P1
P1
P1
KEY POINTS
Cranial computed tomography (CT) is an extremely useful diagnostic tool used routinely
in the care of ED patients.
The EP needs to be able to accurately interpret and act upon certain CT findings
without specialist (e.g., radiologist) assistance, because many disease processes are timedependent and require immediate action.
It has been shown that even a brief educational intervention can significantly improve the
EPs ability to interpret cranial CT scans.
Using the mnemonic blood can be very bad (where blood = blood, can = cisterns, be =
brain, very = ventricles, and bad = bone) the EP can quickly but thoroughly review a
cranial CT scan for significant pathology that demands immediate action.
Basic Principles of CT
The fundamental principle behind radiography is the
following statement: X-rays are absorbed to different
degrees by different tissues. Dense tissues such as bone
absorb the most x-rays, and hence allow the fewest
passing through the body part being studied to reach
the film or detector opposite. Conversely, tissues
with low density (e.g., air and fat) absorb almost
none of the x-rays, allowing most to pass through
to the film or detector opposite. Conventional
radiographs are two-dimensional images of threedimensional structures; they rely on a summation of
tissue densities penetrated by x-rays as they pass
through the body. It should be noted that in plain
radiographs, denser objects, because they tend to
absorb more x-rays, can obscure or attenuate less
dense objects.
753
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ATTENUATION COEFFICIENT
BOX 69-1
WINDOWING
Appearance
Black White
1000 HU +1000 HU
Air, fat, CSF, white matter, gray matter, acute
hemorrhage, bone
Important Densities
Air = 1000 HU
Water = 0 HU
Bone = +1000 HU
ARTIFACT
CT of the brain is subject to a few predictable artifactual effects that can potentially inhibit the ability
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As long as one is systematic in the search for pathology, any number of techniques can be utilized in the
review of head CT images. Some recommend a
center-out technique, in which the examiner starts
from the middle of the brain and works outward.
Others advocate a problem-oriented approach, in
which the clinical history directs the examiner to a
particular portion of the scan. In the authors experience, both of these are of limited utility to the clinician who does not frequently review scans. A preferred
method, one that has been demonstrated to work in
the ED,2 is to use the mnemonic blood can be very
bad (Box 69-2). In this mnemonic, the first letter of
each word prompts the clinician to search a certain
portion of the cranial CT scan for pathology. The
clinician is urged to use the entire mnemonic when
examining a cranial CT scan because the presence of
one pathologic state does not rule out the presence
AS
Ethmoid sinus
Sphenoid
sinus
Temporal
lobe
Cerebellar
tonsil
Medulla
Foramen
magnum
L
Medulla
Mastoid
air cells
Cerebellum
Frontal lobe
Suprastellar
cistern
Suprasellar
cistern
Dorsum
sellae
Sylvian
cistern
Temporal
lobe
Pons
L
IVth
ventricle
Cerebellum
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Circummesencephalic
(ambient) cistern
Pons
IVth ventricle
Cerebellum
Circummesencephalic
(ambient) cistern
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SECTION VIII
Caudate nucleus
Anterior
limb
(internal
capsule)
Frontal horn
IIIrd
ventricle
L
Sylvian
cistern
Cerebellum
Quadrigeminal
cistern
Lentiform
nucleus
Sylvian
cistern
Quadrigeminal cistern
Posterior limb
(internal capsule)
Calcified falx
Central
sulcus
Falx cerebri
(calcified)
Lateral
ventricle
Occipital
horn
Calcified
choroid
Blood
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Gyri
Sulci
Epidural Hematoma
Subdural Hematoma
Subdural hematoma appears as a sickle- or crescentshaped collection of blood, usually over the cerebral
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BOX 69-2
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10
Intraparenchymal Hemorrhage
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Intraventricular Hemorrhage
Intraventricular hemorrhage can be traumatic or secondary to intraparenchymal hemorrhage or subarachnoid hemorrhage with ventricular rupture.
Identified as a white density in the normally black
ventricular spaces, it is associated with a particularly
poor outcome in cases of trauma (although this may
be more of a marker than a causative issue). Hydrocephalus can be the end result regardless of the etiology. Cerebrospinal fluid (CSF) is produced in the
lateral ventricles at a rate of 0.5 to 1 mL per minute,
and this will occur regardless of the intraventricular
pressure. A block at any point in the CSF pathway
(lateral ventricles foramen of Monro 3rd ventricle aqueduct of Sylvius 4th ventricle foramina of Luschka and Magendie cisterns arachnoid
granulations) will result in hydrocephalus, with associated increased intracranial pressure and the ultimate potential for herniation.
Subarachnoid Hemorrhage
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A
hemorrhage is most commonly aneurysmal (75%80%), but it can also occur with trauma, tumor, arteriovenous malformations and dural malformations.
As a result of arachnoid granulations becoming
plugged with red blood cells or their degradation
products, hydrocephalus complicates approximately
20% of cases of subarachnoid hemorrhage.
The ability of a CT scanner to demonstrate subarachnoid hemorrhage depends on a number of
factors, including the generation of scanner, the time
since the initial bleeding, and the skill of the examiner. According to some studies, the CT scan is 95%
to 98% sensitive for subarachnoid hemorrhage in the
first 12 hours after the ictus.9-11 This sensitivity is
reported to decrease as follows:
90%-95% at 24 hours
80% at 3 days
50% at 1 week
30% at 2 weeks
Extracranial Hemorrhage
Cisterns
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Suprasellar
cistern
Pons
Circumesencephalic
cistern
Top of fourth
ventricle
Suprasellar
cistern
Cerebral
peduncles
Sylvian
cistern
Interhemispheric
cistern
Quadrigeminal
Circumesencephalic cistern
cistern
Quadrigeminal
cistern
Tempocal horn
of lateral ventricle
Occipital horn
of lateral ventricle
FIGURE 69-9 Three important cerebrospinal fluid cisterns: A, cisterns viewed at high pontine level; B, cisterns viewed at level of
cerebral peduncles; C, cisterns viewed at high midbrain level.
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through egress from the 4th ventricle. Hydrocephalus frequently is first evident in dilation of the temporal horns, which are normally small with a slit-like
morphology.
When examining the ventricular system for hydrocephalus, the clinician needs to take in the entire
picture of the brain, as ventricles can be large for
reasons other than increased pressure (e.g., atrophy).
If the ventricles are large, the clinician should investigate whether other CSF spaces in the brain are large
(e.g., sulci, cisterns). In this case, it is likely that this
enlargement is the result of brain volume loss rather
than the increased ventricle size. Conversely, if the
ventricles are large, but the brain appears tight
with sulcal effacement and loss of sulcal space, then
the likelihood of hydrocephalus is high. The clinician also should look for evidence of increased intracranial pressure (e.g., cisternal effacement).
a lacunar infarction, which are small, discrete nonhemorrhagic lesions usually secondary to hypertension and found in the basal ganglia region. They
frequently are clinically silent.
Ventricles
Pathologic processes can cause either dilation (hydrocephalus) or compression/shift of the ventricular
system (Fig. 69-14). Additionally, hemorrhage can
occur into any of the ventricles, resulting in the
potential for obstruction of flow and resulting hydrocephalus. The term communicating hydrocephalus
is used when there is free CSF egress from the ventricular system, with a blockage at the level of the
arachnoid granulations. The term noncommunicating
hydrocephalus is used if there is obstruction anywhere
along the course of flow from the lateral ventricles
Bone
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REFERENCES
Summary
Cranial CT is integral to the practice of emergency
medicine and is used on a daily basis to make important, time-critical decisions that directly impact the
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1. Schreiger DL, Kalafut M, Starkman S, et al: Cranial computed tomography interpretation in acute stroke. JAMA
1998;279:1293-1297.
2. Perron AD, Huff JS, Ullrich CG, et al: A multicenter study
to improve emergency medicine residents recognition of
intracranial emergencies on computed tomography. Ann
Emerg Med 1998;32:554-562.
3. Leavitt MA, Dawkins R, Williams V, et al: Abbreviated educational session improves cranial computed tomography
scan interpretations by EPs. Ann Emerg Med 1997;
30:616-621.
4. Alfaro DA, Levitt MA, English DK, et al: Accuracy of interpretation of cranial computed tomography in an emergency medicine residency program. Ann Emerg Med 1995;
25:169-174.
5. Roszler MH, McCarroll KA, Donovan RT, et al: Resident
interpretation of emergency computed tomographic scans.
Invest Radiol 1991;26:374-376.
6. Arendts G, Manovel A, Chai A: Cranial CT interpretation
by senior emergency departments staff. Australas Radiol
2003;47:368-374.
7. Saketkhoo DD, Bhargavan M, Sunshine JH, et al: Emergency department image interpretation services at private
community hospitals. Radiology 2004;231:190-197.
8. Lowe RA, Abbuhl SB, Baumritter A, et al: Radiology services
in emergency medicine residency programs: A national
survey. Acad Emerg Med 2002;9:587-594.
9. Boesiger BM. Shiber JR: Subarachnoid hemorrhage diagnosis by computed tomography and lumbar puncture: Are
fifth generation CT scanners better at identifying subarachnoid hemorrhage? J Emerg Med 2005;29:23-27.
10. Van der Wee N, Rinkel GJE, van Gijn J: Detection of subarachnoid hemorrhage on early CT: Is lumbar puncture
still needed after a negative scan? J Neurol Neurosug Psychiatry 1995;58:357-359.
11. Morgenstern LB: Worst headache and subarachnoid hemorrhage prospective, modern computed tomography and
spinal fluid analysis. Ann Emerg Med 1998;32:297-304.
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