structural changes.
1 Brain atrophy refers to the reduction of brain tissue caused by various reasons and the subsequent enlargement of the ventricle and subarachnoid space.
CT manifested as sulci (wider than 5mm), split brain, widening of cistern, and enlargement of ventricle.
Figure 7: Imaging manifestations of cerebral atrophy 2 Hydrocephalus Hydrocephalus refers to the abnormal expansion of the ventricular system due to imbalance in the production and absorption of cerebrospinal fluid or obstacles to the circulation of cerebrospinal fluid.
A variety of intracranial lesions can cause hydrocephalus.
According to the pathogenesis, it is divided into communicative and obstructive hydrocephalus: communicative hydrocephalus generally enlarges the ventricular system, and the brain cistern is widened; obstructive hydrocephalus obstructs the proximal ventricle to enlarge, but the cerebral cistern does not widen.
Figure 8: Imaging manifestations of hydrocephalus 3 Cerebral herniation Cerebral herniation is a serious complication of intracranial hypertension caused by a variety of intracranial diseases.
Cerebral herniation can be divided into temporal lobe sulcus hernia, tentorium notch hernia, cerebellar tonsil hernia, and subfalcular hernia.
Different types of hernia have different characteristics, but they will all have mass effect and structural changes.
Figure 9: Imaging manifestations of brain herniation.
A.
Patients with multiple traumatic brain injuries.
Axial gross pathological section of the ventricle showed severe subfalx herniation.
The ventricle crosses the midline, and the cingulate gyrus is incarcerated under the scythe.
The infarction of the blood supply area of the left posterior cerebral artery was secondary to hernia under the tentorium notch.
B.
Axial CT plain scan showed a hernia under the falx, and it was seen that the left side ventricle was severely compressed and the right side ventricle was slightly enlarged. The third step, non-hemorrhagic changes 1 Cerebral infarction It was previously believed that CT can show early cerebral infarction only 24-48h after onset.
Nowadays, with the advancement of CT technology, cerebral infarction within 4-6h can be seen on CT Performance.
The CT manifestations of cerebral infarction include disappearance of the sulcus, swelling of the gyri; obscure lenticular nucleus sign; disappearance of the insula sign; high density of the middle cerebral artery.
CT perfusion imaging can detect abnormal areas of perfusion early and clearly distinguish between reversible (penumbra) and irreversible (infarct) tissues.
Figure 10: Imaging manifestations of middle cerebral artery hyperdensity sign A.
Coronary diagram showing occlusion of the M1 segment of the left middle cerebral artery, and the proximal occlusion affects the entire middle cerebral artery (MCA) blood supply area, including the basal ganglia (supplied by the lenticular artery) .
B.
The early signs of acute ischemia on the first CT scan include mild blurring of gray matter boundaries, such as blurring of the basal ganglia and island-zone sign.
Compared with the right middle cerebral artery, the left middle cerebral artery has a high density shadow.
2 Calcification Intracranial pathological calcification refers to the deposition of calcium salt with hydroxyapatite as the main component in brain tissue.
There are many pathological factors that cause intracerebral calcification.
The common causes are neoplastic, infectious, vascular, congenital and hereditary, metabolic and other causes of calcification.
CT examination is a more sensitive method to find intracranial calcification, showing that the effect of intracranial calcification is better.
Table 1: Types of calcification and common lesions knocking on the blackboard 1.
CT is one of the clinically simple and practical examination items.
As a neurologist, you must learn to interpret CT images efficiently and accurately; 2.
Bleeding is often the easiest problem to find When a patient is suspected of cerebrovascular disease, hemorrhage needs to be diagnosed or ruled out at the first time; 3.
It is very important to find structural and morphological abnormalities.
Cerebral herniation is often serious or even fatal; 4.
When CT suspects ischemic lesions , It is feasible to further in-depth examination of brain MRI. References: [1] Toyoda K et al.
Diagnostic imaging of hemangiomas in the brain.
Brain Nerve 2011 Jan; 631 (1) [2] "Neuroimaging" compiled by Lou Xin, Peking University Medical Press [3] Capone PM , Et al.
Neuroimaging of Normal Pressure Hydrocephalus and Hydrocephalus.
Neurol Clin 2020 02; 381(1) [4] "Interpretation of CT and MRI Images of the Central Nervous System" edited by Quanguan Democracy, People's Medical Publishing House.
Channel Article Arrangement: Liny Article Review: Li Tuming Deputy Chief Physician Editor: Mr.
Lu Li Copyright Statement The original text is welcome to forward to the circle of friends-End-Call for contributions welcome to the editor's mailbox: yxjsjbx@yxj.
org.
cn Please specify: [Submission] Hospital +Department+Name Contributions are in the form of word documents, and the remuneration is favorably edited.
WeChat: chenaFF0911
How to read brain CT? Teach you hand in hand, full of dry goods! As a neurologist, brain CT is often the first examination item that needs to be done to judge the condition, especially in emergency situations.
So, how can brain CT make an efficient and accurate interpretation? Xiaobian will take you to study together! The first step is to search for possible hemorrhage and cerebral hemorrhage.
The first choice is head CT.
When interpreting brain CT, the first step is to look for possible hemorrhage problems.
Cerebral hemorrhage is often secondary to hypertension, aneurysm, vascular malformation, amyloid cerebrovascular disease, anticoagulant or thrombolytic therapy, blood disease, tumor and stroke.
CT can accurately display the location, size, brain edema and whether it has penetrated into the ventricle, etc.
, which can help guide treatment and determine prognosis.
1 Hypertensive intracerebral hemorrhage Location: Basal ganglia-the outer capsule is the most common, followed by the thalamus, brainstem and cerebellum, and a few are located in the brain lobe.
Form: Sudden round or round-like high-density clumps, generally single shot, ranging in size from dots to several centimeters.
Other manifestations: cerebral edema, intraventricular hemorrhage, space-occupying effect, etc.
Figure 1: Imaging manifestations of hypertensive intracerebral hemorrhage.
A.
Axial schematic diagram shows a typical acute hypertensive basal ganglia/external cyst hematoma.
The hematoma breaks into the lateral ventricle and reaches the third ventricle through the interventricular foramen.
B.
Axial CT showed a typical hematoma of the left basal ganglia, involving the putamen and outer capsule (intrastriatal capsule).
Low-density shadows can be seen in the white matter around the ventricle, which may be due to local chronic small vessel ischemia.
2 Amyloid cerebrovascular disease (CAA) in the acute phase is manifested by high-density brain lobes, surrounded by edema of varying degrees.
For CAA microhemorrhages, CT diagnosis is more difficult, and more sensitive SWI and T2* sequences are often required.
Figure 2: CAA imaging appearance A.
The schematic diagram of the CAA axis shows the "blood-liquid level" of acute cerebral hematoma, accompanied by multiple microhemorrhages and old lobe hemorrhage.
B.
CT axial view shows acute cerebral hemorrhage in the right occipital lobe.
3 Subdural hematoma Morphology: crescent-shaped or half-moon-shaped high-density shadow under the cranial plate in the acute phase.
Location: Diffusely extend along the convex surface of the brain or the sickle or tentorium.
Others: Can pass through the cranial suture, but cannot cross the dural attachment point.
Figure 3: Imaging manifestations of subdural hematoma.
A.
Schematic diagram showing that acute subdural hematoma compresses the left cerebral hemisphere and lateral ventricle, causing the midline to shift.
There are cortical contusions and axonal injuries at the same time.
B.
Axial CT plain scan showed a typical acute subdural hematoma extending along the convex surface of the left side of the brain and compressing the subarachnoid space below.
Small punctate low-density foci in a high-density acute subdural hematoma suggest that the acute hematoma has a risk of rapid expansion.
4 Cavernous vascular malformation Cavernous vascular malformation is a kind of benign vascular hamartoma, which consists of tightly arranged immature "cavernous" vascular masses, which may contain thrombus and hemorrhage in the lesion.
CT generally manifests as round or round-like with clear borders to slightly higher density shadows, which may be combined with spot-like calcification, generally without edema around, and larger lesions may have mild edema.
Figure 4: Imaging manifestations of cavernous hemangioma A.
Axial schematic diagram showing cavernous vascular malformations at different stages: typical "popcorn"-like lesions with multi-chamber hemorrhage, surrounded by hemosiderin rings, and multifocal scattered " Black spots".
B.
CT plain scan showed mixed density masses of right thalamus with mild edema and liquid level.
5 Subarachnoid hemorrhage is most often manifested as diffuse high-density shadow of the basal cistern.
In severe cases, the blood can extend to the sylvian fissure, the anterior and posterior longitudinal fissure cistern, the ventricular system or the convex surface of the brain.
The distribution of blood can indicate the location of a ruptured aneurysm: if the aneurysm is located in the internal carotid artery segment, it often shows asymmetrical hemorrhage in the suprasellar cistern; it is more common in the middle cerebral artery segment with lateral hemorrhage; it is in the anterior communicating artery segment.
Hemorrhage at the base of the anterior longitudinal fissure. Figure 5: Imaging manifestations of subarachnoid hemorrhage A.
CT plain scan showed diffuse subarachnoid hemorrhage in the basal cistern.
Note the enlargement of the temporal horns on both sides of the lateral ventricle, which is consistent with the early ventricular obstructive hydrocephalus.
B.
Coronary CTA shows that the saccular aneurysm protrudes upward from the anterior communicating artery.
6 Intraventricular hemorrhage is often secondary to deep intracerebral hematoma rupture into the ventricle or ventricular penetrating injury or retrograde subarachnoid hemorrhage from the fourth ventricle.
Blood clots can cause obstructive hydrocephalus.
Figure 6: The second step of the imaging manifestation of intraventricular hemorrhage, to determine whether there are morphological and structural changes.
1 Brain atrophy refers to the reduction of brain tissue caused by various reasons and the subsequent enlargement of the ventricle and subarachnoid space.
CT manifested as sulci (wider than 5mm), split brain, widening of cistern, and enlargement of ventricle.
Figure 7: Imaging manifestations of cerebral atrophy 2 Hydrocephalus Hydrocephalus refers to the abnormal expansion of the ventricular system due to imbalance in the production and absorption of cerebrospinal fluid or obstacles to the circulation of cerebrospinal fluid.
A variety of intracranial lesions can cause hydrocephalus.
According to the pathogenesis, it is divided into communicative and obstructive hydrocephalus: communicative hydrocephalus generally enlarges the ventricular system, and the brain cistern is widened; obstructive hydrocephalus obstructs the proximal ventricle to enlarge, but the cerebral cistern does not widen.
Figure 8: Imaging manifestations of hydrocephalus 3 Cerebral herniation Cerebral herniation is a serious complication of intracranial hypertension caused by a variety of intracranial diseases.
Cerebral herniation can be divided into temporal lobe sulcus hernia, tentorium notch hernia, cerebellar tonsil hernia, and subfalcular hernia.
Different types of hernia have different characteristics, but they will all have mass effect and structural changes.
Figure 9: Imaging manifestations of brain herniation.
A.
Patients with multiple traumatic brain injuries.
Axial gross pathological section of the ventricle showed severe subfalx herniation.
The ventricle crosses the midline, and the cingulate gyrus is incarcerated under the scythe.
The infarction of the blood supply area of the left posterior cerebral artery was secondary to hernia under the tentorium notch.
B.
Axial CT plain scan showed a hernia under the falx, and it was seen that the left side ventricle was severely compressed and the right side ventricle was slightly enlarged. The third step, non-hemorrhagic changes 1 Cerebral infarction It was previously believed that CT can show early cerebral infarction only 24-48h after onset.
Nowadays, with the advancement of CT technology, cerebral infarction within 4-6h can be seen on CT Performance.
The CT manifestations of cerebral infarction include disappearance of the sulcus, swelling of the gyri; obscure lenticular nucleus sign; disappearance of the insula sign; high density of the middle cerebral artery.
CT perfusion imaging can detect abnormal areas of perfusion early and clearly distinguish between reversible (penumbra) and irreversible (infarct) tissues.
Figure 10: Imaging manifestations of middle cerebral artery hyperdensity sign A.
Coronary diagram showing occlusion of the M1 segment of the left middle cerebral artery, and the proximal occlusion affects the entire middle cerebral artery (MCA) blood supply area, including the basal ganglia (supplied by the lenticular artery) .
B.
The early signs of acute ischemia on the first CT scan include mild blurring of gray matter boundaries, such as blurring of the basal ganglia and island-zone sign.
Compared with the right middle cerebral artery, the left middle cerebral artery has a high density shadow.
2 Calcification Intracranial pathological calcification refers to the deposition of calcium salt with hydroxyapatite as the main component in brain tissue.
There are many pathological factors that cause intracerebral calcification.
The common causes are neoplastic, infectious, vascular, congenital and hereditary, metabolic and other causes of calcification.
CT examination is a more sensitive method to find intracranial calcification, showing that the effect of intracranial calcification is better.
Table 1: Types of calcification and common lesions knocking on the blackboard 1.
CT is one of the clinically simple and practical examination items.
As a neurologist, you must learn to interpret CT images efficiently and accurately; 2.
Bleeding is often the easiest problem to find When a patient is suspected of cerebrovascular disease, hemorrhage needs to be diagnosed or ruled out at the first time; 3.
It is very important to find structural and morphological abnormalities.
Cerebral herniation is often serious or even fatal; 4.
When CT suspects ischemic lesions , It is feasible to further in-depth examination of brain MRI. References: [1] Toyoda K et al.
Diagnostic imaging of hemangiomas in the brain.
Brain Nerve 2011 Jan; 631 (1) [2] "Neuroimaging" compiled by Lou Xin, Peking University Medical Press [3] Capone PM , Et al.
Neuroimaging of Normal Pressure Hydrocephalus and Hydrocephalus.
Neurol Clin 2020 02; 381(1) [4] "Interpretation of CT and MRI Images of the Central Nervous System" edited by Quanguan Democracy, People's Medical Publishing House.
Channel Article Arrangement: Liny Article Review: Li Tuming Deputy Chief Physician Editor: Mr.
Lu Li Copyright Statement The original text is welcome to forward to the circle of friends-End-Call for contributions welcome to the editor's mailbox: yxjsjbx@yxj.
org.
cn Please specify: [Submission] Hospital +Department+Name Contributions are in the form of word documents, and the remuneration is favorably edited.
WeChat: chenaFF0911
