everything a medical student should know about a ct scan of the head by thanh binh nguyen...
TRANSCRIPT
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EVERYTHING A MEDICAL STUDENT SHOULD KNOW ABOUT A CT SCAN OF THE
HEAD
By Thanh Binh NguyenNeuroradiologistOttawa Hospital
Last updated July 2007
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What is a CAT scan?
CAT scan stands for Computed Assisted Tomography
Cross sectional images are obtained by multiple measurements of the x-rays attenuation from several projections.
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What are we measuring?
The attenuation coefficient reflects the reduction in the x-ray intensity by the material relative to water.
The Hounsfield Unit is the scale used. (HUwater=0, HUbone >500, HUlung=-500)
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CT and radiation
Effective dose takes into account which tissue has absorbed what radiation dose (expressed in Sievert)
We can decrease the effective dose in CT by reducing the tube current but image noise will be increased
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Radiation and risk of cancer
Lifetime risk of developing fatal cancer from radiation exposure in a population is 0.005% per milliSievert(mSv)
Exposure from mSV1. Natural background 3 /yr2. CT head 23. CT spine 10
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STROKE
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*Canadian Heart and Stroke Foundation
Canadian Stroke Facts*
40,000-50,000 new stroke’s /year
65% of survivors have disability
4th leading cause of death
Longest length-of-stay for any diagnosis (37 d)
Leading cause of transfer to long term care
Leading cause of neuro disability in adults
Cost >$2.7 billion/year $27,500 / acute stroke $46,000-$122,000 /
patient for chronic care
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Stroke
denotes a persistent loss of neurologic function with sudden onset
diverse etiologies...
Ischaemic Cerebrovascular StrokeVenous Congestion / StrokeHemorrhagic Stroke
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Anatomy
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Arterial Territories Anterior Cerebral Middle Cerebral Posterior Cerebral Basilar Superior Cerebellar Anterior Inferior
Cerebellar Posterior Inferior
Cerebellar
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Supratentorial Territories
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From Osborne, A: Neuroradiology
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Left PCA
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MCA
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ACA
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Anterior choroidal infarct
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Watershed (between ACA and MCA)
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Ischaemic CV Stroke
Thromboembolic most common Hemodynamic
Atherosclerotic Dissection Vasospasm Hypotensive /asphyxia (watershed)
Migraine Vasculitis Thrombotic: hypercoagulable states
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Hemorrhagic Stroke
Primary Intracerebral bleed Hypertensive Amyloid angiopathy Arteriovenous malformations Neoplasms Trauma
Subarachnoid hemorrhage Aneurysm AVM’s Trauma
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HypertensiveHemorrhage
Classically involvesthe deep nucleii
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Amyloid angiopathy
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Hyperdense vessel sign
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Hyperdense vessel sign & loss of gray/whitejunction...
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Left insular ribbon sign & effacement of sulci
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NEOPLASM
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APPROACH TO BRAIN TUMOR Intra-axial(from the brain) versus Extra-axial
(from the meninges or skull) Location (supratentorial vs infratentorial) Age of patient Imaging characteristics Could you this be something other than
neoplasm (infarction, abscess, etc…)? CT with contrast or MRI is often needed.
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EDEMA
Vasogenic edema: Involves white matter primarily with sparing
of gray matter Seen with brain tumors, abscess
Cytotoxic edema Involves both white matter and gray matter Seen with infarction
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BRAIN TUMORS
Extraaxial: meningioma Intraaxial:
Primary Glial tumors: low grade to high grade
astrocytoma (glioblastoma multiforme) Non glial tumor (lymphoma,
hemangioblastoma, etc…)
Metastasis (lung, breast, colon, etc…)
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Unenhanced CT of the head shows a mass in the left frontal lobe with vasogenic edema
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Ring enhancing lesion (GBM)
Vasogenic edema
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GLIOMAS
Astrocytomas 85% of cerebral gliomas Young to middle-aged adults (20-50 years) Varying degree of malignancy. Highest grade is
glioblastoma multiforme which presents as a mass with ill-defined margins, variable enhancement and extensive vasogenic edema.
Oligodendrogliomas Young, middle-aged adult Solid, well-defined mass with calcification
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70 year old gentleman complaining of dizziness and off balance for one week with associated nausea and vomiting. He also had attack of left facial numbness and left arm numbness for a week. Cerebellar exam showed nystagmus of lateral gaze and left-sided incoordination
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Left tonsillar herniation
C- C+
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C- C+
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C- C+
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Hyperdense cerebellar mass seen on plain CT scan which enhances homogeneously and causes compression of the 4th ventricle and hydrocephalus
C- C+
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DIAGNOSIS
BURKITT LYMPHOMA
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Enhancing nodule at corticomedullary junction
Vasogenic edema: involves whiter matter more than gray matter
Ct scan of the head with contrast in patient with renal cell carcinoma
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DIAGNOSIS
METASTASES Hematogenous seeding to
corticomedullary junction Usually in MCA territory Usually the degree of edema is out of
proportion to the size of the lesion
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Ct scan of the head without contrast
Hyperdense mass
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Enhances homgeneously and appears extraaxial
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Thickening of the adjacent bone (hyperostosis)
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DIAGNOSIS
MENINGIOMA
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INFECTION
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INTRACRANIAL INFECTION
Intraaxial: Encephalitis Cerebritis Abscess
Extraaxial: Subdural empyema Epidural abscess Meningitis
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CEREBRAL INFECTION
Encephalitis: generalized and difuse infection of the brain. Often of viral origin (ex.herpes simplex)
Cerebritis: localized but poorly demarcated area of parenchymal softening.
Abscess: follows cerebritis. Occurs when a central zone of necrosis becomes encapsulated.
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MODE OF SPREAD
Hematogenous spread: could reach the corticomedullary junction or leptomeninges.
Direct extension: ex.sinusitis leading to epidural abscess or subdural empyemas
Spread along the nerves (ex.herpes encephalitis along the trigeminal nerve)
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Ring enhancing lesion
Vasogenic edema
ABSCESS (could look similar to metastatic lesion on CT)
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SUBDURAL EMPYEMA (C-)
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SUBDURAL EMPYEMA (C+)
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Basal leptomeningitis (seeding of the subarachnoid space)
TUBERCULOSIS
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TUBERCULOSIS
Multiple tuberculomas seen on MRI exam with contrast
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THE END