Dr Rudolf H Pakpahan Sp.

Rad
Dr Netty Lubis Sp.Rad
Radiology FK - USU
MODALITIES
1. X-Ray
2. CT Scan
3. MRI
The Skull
The standard projections are :
1. The lateral view

2. The PA view
Routine method of study of Skull
X ray
Examine : the inner and outer table
Examine trabeculasi and densitas bone
Examine: Sutures
Examine :Vascular markings
Examine : sella
Examine : intracranial kalsifikasi
Normal Skull Films
AP Skull-X Ray
Lateral Skull-X Ray
AP view
Lateral view
Abnormal Skull
1.Fracture.
2.Metastasis
3.Congenital disorders
4.Kalsifikasi
5.Raised intracranial pressure

Metastasis

Lesi lytik
Lesi lytik luas
Multiple Myeloma
Congenital disorders

Scaphocephaly
Scaphocephaly

Scaphocephaly
Raised intracranial pressure

Hydrocephalus
Raised intracranial pressure
Computed tomography
CT schematic
INDICATION

1.HEAD INJURY
2.CEBROVASLULAR DISEASES (CVD)
3.BRAIN TUMOR
4.CEREBRAL INFECTION
5.CONGENITAL DISORDER
6.CEREBRAL ATROPHY OR
7.DEGENERATIVE DISEASES
THE BRAIN LAYER ANATOMY
SKIN
BONE
EPIDURAL
DURAMATER
SUBDURAL
ARACHNOID
SUBARACHNOID
PIAMATER
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B
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L
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R

A
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ANATOMY BRAIN
HEAD Scan NORMAL
High density (hiperdens) : densitas lesi
lebih tinggi dari jaringan normal.

Isodens :densitas lesi sama dengan
jaringan sekitarnya

Low density(hipodens): densitas lesi
lebihrendah dari jaringan normal

Skull Fractures
-Associated with pneumocephaly
(air in head) rarely can develop
tension pneumocephalus
-Only significant if open to
air,cosmetically disfiguring(greater
than full thickness displacement)
or
associate with air sinus
(for risk of infection) or
underlying bleed
(epidural hematom)
-Treatment ONLY for
cosmetic or prevention of
infection ( if open
to air or to an air sinus
Fracture
Intracranial Hemorrhage
Intracranial hemorrhage can be classified
according to the space occupied by the
blood:
Epidural Hemorrhage
Subdural Hemorrhage
Subarachnoid Hemorrhage
Intraparenchymal Hemorrhage
Intraventricular Hemorrhage
Intracranial Hemorrhage:
Types
Epidural Hemorrhage
Between skull and dura, limited by
periosteal layer so stops at sutures of
skull and thus biconvex (lens) shaped
Due to middle meningeal artery
tear,often associated with skull fracture
E
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D
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L

H
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Subdural Hematoma
Occur in the 4 As : alcoholic,anti-
coagulant-treated,aged and abuse victims
(shaken baby syndrome)
Between dura and archnoid of brain
Follow contour of brain so Crescent Shape.
Due to cortical bridging vein tear as
hemoglobin broken down,blood changes color
on CT scan and can be easily mised
(see sub acute )
Usually patients with
subdural hematoma have
worse Brain injury than
epidural hematoma
Small size bleeds can be
spontaneusly absorbed by
the body,but if midline
shift is presentSurgical
evacuation
Subdural Hemorrhage
ACUTE SUB ACUTE
CHRONIC
Subarachnoid Hemorrhage
Subarachnoid hemorrhage is
generally feathery in appearance
on CT scan, as itsmixed in with
cerebrospinal fluid
The MOST COMMON cause of
subarachnoid haemorrhage is
1.Trauma
2.The 2 nd and 3 rd most
common causes are
aneurysms or arteriovenous
malformations
No intervention is generally
performed for subarachnoid
hemorrhage alone.
However ,subarachnoid
hemorrhage can cause
hydrocephalus (due to
obstruction of CSF flow)
or vasospasm (due to ?
blood product irritating a
vessel) in delayed fashion
S
A
H
S
A
H
Intraparenchymal Hemorrhage
Called Contusions in trauma
bruising of the brain
Coup ( direct injury of brain impact) or
contrecoup (injury due to brain
hitting skull opposite side as skull
decelerates but brain doesnt)-usualy
temporal/frontal.

-Can develop extreme amount
of edema or blossom,so must
follow closely with repeat CT
scans
-Can be caused by
hypertensive hemorrhage in
characteristic locations
(basal ganglia,thalamus pons,
cerebellum) or arteriovenous
malformations


-In older patients (> 60 )
can be caused by
cerebral amyloid
angiopathy, usually in
a lobar location
-Surgical evacuation if
excessive mass effect

Intraparenchymal
hemorrhage
Intraventricular Hemorrhage
-Usually due to extension of
intraparenchymal bleed (most
Commonly from hypertension
-Treatment depends on whether
hydrocephalus develops then
patients may need ventriculostomy
placement
Intraventricular
hemorrhage
CEREBRAL STROKE
Stroke is disease
cerebrovasculer (venous of
brain) which marked with death
tissue brain (infarct cerebral)
happened because the less of
oxygen and blood strem to
brain.
Stroke divided to become two
type
1.Cerebral infarction(ischemi
attack,encephalomalacia)
thrombotic material occludes
an artery,the supply area of
which then becomes necrotic
as a result of the local ischaemi
Computed tomography (CT)
-The first few hours after vascular
occlusion CT NORMAL
-Later the density decreases
hypodense lesion


Stroke hemorrhage :
-The majority of cases a result of
hypertensive arteriosclerosis.
-Less frequent causes are vascular
malformation, anticoagulant
therapy,vasculitis,amyloid angiopathy,
tumour haemorrhage and hemorrhagic
infarction in embolism or sinus
thrombosis
Computed tomography
-the fresh haematoma is sharply
demarcated,round or oval of homogeneously
increased density (55 99 HU)
hyperdense lesion
Cerebral infarct
Infarct pons
Cerebral hemorrhage
INFECTIOUS DISEASES
Subdural Empyema

-about 13 to 20 % of all cases of intracranial
bacterial infection
-the most common cause of sub empyema
is paranasal sinusitis
-NCCT : crescentic or lentiform-shaped
area of low density (0 to 16 HU)
-CECT : a zone of enhancement separates the
hypodense extra cerebral collection
Subdural Empyema

CT
MRI
INFECTIOUS DISEASES
CEREBRAL ABSCESS
-is an encapsulated inflammation
-the centrally softened and infected area is
surrounded by granulation tissue rich in
capillaries and fibrolasts( abscess
membrane) agethickens to form a
multilayered connective-tissue capsule
rich in vessel and collagen

Compoted tomography
-NCCT
mass effect on the ventriculer
system or the midline structures
is noted in more than
80% of brain abscess.
ill defined hypodense lesion

-CECT ring contras enhancement
Cerebral abscess

Cerebral abscess

Cerebral abscess

CEREBRITIS
Result from initial infection of the brain
parenchyma
Brain cerebritis and abcess occur as
result of preceding extracerebral
infection(such as otitis
mastoiditis,sinusitis,facial cutaneus
infection,dental abscess,penetrating
skull injury)


NCCT :
- area hypodensity in the white matter with poorly
defined borders regional or widespread mass effect
CECT:
-early stage no contrast enhancement
- Mottled irreguler areas of enhancement mostly
in the regional gray matter

MR is more accurate than CT in the evaluation
of the Early stages of cerebritis
Hydrocephalus
Normal CSF flow is from lateral
ventricles to third ventricle, via
aquaduct silvii to fourth V, then
through foramina of
magendieand luschka to
subarachnoid space,then
absorption via arachnoid
granulations into the superior
sagittal sinus
-Any obstruction on this pathway
can cause hydrocephalus
-Treatment is temporarily by
diverting spinal fluid via
ventriculostomy catheter
permanently,a shunt ( e.g.
ventriculoperitoneal , or VP
shunt)
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BRAIN TUMOURS
CT or MRI Findings
Lesion location and extent
Intraaxial or extraaxial
Supratentorial or infratentorial
Single or multiple
Tumor margin
Well circumscribed or poorly
marginated
Reguler or irreguler
CT or MRI findings
Tumor characterization
calcification
Homogeneous or inhomogeneous
contrast enhancement
Necrotic,cystic
Mass effect
Localized,focal shift
Generalized,remote effects
CT or MRI findings
Edema
Vasogenic , interstitial
Brain herniations
Subfalcine
Descending transentorial
Ascending transentorial
Tonsillar
BRAIN TUMOURS

Brain Tu (pylocytic astrocytoma)

Brain tumors
CT vs MRI
CT MRI
Biaya Mahal Sangat mahal
P.Rad sedang - tinggi (-)
Prinsip X-ray Magnet &
gel radio
Waktu Biasa +/- 5 mnt +/- 30 mnt
Soft tissue tidak baik sangat baik
Tulang Baik tidak baik
Perub-imag (-) images beberapa
potongan potongan

MRI : Normal brain (axial)
MRI : Normal brain (sagital)
MRI : normal brain (coronal)
MRI ( T 1 and T2)
MRI VS CT
Encephalitis :11(MRI) 3 (CT)
Infarct Acute : 82 % 58 %

CT : -Beberpa jam pertama normal
pada : 60 % pasien walau klinis
sdh ada
-Scan ulang 48 jam setelah stroke
area hypodense ( dark)
MRI lebih sensitif dibanding CT,
Beberaoa menit setelah klinis /
sympton Gambaran MRI (+)
Cerebral Infarct
CT
T1 MRI T2 MRI
Cerebral infract

Encephalitis
Encephalitis

Subarachnoid hemorrhage

Brain tumor (sagital)
MRI : Brain tumor

Dandy Walker malformation

Chiari Malformation type II