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NORMAL – PLAIN CT SCAN, AXIAL VIEW

1. Check the density
Gray = ISODENSE = brain tissue

HYPODENSE = anything that’s black that contains water (e.g. ventricles)

HYPERDENSE = whatever is white in relation to the brain (structures composed of

calcium = kaya sya maputi = e.g. skull)
Blood = contains calcium = if hyperdensity inside parenchyma = probably a bleed

*physiologic changes*
*(red arrow) CALCIFIED CHOROID PLEXUS = once calcified calcium deposits in it =
normally calcifies @ 18 y/o
Location: Temporal horn of the lateral ventricles
*(blue arrow) also calcifies @ age 18 = PINEAL GLAND

ALWAYS COMPARE LEFT & RIGHT

(orange circle) Frontal horn of lateral ventricles containing CSF

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ABNORMAL
Describe the abnormality. (red circle)
- HYPODENSITY (black)= INFARCT = Infarcted brain tissue is edematous = contains water
(hypodense in relation to the blood tissue)
- Hyperdensity (white) = bleed

- Diagnosis of an infarct : base it on the arterial distribution

Which artery is infarcted?
Identify what structure of the brain.
THALAMUS, LEFT
Blood supply: PCA (supplies thalamus together with occipital lobe)

(yellow arrow) imaginary line: INTERNAL CAPSULE = medial to it is THALAMUS

(green arrow) CAUDATE

Evaluate the sylvian fissures..

Many sulci = brain is already atrophic

Frontal horns of the lateral ventricles WIDEN = d/t atrophy (lumuluwag yung mga canal) = common
in brain of elderly

Complete diagnosis: ACUTE CEREBRAL INFARCTION, LEFT PCA DISTRIBUTION

Give a possible symptom or complain of the patient

SENSORY DEFICIT
HEMIPARESIS
DIFFICULTY SLEEPING (sleep-wake cycle is disrupted; level of ARAS goes as high as the diencephalon
which involves thalamus, hypothalamus, etc)

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ABNORMAL

Describe: HYPODENSE
Other abnormalities:
- DEVIATION/MIDLINE SHIFT (always trace the midline)
- COMPRESSION OF THE LATERAL VENTRICLE, RIGHT FRONTAL HORN
- NO MORE SULCI because of EDEMA (interstitial)

Distribution: MCA
Segment/branch: MAIN TRUNK (M1)

M1 = whole MCA is infarcted = poor prognosis

Edema secondary to infarct: interstitial

Edema secondary to tumor & CNS infection: vasogenic edema

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(blue arrows) HYPERDENSITIES = bleed
(+) bleeding inside the infarcted area = HEMORRHAGIC CONVERSION = infarct dati,
ngayon nag bleed na din = difficult to manage; you cannot give
antiplatelet/anticoagulants bec there is already active bleeding inside the brain

Pathophysiology: REPERFUSION INJURY

Autoregulation = infarcted area of the brain -> all other arteries will supply blood on
that infarcted area of the brain -> bec there are so many other arteries from the
meninges, they try to supply the infarcted area of the brain -> sudden onset of blood
flow to that already infarcted area -> causes damage to the already damaged area of
the brain -> bleed
= poor prognosis:
1. cannot give meds for secondary prevention
2. Bleeding may enlarge, expand and expand and expand
3. No medicine that can hinder a bleeding artery from bleeding

Tx: DECOMPRESSION
How? = HEMICRANIECTOMY (not craniotomy)
Hemi = half
Craniectomy = remove the entire skull
Craniotomy = your just putting a hole (done if bleed)

(if infarct) DECOMPRESSIVE HEMICRANIECTOMY = must have a wide incision of the

skull

If only partial is removed = ineffective, very fatal = lalabas ang utak in the small hole
like toothpaste (saggy, parang taho) = brain tissue is dead

Others:
OSMOTIC DIURESIS = medical decompression = mannitol, hypertonic saline = have
ceratin period of effectiveness

*this is the ANTERIOR circulation

*what you see is the top of the brain

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*whenever you see the sphenoid wing with the mastoid air cells of ear = POSTERIOR
circulation

FL = frontal lobe
TL = temporal lobe
BS = brainstem
SW = sphenoid wing
MAC = mastoid air cells
CBL = cerebellum

ABNORMAL
Describe: HYPODENSITY
Where: LEFT CEREBELLUM
Arterial supply: SUPERIOR CEREBELLAR ARTERY

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(L) INFERIOR
(R) SUPERIOR PORTION OF CEREBELLUM
Look at brainstem = ipit na ipit

(orange arrow) fourth ventricle

What else do you see?

- COMPRESSION OF FOURTH VENTRICLE AND THE BRAINSTEM
- (+) MIDLINE SHIFT

(yellow arrows) temporal horns of the lateral ventricle

- OBSTRUCTIVE HYDROCEPHALUS

HYPODENSITY at the LEFT CEREBELLAR AREA with MIDLINE SHIFT and resulting to
OBSTRUCTIVE HYDROCEPHALUS

(blue arrow) third ventricle = also opened bec of hydrocephalus (normally should be
closed)

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ABNORMAL
POSTERIOR CIRCULATION (presence of sphenoid wing and mastoid air cells)
ASSYMETRIC (pantay ba? Look at the eyes)

Abnormality: HYPERDENSITY
Where: BRAINSTEM - PONS

Midbrain = like an inverted shorts, or inverted mickey mouse

Pons = circular in shape
Medulla = 1 cm widest diameter

Diagnosis: PONTINE BLEED, RIGHT

Why right? = most of the volume of the bleed is at the right portion of the brain
How would you know the severity of the bleed? = PONS anatomically speaking has a
diameter of 3 cm = how you describe the volume of bleed in the brainstem is
measured by the WIDEST CENTIMETER of that bleed

(red circle) approx. 2 cm widest diameter

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if the bleed is 3 cm in its widest diameter = entire pons is already destroyed

How do you appraise the px? = the bleeding is just small but it’s in the wrong place =
controls wakefulness, breathing, cardiac rate

Px most probably:
GCS 3
COMATOSE
AMBUBAGGING/HOOKED TO VENTILATOR (they do not have spontaneous breathing)
Sometimes they suffer from CARDIAC DYSRHYTHMIAS

Any bleeding in the brainstem – POOR PROGNOSIS

Management:
Tranexamic acid? -NO
- CONTROL BP
1. Nicardipine drip
2. Diuretics
- ORAL MEDICATIONS AT THE ONSET OF STROKE? –NO = only give EASILY
TITRATABLE ANTIHYPERTENSIVE MEDS
- NEUROSURGICAL INTERVENTION? –NO = midline structure, you cannot get into it
without destroying normal neurons unless you do it intranasally; lesion is already
irreparable;

What is the content of brainstem? Neurons or axons? -AXONS = contains (ascending

& descending pathways) tracts = (neuronal cell bodies are found at the cortices)
Will mannitol or any form of osmotic diuresis work on this area of the brain? –NO bec
mannitol works on the neuronal cell bodies

- ABC’s
Most probably px has decreased sensorium, DOB,
control BP, decrease temp (high temp puts the px in a hypercoagulable state giving
added insult to injury) to as low as 34-35 C (use cooling systems) to lower the
metabolic rate of brain

- GIVE ANTIHYPERTENSIVE MEDICATIONS

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ABNORMAL
HYPERDENSITY
LEFT BASAL GANGLIA

*most of the stroke/bleed that you see in the hospital 50% of them has this type of
bleed

Bec of the large bleed = thalamus at the medial area is already compressed

MIDLINE SHIFT? -YES, SLIGHT

Diagnosis: INTRACEREBRAL HEMORRHAGE, LEFT BASAL GANGLIA

Bleed volume = approx. 45-50 cc

[picture b]
Px underwent CRANIOTOMY
- Skull defect = small hole (blue arrow)
- Compare the skull with picture a

Where will we base our decision to undergo neurosurgical intervention in px with

intracerebral hemorrhages
1. Sensorium (decrease = hematoma is expanding)
2. Volume (<30 cc = manage medically; >30 cc = always have px be monitored by a
neurosurgeon)

*Most of the bleed are secondary to HYPERTENSION

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ABNORMAL
BASE OF BRAIN (bleeding inside brain chances are there will be pooling of blood at
the base of the brain) = BASAL CISTERN

HYPERDENSITY AT THE BASAL CISTERN

Why basal cistern?

The cut will tell you that it is at the base of the brain at the level of the ear
Cistern is usually star shaped = STAR OF DAVID SIGN (red circle) = pathognomonic for
SUBARACHNOID HEMORRHAGES

Others:
(yellow arrows) opening of the temporal horns of the lateral ventricles =
HYDROCEPHALUS

SUBARACHNOID HEMORRHAGE plus an OBSTRUCTIVE HYDROCEPHALUS

-may be secondary to aneurysms, ruptured AVM, ruptured hemangioma, anything
that ruptures in the brain

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NORMAL

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HYPODENSITY
RIGHT

VENTRICLES ARE ENLARGED AND CONNECTED = means its at the top of the brain =
cannot see caudate nucleus, internal capsule, thalamus anymore = subcortical
area/periventricular area

Arterial supply: ACA

Type of infarct: LACUNAR INFARCT = <1.5 cm in widest diameter

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