CLINICAL APPROACH TO CT BRAIN
TEE CHEN GIAP
Just another medical student stuck at home
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
DESCRIBE THIS CT SCAN.
NORMA
L
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
Intuition
Sir
HISTORY OF CT
Allan
Godfrey
Cormack
Hounsfield
Dr. William H.
Oldendorf
DISCLAIMER
CT BRAIN for today,
ENT sinuses, sagittal/coronal views, base of skull etc
May be topics for another time only briefly
OUR OBJECTIVES
and no…. No MRIs
To give EVERYONE here a SYSTEMATIC approach to CT Brain (axial).
To share what I find works well in CT Brain Interpretation.
To translate what we’ve learnt in Pre-Clinicals and textbooks, onto CT Brain
To hopefully, make more of us competent undergraduate CT Brain Interpreters,
for incoming clinical practice. Not all to be Radiologists! (Physicians woo!)
At least be able to come up with something during OSCEs :P
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CT SCAN
Common Indications:
1. Polytrauma
2. Altered GCS
3. Headache with W/S
4. Seizure
5. T.B.I.
6. Neurological Deficits
7. Raised ICP
8. Basal Skull #
9. Hypoxia
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
Hyperdense
Isodense
Hypodense
Super dense Giap +9999
The denser it is, the whiter it appears on CT.
Density: Grey Matter > White Matter, therefore appears whiter!
Real Life: White – Grey – White
CT: Grey – White – Grey
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
A SYSTEM TO CT BRAIN ANALYSIS
Identification ISSUES:
Settings, View, Contrast + Anatomy?
“Blood Can Be Very Bad” + Level?
Blood
Cistern + Structures?
Brain
Ventricles + Wait is that blood in the
middle?
Bone
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CLINICAL ANATOMY
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
Never forget:
Monroe-Kellie Doctrine
INTEGRATION
Identification
Settings, View, Contrast
“Blood Can Be Very Bad”
Tackling:
+ Anatomy?
+ Level?
+ Structures?
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
INTEGRATION
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
C
PRO TIP –
If you can’t remember a single thing (in OSCE)
because you’ve been stunned by my beautiful voice
(probably coz Giap’s bad at teaching) Right
Intracerebral
“REGIONS” Ischemia
Right
Frontotemporal
Ischemia
Right
Frontal Lobe
MCA ischemia
involving the caudate
nucleus
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Error 404 Recognition
PRO TIP# 2 –
NEVER COMMENT ON
SOMETHING YOU ARE NOT
SURE OF IN EXAMS
I.R.L: PLEASE CONTINUE TO
LEARN! ASK THE
RADIOLOGIST/SUPERVISOR
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Error 404 Recognition
PATTERN RECOGNITION
LUCID INTERVAL
Acute on Chronic
Subdural
Hematoma
Extradural Acute Subdural Subarachnoid
Hematoma Hematoma Hemorrhage @
suprasellar cistern
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
PATTERN RECOGNITION
Hydrocephalus
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
PATTERN RECOGNITION
Cerebral Abscess
@ Right
Temporal Lobe
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
PATTERN RECOGNITION
Intracranial Tumour
@ Right Fronto-
Parietal Region
(Metastasis)
before and after
contrast
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
Watershed
Infarct
ACA-MCA
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
SLIGHTLY
ADVANCED
STUFF
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CEREBRAL 2 other cerebral edema types
Osmotic & Hydrostatic Cerebral Edema
EDEMA TYPES
CYTOTOXIC VASOGENIC
CELL DEATH BBB Involvement
Both White Grey White Matter
Involvement Grey finger-like
projections
Seen in:
Ischemia Seen in:
Hypoxia Tumours
(ATP Depletion) Trauma
Infarct
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CT – MCA SIGNS
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
Questions?
Before we attempt the cases
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CASES
Remember, it’s super okay to make mistakes now!
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CASE 1
Hydrocephalus
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CASE 2
A young man
came to A&E Left Fronto-
Parietal Acute
after a flower Extradural
pot fell onto Hematoma
his head.
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CASE 3
50 years old
gentleman, H/O
Hypertension Acute
3 days Rt Hand Pontine Hemorrhage
Weakness and
Dizziness
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CASE 4
chronic subdural hematoma affecting the
left fronto-temporal region.
There is mass effect with a midline shift of
approximately 7 mm to the right.
65 years old gentleman,
Confusion and shortness of There is age-appropriate brain atrophy.
breath in a patient with past There is moderate periventricular and
subcutaneous cortical white matter
medical history of alcohol hypoattenuation most commonly seen in
abuse. chronic small vessel ischemia.
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
CASE 5
Showed a mature
infarct in the left
perisylvian cortex,
70y/o gentleman clearly depicting the
'loss of insular ribbon
Presented with right sign'.
sided weakness. history
of previous stroke Early Left MCA Infarct!
episode
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
Final Questions?
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
Thank you very much
Stay tuned for the next lineup of peer lectures!
Intro System Clinical Integrate Pattern Interpret Q&A 1 Cases Q&A 2
Anatomy Recognition
