gemc: systematic evaluation to non-traumatic head cts: resident training
DESCRIPTION
This is a lecture by Dr. Rashmi U. Kothari from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.TRANSCRIPT
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Project: Ghana Emergency Medicine Collaborative Document Title: Systematic Evaluation to Non-Traumatic Head CTs Author(s) Rashmi U. Kothari, MD (KCMS/MSU), 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
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Systematic Evaluation to Non-Traumatic Head CTs
Rashmi U. Kothari, MD KCMS/MSU
Source Undetermined
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Why do you need to be able to evaluate a CT
Ø Radiology report is not immediately available
Ø Need immediate intervention
Ø Don’t trust anyone
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Course Outline
Ø Basic principles of CT
Ø Basic anatomy
Ø Systematic approach
Ø CT Potpourri
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Course Goals
Ø Learn “Blood Can Be Very Bad” approach to reading CTs
Ø Identify classic CT findings
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Disclaimer
Ø Make you a neuroradiologist
Ø Teach you cause of finding of abnormality
Ø Help you with contrast CTs
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Basic Principles of CT Imaging Source Undetermined
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X-rays Absorbed Differently by Different Tissues
Radiodense
Bone
Metal
Calcium
Blood
Grey matter
Radiolucent
Air
Spinal fluid
Ischemic infarct
Edema
White matter
Source Undetermined
Source Undetermined
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Attenuation (amount of radiation blocked by tissue)
Air Blood Bone
-1000 HU +1000 HU
HU=Hounsfield Units
50-100 HU
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Windowing
Ø Blood
Brain Blood
Bone Source Undetermined
Source Undetermined
Source Undetermined
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CT Anatomy
Ø Six levels of cuts Ø Cortical sulci Ø Lateral Ventricles Ø Basal Ganglia Ø 3rd Ventricle Ø Midbrain Ø Pons
Source Undetermined
Source Undetermined
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CT Anatomy: Cortical Sulci & Lat. Ventricle
Falx Cortical sulci
Frontal lobe Parietal lobe Lateral ventricles Occipital lobe
Source Undetermined
Source Undetermined
Source Undetermined
Source Undetermined
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CT Anatomy: Basal Ganglia & 3rd Ventricle
Anterior horns Insular ribbon Sylvian fissure 3rd ventricle Quadrigeminal cistern
Anterior horns Choroid plexus .
Source Undetermined
Source Undetermined
Source Undetermined
Source Undetermined
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CT Anatomy: Midbrain & Pons
Frontal sinus Suprastellar cistern Pons 4th ventrical
Sylvian fissure Insular ribbon Ambient cistern (cirummesenphalic cistern)
Source Undetermined
Source Undetermined
Source Undetermined
Source Undetermined
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Systematic Approach to Head CTs
Ø Perron et al: Carolina’s Medical Center
Ø “Blood Can Be Very Bad” pnemonic
Ø Course reviewing 12 scans & short histories
Ø Pre-test 60% to Post-test 78%
Ø http://www.uic.edu/com/ferne/pdf/acep_2005 _peds/perron_ich _acep_2005_peds_ course.pdf
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“Blood Can Be Very Bad”
Ø Blood
Ø Cisterns
Ø Brain
Ø Ventricles
Ø Bone Perron et al: Ann Emerg Med 1998:32:554-562
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“Blood Can Be Very Bad”
Ø Acute blood = hyperdense (white)
Ø 50-100 HU
Ø As it ages it becomes hypodense
Ø At 1-2 weeks it is isodense with brain
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“Blood Can Be Very Bad”
Source Undetermined
Source Undetermined
Source Undetermined
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“Blood Can Be Very Bad”
Ø 4 cisterns: Ø Suprasellar Ø Quadrigeminal Ø Slyvian Ø Ambient
Source Undetermined
Source Undetermined
Source Undetermined
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Andrew D. Perron, MD, FACEP
21
Cisterns: Is there blood?
Are they open? Source Undetermined
Source Undetermined
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“Blood Can Be Very Bad”
Brain Source Undetermined
Source Undetermined
Source Undetermined
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“Blood Can Be Very Bad”
Ventricle
Source Undetermined
Source Undetermined
Source Undetermined
Source Undetermined
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Andrew D. Perron, MD, FACEP
“Blood Can Be Very Bad”
Bone Source Undetermined Source Undetermined
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Classic CT Findings Source Undetermined
Source Undetermined
Source Undetermined
Source Undetermined
Source Undetermined
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Subdural • Concave shape • Venous bleeds • Crosses suture line
Epidural • Lens shape • 85% arterial bleeds • Middle meningeal art • Lucid period
Source Undetermined
Source Undetermined
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Intracerebral Hemorrhage
q 10% of all strokes q 2 major causes
q Hypertension q Blacks & Asians q 50% basal ganglia q Pons q Cerebellum
q Amyloid q Caucasians q Lobar q Recurrent
Source Undetermined
Source Undetermined
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Subarachnoid Hemorrhage
q 5-10% of all strokes q Aneurysms, AVMs,
trauma q Hyperdense, fuzzy q Locations of blood
C-
– Sulci – Sylvian fissure – Circle of Willis – Falx – Tentorium
Source Undetermined
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ICH Normal ICH
SAH SAH SAH
Source Undetermined Source Undetermined Source Undetermined
Source Undetermined Source Undetermined Source Undetermined
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Findings Suggestive of ICH
Ø Normal Calcification Ø Basal ganglia Ø Choroid plexus Ø Pineal gland
C-
Source Undetermined
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Findings Suggestive of ICH
Ø Metal Ø Very hypodense Ø “Sparks” Ø Clips, bullets,
metallic catheters
C-
Source Undetermined
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Findings Suggestive of ICH
C-
?
Source Undetermined
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Volume Averaging (Technical Issues Mimicking ICH)
Ø Orbital roof Ø Petrous portion of
temporal bone Ø Pituitary fossa Ø Brainstem
Source Undetermined Source Undetermined Source Undetermined
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Findings Suggestive of ICH/SAH
?
?
C-
Source Undetermined
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Motion Artifact (Technical Issues Mimicking ICH or SAH)
Ø Streaky Ø Hyperdense Ø Boney prominence
Source Undetermined Source Undetermined
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Evolution of an Infarct
Ultra-Acute 0-3 hours
Acute-Subacute 6hrs-days
Chronic 1 year
Source Undetermined Source Undetermined Source Undetermined
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Ultra-Early CT Findings
Ø Normal Ø Sulcal effacement Ø Loss of insular ribbon Ø Loss of grey-white
interface Ø Acute hypodensity
Source Undetermined
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Sulcal Effacement
Source Undetermined Source Undetermined
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Loss of Insular Ribbon
Source Undetermined
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Loss of Sulci & Acute Hypodensity
Source Undetermined
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Acute Hypodensity
Source Undetermined Source Undetermined
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Acute-Subacute Stroke (hours-days)
Ø Hypodense Ø Well demarcated Ø Mass effect Ø Midline shift Ø Loss of sulci
Source Undetermined
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Old Infarct (months to years)
Ø Density of CSF Ø Well demarcated Ø Ventrical enlargement Ø Sulci enlargement Ø No sulcal effacement Ø No mass effect
Source Undetermined
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Suggestive of an Infarct?
Source Undetermined
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Suggestive of an Infarct?
Tumor Stroke Source Undetermined Source Undetermined
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Case Presentations
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Thalamic ICH
Source Undetermined
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Normal
Source Undetermined
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Chronic Frontal Subdural
Source Undetermined
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Subacute Right Parietal Infarct
Source Undetermined
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continued Source Undetermined
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SAH Normal
Source Undetermined Source Undetermined
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Acute Subdural
Source Undetermined
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Normal
Source Undetermined
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Closed Ventricles
Source Undetermined
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Andrew D. Perron, MD, FACEP
Cisterns: Are they open?
Source Undetermined Source Undetermined
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Metallic Artifact
Source Undetermined
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Brainstem SAH
Source Undetermined
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Chronic MCA Infarct
Source Undetermined
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Left IVH
Source Undetermined
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Epidural
Source Undetermined
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Rt Subacute Epidural
Source Undetermined
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Sagital Sinus
Source Undetermined
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Subacute Infarct
Source Undetermined
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Renal Cell Metastasis
Source Undetermined
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continued Source Undetermined
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SAH Normal
Source Undetermined Source Undetermined
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48 hr old Right Temporal Infarct
Source Undetermined
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Acute on Chronic Subdural
Source Undetermined
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Source Undetermined
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SAH Source Undetermined Source Undetermined
Source Undetermined Source Undetermined
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Rt Parietal Fx with Air
Source Undetermined
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Source Undetermined
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Brain Abscess
Source Undetermined
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Calcification Basal Ganglia
Source Undetermined
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Source Undetermined
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continued Source Undetermined
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hours 3-4 days
7-10 days
months
Source Undetermined Source Undetermined
Source Undetermined Source Undetermined
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Trauma with Air
Source Undetermined
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Dense MCA Sign
Source Undetermined
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Subacute Brainstem Infarct
Source Undetermined
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Atrophy
Source Undetermined
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Trauma with SAH
Source Undetermined
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Bitemporal Edema (Herpes)
Source Undetermined
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Meningioma
Source Undetermined
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Caudate Infarct
Source Undetermined
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IVH Left Lateral Horn
Source Undetermined
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Ultra-Early Right Parietal Infarct Right Sulcal Effacement
Source Undetermined
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Continued Source Undetermined
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Source Undetermined Source Undetermined
Source Undetermined
Source Undetermined Source Undetermined Source Undetermined
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Subacute Infarct (Rt Temporal Lobe)
Source Undetermined Source Undetermined
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Periventricular White Matter Disease
Source Undetermined Source Undetermined
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Chronic Rt Occipital Infarct
Source Undetermined
Source Undetermined
Source Undetermined
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Subacute Subdural
Source Undetermined
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Traumatic Petechae
Source Undetermined
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Loss of Sulci & Sylvian Fissure
Source Undetermined
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Old Lt Lacunar Infarct
Source Undetermined
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Subacute Lt Subdural
Source Undetermined
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Rt MCA Infarct with Hemorrhage
Source Undetermined
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Lt Sagital Vein Thrombosis
Source Undetermined
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Source Undetermined
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SAH with Blood along Falx & in Ventricle
Source Undetermined
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Tumor
Source Undetermined
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Tumor
Source Undetermined
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CT Ground Rule
Radiodense
Bone
Blood
Calcium
Grey matter
Metal
Radiolucent
Spinal fluid
Ischemic infarct
Edema
White matter
Air
Source Undetermined
Source Undetermined
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“Blood Can Be Very Bad”
Ø Blood
Ø Cisterns
Ø Brain
Ø Ventricles
Ø Bone Perron et al: Ann Emerg Med 1998:32:554-562
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Intracerebral Hemorrhage
q Appearance q Hyperdense q Well demarcated q Globular
q Location q Intraparenchymal
q Mimics q Normal Calcification
q Basal ganglia q Choroid plexus q Pineal gland
q Artifacts q Metal q Catheters q Volume Averaging q Motion
Source Undetermined
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Subarachnoid Hemorrhage q Appearance
q Hyperdense q Fuzzy
q Locations of blood q Sulci q Sylvian fissure q Circle of Willis q Falx q Tentorium
q Mimics q Contrast q Calcified Falx q Normal Tentorium q Motion artifact
Source Undetermined
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Ultra-Early Infarct Normal
Sulcal effacement
Loss of insular ribbon
Loss of grey-white interface
Acute hypodensity
Acute-Subacute
Hypodense
Well demarcated
Mass effect
Midline shift
Loss of sulci
Old Infarcts
Density of CSF
Well demarcated
Ventrical enlargement
Sulci enlargement
No sulcal effacement
No mass effect
Source Undetermined
Source Undetermined
Source Undetermined