GEMC: Systematic Evaluation to Non-Traumatic Head CTs: Resident Training
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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/.
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GEMC: Systematic Evaluation to Non-Traumatic Head CTs: Resident Training
- 1. 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/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for selfdiagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
- 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2 To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
- 3. Systematic Evaluation to Non-Traumatic Head CTs Source Undetermined Rashmi U. Kothari, MD KCMS/MSU
- 4. 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
- 5. Course Outline Ø Basic principles of CT Ø Basic anatomy Ø Systematic Ø CT approach Potpourri
- 6. Course Goals Ø Learn “Blood Can Be Very Bad” approach to reading CTs Ø Identify classic CT findings
- 7. Disclaimer Ø Make you a neuroradiologist Ø Teach you cause of finding of abnormality Ø Help you with contrast CTs
- 8. Source Undetermined Basic Principles of CT Imaging
- 9. X-rays Absorbed Differently by Different Tissues Radiolucent Radiodense Air Bone Spinal fluid Source Undetermined Metal Ischemic infarct Calcium Edema Blood White matter Grey matter Source Undetermined
- 10. Attenuation (amount of radiation blocked by tissue) 50-100 HU Air Blood -1000 HU Bone +1000 HU HU=Hounsfield Units
- 11. Windowing Ø Blood Source Undetermined Source Undetermined Source Undetermined Brain Blood Bone
- 12. CT Anatomy Source Undetermined Ø Six levels of cuts Ø Cortical sulci Ø Lateral Ventricles Ø Basal Ganglia Ø 3 rd Ventricle Ø Midbrain Ø Pons Source Undetermined
- 13. CT Anatomy: Cortical Sulci & Lat. Ventricle Falx Cortical sulci Source Undetermined Source Undetermined Frontal lobe Parietal lobe Lateral ventricles Occipital lobe Source Undetermined Source Undetermined
- 14. CT Anatomy: Basal Ganglia & 3rd Ventricle Anterior horns . Choroid plexus Source Undetermined Source Undetermined Anterior horns Insular ribbon Sylvian fissure 3rd ventricle Quadrigeminal cistern Source Undetermined Source Undetermined
- 15. CT Anatomy: Midbrain & Pons Sylvian fissure Insular ribbon Ambient cistern (cirummesenphalic cistern) Source Undetermined Source Undetermined Frontal sinus Suprastellar cistern Pons 4th ventrical Source Undetermined Source Undetermined
- 16. Systematic Approach to Head CTs Ø P erron et al: Carolina’s Medical Center Ø “ Blood Can Be Very Bad” pnemonic Ø C ourse reviewing 12 scans & short histories Ø P re-test 60% to Post-test 78% Ø h ttp://www.uic.edu/com/ferne/pdf/acep_2005 _peds/perron_ich _acep_2005_peds_ course.pdf
- 17. “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
- 18. “Blood Can Be Very Bad” Ø Acute blood = hyperdense (white) Ø 50-100 Ø As Ø At HU it ages it becomes hypodense 1-2 weeks it is isodense with brain
- 19. “Blood Can Be Very Bad” Source Undetermined Source Undetermined Source Undetermined
- 20. “Blood Can Be Very Bad” Ø 4 cisterns: Suprasellar Ø Quadrigeminal Ø Slyvian Ø Ambient Ø Source Undetermined Source Undetermined Source Undetermined
- 21. Cisterns: Is there blood? Source Undetermined Source Undetermined Are they open? 21 Andrew D. Perron, MD, FACEP
- 22. “Blood Can Be Very Bad” Source Undetermined Source Undetermined Brain Source Undetermined
- 23. “Blood Can Be Very Bad” Source Undetermined Source Undetermined Source Undetermined Ventricle Source Undetermined
- 24. “Blood Can Be Very Bad” Source Undetermined Bone Source Undetermined Andrew D. Perron, MD, FACEP
- 25. Source Undetermined Source Undetermined Classic CT Findings Source Undetermined Source Undetermined Source Undetermined
- 26. Epidural • Lens shape • 85% arterial bleeds • Middle meningeal art • Lucid period Source Undetermined Subdural • Concave shape • Venous bleeds • Crosses suture line Source Undetermined
- 27. Intracerebral Hemorrhage q 10% of all strokes Source Undetermined Source Undetermined 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
- 28. Subarachnoid Hemorrhage q 5-10% of all strokes q Aneurysms, AVMs, trauma q Hyperdense, fuzzy q Locations of blood C- Source Undetermined – Sulci – Sylvian fissure – Circle of Willis – Falx – Tentorium
- 29. ICH Source Undetermined Source Undetermined SAH Normal Source Undetermined Source Undetermined SAH ICH Source Undetermined Source Undetermined SAH
- 30. Findings Suggestive of ICH Ø N ormal Calcification Ø Basal ganglia Ø Choroid plexus Ø Pineal gland CSource Undetermined
- 31. Findings Suggestive of ICH Ø Metal Ø Very hypodense Ø “Sparks” Ø Clips, bullets, metallic catheters CSource Undetermined
- 32. Findings Suggestive of ICH ? CSource Undetermined
- 33. 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
- 34. Findings Suggestive of ICH/SAH ? ? CSource Undetermined
- 35. Motion Artifact (Technical Issues Mimicking ICH or SAH) Ø Streaky Ø Hyperdense Ø Boney prominence Source Undetermined Source Undetermined
- 36. Evolution of an Infarct Source Undetermined Source Undetermined Ultra-Acute Acute-Subacute 0-3 hours 6hrs-days Source Undetermined Chronic 1 year
- 37. 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
- 38. Sulcal Effacement Source Undetermined Source Undetermined
- 39. Loss of Insular Ribbon Source Undetermined
- 40. Loss of Sulci & Acute Hypodensity Source Undetermined
- 41. Acute Hypodensity Source Undetermined Source Undetermined
- 42. Acute-Subacute Stroke (hours-days) Ø Hypodense Ø Well demarcated Ø Mass effect Ø Midline shift Ø Loss of sulci Source Undetermined
- 43. 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
- 44. Suggestive of an Infarct? Source Undetermined
- 45. Suggestive of an Infarct? Source Undetermined Tumor Source Undetermined Stroke
- 49. Chronic Frontal Subdural Source Undetermined
- 50. Subacute Right Parietal Infarct Source Undetermined
- 56. Cisterns: Are they open? Source Undetermined Source Undetermined Andrew D. Perron, MD, FACEP
- 59. Chronic MCA Infarct Source Undetermined
- 62. Rt Subacute Epidural Source Undetermined
- 65. Renal Cell Metastasis Source Undetermined
- 68. 48 hr old Right Temporal Infarct Source Undetermined
- 69. Acute on Chronic Subdural Source Undetermined
- 71. Source Undetermined Source Undetermined SAH Source Undetermined Source Undetermined
- 72. Rt Parietal Fx with Air Source Undetermined
- 75. Calcification Basal Ganglia Source Undetermined
- 78. hours 3-4 days Source Undetermined Source Undetermined months 7-10 days Source Undetermined Source Undetermined
- 79. Trauma with Air Source Undetermined
- 80. Dense MCA Sign Source Undetermined
- 81. Subacute Brainstem Infarct Source Undetermined
- 83. Trauma with SAH Source Undetermined
- 84. Bitemporal Edema (Herpes) Source Undetermined
- 87. IVH Left Lateral Horn Source Undetermined
- 88. Ultra-Early Right Parietal Infarct Right Sulcal Effacement Source Undetermined
- 90. Source Undetermined Source Undetermined Source Undetermined Source Undetermined Source Undetermined Source Undetermined
- 91. Subacute Infarct (Rt Temporal Lobe) Source Undetermined Source Undetermined
- 92. Periventricular White Matter Disease Source Undetermined Source Undetermined
- 93. Chronic Rt Occipital Infarct Source Undetermined Source Undetermined Source Undetermined
- 96. Loss of Sulci & Sylvian Fissure Source Undetermined
- 97. Old Lt Lacunar Infarct Source Undetermined
- 98. Subacute Lt Subdural Source Undetermined
- 99. Rt MCA Infarct with Hemorrhage Source Undetermined
- 100. Lt Sagital Vein Thrombosis Source Undetermined
- 101. Source Undetermined
- 102. SAH with Blood along Falx & in Ventricle Source Undetermined
- 105. CT Ground Rule Radiolucent Radiodense Spinal fluid Bone Ischemic infarct Blood Source Undetermined Edema Calcium White matter Grey matter Air Metal Source Undetermined
- 106. “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
- 107. Intracerebral Hemorrhage q A ppearance q Hyperdense q Well demarcated q Globular q L ocation q Intraparenchymal Source Undetermined q M imics q Normal Calcification q Basal ganglia q Choroid plexus q Pineal gland q Artifacts q Metal q Catheters q Volume Averaging q Motion
- 108. Subarachnoid Hemorrhage q Appearance q Hyperdense q Fuzzy q Locations of blood q Mimics q Contrast q Calcified Falx q Normal Tentorium q Motion artifact q Sulci q Sylvian fissure q Circle of Willis q Falx q Tentorium Source Undetermined
- 109. Ultra-Early Infarct Old Infarcts Normal Density of CSF Sulcal effacement Well demarcated Loss of insular ribbon Ventrical enlargement Loss of grey-white interface Sulci enlargement Acute hypodensity Source Undetermined No sulcal effacement No mass effect Acute-Subacute Hypodense Well demarcated Mass effect Midline shift Loss of sulci Source Undetermined Source Undetermined