Common Neurosurgical Images

Specialty Clerkship

Division of Neurosurgery
Department of Surgery
Queen Mary Hospital
Basic Anatomy 1
 Basic Anatomy 1
Frontal air sinus

Anterior
Greater wing of
cranial fossa
sphenoid

Middle cranial
fossa

Petrous temporal
Posterior
bone
cranial fossa

Bone window Mastoid air cells

Basic Anatomy 2
 Basic Anatomy 2

Sylvian fissure

Third ventricle
Basal cistern
Tentorium cerebelli ‘smile’
Blood within sagittal
Cerebellum and transverse sinus
Basic Anatomy 3
 Basic Anatomy 3
Pituitary fossa
Brain stem
Frontal lobe This level – Pons
Rostral – midbrain
Temporal lobe Caudal – medulla
oblongata

Cerebellar 4th ventricle

hemisphere

Cerebellar vermis
Basic Anatomy 4
 Basic Anatomy 4
Lateral ventricle

Frontal lobe
Basal ganglion

Thalamus
Parietal lobe
Falx cerebrii

Occipital lobe
M/27. Fell from height. Diagnosis ?
 Epidural haematoma

Dura
F/78. Found collapsed at home.
GCS 14/15. Diagnosis ?
 Acute subdural hematoma

Hyperdense
Mid-line shift acute
haematoma
Normal sulcus
M/80. Bilateral lower limbs weakness for 1 week.
On asprin. Diagnosis ?
 Acute-on-chronic subdural
haematoma

Hypodense
chronic
blood

Hyperdense
acute blood
M/72. Minor head injury 1 week ago. Now
headache and left-sided weakness. Diagnosis?
 Subacute subdural hematoma
Subacute
isodense
haematoma
Gray-white
junction shifted
inward
Obliterated
ventricle
Effacement
of sulci
 F/50. Hit by car. GCS 5/15.
Diagnosis ?

Diagnosis ? Diagnosis?
 Severe head injury
Delayed appearance
Traunatic SAH
of contusion

Epidural
haematoma

Severe brain swelling with Patent cistern Craniectomy

Compressed
obliterated basal cistern after decompression
brain stem
F/52. Sudden severe headache.
GCS 8/15. Diagnosis ?
Subarachnoid haemorrhage

SAH in cisterns
Blood in Sylvian fissure and sulci
What investigation next?
 Digital subtraction angiography (DSA)

?
Lateral view
Anterio-posterior view
What arteries are being studied?
 Right ICA injection. (Normal)

ACA
MCA

ACA

MCA

ICA
ICA
Lateral view
AP view
 What arteries are being studied?

?
?

?
?
Anterio-posterior view Lateral view
Right vertebral artery injection. (Normal)

PCA
PCA

PCoA

Basilar artery
Vertebral artery
Vertebral artery
Lateral view
AP view
F/66. Severe headache. GCS 13/15. Diagnosis?
Anterior comminicating artery aneurysm
(ACoA) aneurysm rupture

Right Left
ACA ACA

ACoA
MCA
ICA
Aneurysm

Blood clot in subarachnoid Left ICA DSA AP view

space and ACA territory
M/45. Sudden collapse during exercise. GCS 8/15.
Diagnosis ?
 Middel cerebral artery (MCA) aneurysm
rupture

Aneurysm

Clot in MCA territory Right ICA DSA AP View

(Sylvian fissure)
F/24. Hit by train. GCS 14/15.
Diagnosis?
 Traumatic intracerebral
haemorrhage or ‘contusion’

Heterogenous (salt and pepper) appearance of haematoma

within brain parenchyma
M/37. Sudden left-sided weakness.
Diagnosis?
 Spontaneous intracerebral
haemorrhage (Lobar in location)

Homogenous haematoma
 M/54. Known hypertension. Sudden
right-sided weakness. Diagnosis?

Structure?

Structure?

Structure?

Structure?

Structure?

Structure?
 Spontaneous intracerebral
haemorrhage (Basal ganglion)

Caudate nucleus
Lentiform
nucleus
Internal capsule

Third ventricle

Thalamus

Pineal calcification
F/45.Sudden collapse GCS 5/15.
Diagnosis?
 Intraventricular haemorrhage

Blood in third ventricle Total haematocephalus

causing CSF obstruction
M/58. Recent CVA. Diagnosis?

Diagnosis ?

Diagnosis ?
 Hydrocephalus
Periventricular oedema

Calcification
in choroidal
plexus
Dilated temporal horn
Round 3rd ventricle
Dilated 4th ventricle
Intraventricular blood
M/65. Sudden ataxia and headache.
Diagnosis ?
 Cerebellar haemorrhage
Dilated
temporal
Brain stem
horn
compression

Hydrocephalus
F/45. Sudden diplopia. Diagnosis?
Brain stem haemorrhage
M/65. Left-sided weakness 1 day ago.
Now deteriorating GCS. Diagnosis ?
 Massive MCA infarction
Loss of gray-white
differentiation
Mid-line shift and
subfalcine herniation
Brain swelling and
effacement of sulci
M/27. Recent upper airway infection. Now headache
and confusion. What investigation next ?
 Diagnosis?

Plain CT scan Contrast CT scan

 Brain abscess
Oedema Pus

Contrast CT scan with ring

Plain CT scan enhancement of the abscess capsule
M/45. Chronic smoker. Now headache
and confusion. Most likely diagnosis ?

Plain CT Contrast CT
 Multiple metastasis

Contrast CT
Plain CT
Note contrast in cortical
vessels and large veins
M/71. Recent headache for 3 weeks.
What next? Most likely diagnosis ?
 Meningioma

Mass with Contrast CT

Plain CT oedema
What investigation is this?

? Sequence ? Sequence
 MRI
Septum pallucidum

T1-weighted image with T2-weighted image

Gadolinium in vessels
 F/38. Bitemoral hemianopia. Diagnosis?
Structure? Structure? Structure?

Structure?
Structure? Structure?

Structure? Structure? Structure? Structure?

 Pituitary adenoma (Contrast MRI)
Lateral ventricle 3rd ventricle Hypothalamus
Cerebral aqueduct
Pituitary stalk
Optic chiasm

Midbrain Medulla
Sphenoidal sinus oblongata
Pons
M/54. Left-sided tinnitus.
Most likely diagnosis ?
 Left acoustic neuroma
Semicircular canal

Widened internal acoustic meatus

Cerebellopontine angle
M/30. Good past health. Found
collapsed. Diagnosis?
Right frontal ICH. What next?

subfalcine herniation

Oedema around haematoma

 Magnetic resonance imaging (MRI)
Diagnosis? What next?

Flow void
Arterio-venous malformation (AVM)
The end