SKULL AND BRAIN

IMAGING MODALITIES
Plain skull films

Normal
 sutures remain visible even when fused and should
not be mistaken for fractures
 Blood vessels Seen as linear or star-shaped
translucencies
 normal arachnoid granulations seen as small
lucencies in the inner table
 position of a calcified pineal gland identify the
midline of the brain
Abnormal plain films
Bone lysis
 Focal areas of bone lysis
 metastasis
 myeloma
 Large areas :
 Langerhans histiocytosis (histiocytosis X), (geographical skull)
 Paget's disease (osteoporosis circumscripta.)

Bone sclerosis
 hyperostosis frontalis interna (commonest cause )

 Localized sclerosis
 meningioma
 metastasis
 fibrous dysplasia
 widespread sclerosis
 Paget's disease
CT
Normal head CT
 cerebrospinal fluid (CSF) seen as water density
 larger arteries can be recognized when opacified by contrast
medium
 falx appears denser than the brain
 details of the posterior fossa may be obscured by artefacts
from the overlying temporal and occipital bones
Abnormal head CT
Abnormal tissue density
• High density
recent haemorrhage
calcified lesions
contrast enhancement
• Low density

neoplasms
infarcts
oedema
lipoma
Mass effect
• displaced or compressed lateral ventricles

• Shift of midline structures

non-communicating hydrocephalus
communicating hydrocephalus
• Secondary to atrophy of brain tissue
MRI of the brain
 Advantages:
 Axial, coronal and sagittal projections
 possible to recognize flowing blood without the need for
contrast medium (Magnetic resonance angiography)
 Better contrast resolution ( grey & white matter)
 ability to demonstrate plaques of demyelination
 disadvantages of MRI
 inability to show calcification
 lack of bone detail
 relative expense of the technique
 difficulty of monitoring seriously ill patients whilst lying
within the scanner.
Neurosonography
 scan the heads of neonates and young babies
 is best done through an open fontanelle
 particularly useful in:
 intracerebral haemorrhage
 ventricular dilatation
SPECIFIC BRAIN DISORDERS
Brain tumours

Glioma
 CT
 solitary, irregular mass surrounded by oedema
 usually hypodense but may be hyperdense or mixed.
 Most show partial enhancement
 sometimes only the outer portion enhances (ring
enhancement)
 may calcify
 Compression or displacement of the ventricles
 MRI
 lower in signal intensity than the normal brain on the Tl
 higher on T2.
Brain metastases
 typically multiple
 may be of high or low density
 often surrounded by substantial oedema
 usually show contrast enhancement

 Meningioma
 Commonest sites:
 parasagittal region
 cerebral convexities
 sphenoid ridges.
 slightly denser than the brain
 tumour shows marked enhancement
 Sclerosis and thickening of the adjacent bone
 compressing the brain from outside
Acoustic neuroma
 arise in the internal auditory canal or immediately
adjacent to the internal auditory meatus in the
cerebellopontine angle

Pituitary tumours
 microadenomas (<lcm).
 macroadenomas (>1 cm)
 enlargement of the pituitary fossa on a skull x-ray
 may be pressing on the optic chiasm
 enhance vividly following intravenous contrast
administration
 MRI
 preferred investigation
 showing very small tumours, smaller than can be
seen with CT
 low intensity region compared to the normally
enhancing pituitary gland.
Stroke
 Cerebral infarction
 CT:
 Changes of acute infarction are not usually recognized on CT before six
hours
 Early (>6hr): reduced parenchymal attenuation
 next few days: low attenuation area (vascular distribution)
 Chronic: resolve leaving an atrophic area and/or a persistent scar
 normal CT examination does not exclude the diagnosis.
 MRI
 hyperintense areas on a T2-weighted scan within 8 hours of the onset
 Enhancement with gadolinium shows changes sooner
 Doppler ultrasound of the neck
 atheromatous plaque and degree of stenosis
 Cerebral haemorrhage
 demonstrable on CT immediately high attenuation
 following week or two leaving low density
 frequently causing mass effect
 blood may also be identified in the subarachnoid space and
within the ventricles
 MRI is the preferred In the subacute and chronic phases
 Subarachnoid haemorrhage
 high density blood in the cortical sulci Sylvian fissures and
basal cisterns
Infection
 Acute meningitis
 CT and MRI are usually normal
 may show hydrocephalus

Encephalitis
 viral or an immune reaction
 CT and MRI
 unilateral or bilateral focal abnormal areas often in a characteristic
distribution appearing as low attenuation on CT and high signal on a
T2-weighted MRI scan

abscess
 pyogenic
 tuberculous
 fungal
 parasitic organisms
 low density on CT
 may be surrounded by oedema
 wall of the abscess enhances
Multiple sclerosis
 MRI is the key imaging modality for multiple sclerosis
 Plaques are seen in the white matter
 particularly in the periventricular
 areas of high signal on a T2-weighted scan
 Contrast enhancement occurs with acute plaques

Ageing
 dilatation of the ventricles
 widening of the cortical sulci
 low attenuation areas in the deep white matter
 small infarcts in the brain substance
 particularly in the basal ganglia and capsular regions
HEAD INJURY
FRACTURES
Signs:
 linear translucencies
 depressed fracture appears dense rather than lucent because the
fragments overlap.
 Fluid levels in the sinuses may indicate a fracture
 extradural haematoma should be carefully considered if a fracture
crosses the groove for the middle meningeal artery
FRACTURES
differences between fractures & normal vascular markings:
 Fractures sometimes appear more translucent than vascular
markings.
 Fractures may branch abruptly.
 Fractures have straight or jagged edges, which fit together.
Venous channels have undulating irregular edges which cannot be
fitted together.
 Arterial grooves have parallel sides and they occur in known
anatomical sites.
 Sutures also occur in recognized anatomical positions and show
definite regular interdigitations
CT IN HEAD INJURY

 carried out in all patients who have had a significant head

 performed without intravenous contrast administration

 Extradural haematoma
 Lens shaped
 smoothly demarcated high density area
 associated with a skull fracture
 does not cross the suture line, but cross the dural reflections

 Subdural haematoma
 conforms to the shape of the underlying brain
 most commonly over the convexity of the brain
 can also arise along the flax and tentorium
 crosses the suture line but not dural reflections.
 fracture is uncommon.
Intracerebral lesions
 Oedema.
 may cause the whole brain to swell
 homogeneous low density
 compression of the ventricles
 Contusions
 areas of low attenuation
 may be associated with haemorrhage.
 Intracerebral haematomas
 areas of high density
 may be multifocal
 may be mass effect
 displacement of the ventricles

 accompanying brain oedema.