C ENRTAL NERVOUS SYSTEM

RADIOLOGY
DR. MOHAMAD MATAR
 Skull fractures
● closed traumatic brain injury
● penetrating brain injury

Skull fractures can be broadly divided in a

variety of way:
• anatomically
• base of skull
• skull vault
• associated with overlying wound
• open (compound)
• Diagnosis :
– X-ray
– CT.
• presentationhead injury following impact
trauma, e.g. fall, RTC
• symptoms associated with underlying injury
• extradural hemorrhage
• subdural hemorrhage
• subarachnoid hemorrhage
• there may be an associated base of skull injury
• CSF rhinorrhea
• Battle sign (bruising over mastoid process)
• raccoon eyes
Battle sign : middle cranial fossa fracture.
result of extravasation of blood along the path of the posterior auricular artery
 Raccoon Eyes
• blood from skull fracture seeps into the soft
tissue around the eyes.
• Raccoon eyes may be accompanied by Battle's
sign, an ecchymosis behind the ear.
• If bilateral, it is highly suggestive of basilar
skull fracture
 intra axial haematoma
• HT related ( mostly basal ganglia).
• Vascular anomaly.
• Lesions ( benigen / malignanat.
• Trauma.
hemorrhagic brain tumors
hemorrhagic brain tumors
 Extra axial haematoma.
• extradural hemorrhage
• subdural hemorrhage
• subarachnoid hemorrhage
 Subdural hematomas
• Subdural hematomas are interposed between
the dura and arachnoid.
• Typically crescent-shaped.
• They are usually more extensive than
extradural hematomas.
• In contrast to extradural hemorrhage, SDH is
not limited by sutures but are limited by dural
reflections, such as the falx cerebri, tentorium,
and falx cerebelli.
acute SDH causing sub-falcine herniation
bilateral chronic subdurals
isodense left SDH
 Extradural hemorrhage
• Also known as an epidural hematoma, is a
collection of blood that forms between the
inner surface of the skull and outer layer of the
dura, which is called the endosteal layer.
• They are usually associated with a history of
head trauma and frequently associated skull
fracture.
• The source of bleeding is usually arterial, most
commonly from a torn middle meningeal
artery.
• EDHs are typically biconvex in shape and can
cause a mass effect with herniation. They are
usually limited by cranial sutures, but not by
venous sinuses.
typical bi-convex shape
massive
EDH
 Subarachnoid hemorrhage
• Risk factors include 2:
• family history
• hypertension
• heavy alcohol consumption
• abnormal connective tissue
• autosomal dominant polycystic kidney disease
• Ehlers-Danlos disease type IV
• Marfan syndrome
• neurofibromatosis type 1
Causes include 1:
• trauma
• spontaneous
• ruptured berry aneurysm: 85% 1
• perimesencephalic hemorrhage: 10% 4
• arteriovenous malformation
• cerebral amyloid angiopathy
• ruptured mycotic aneurysm
• reversible cerebral vasoconstriction syndrome
 ACUTE CVA
• Stroke is a leading cause of death and disability
worldwide. Imaging plays a critical role in
evaluating patients suspected of acute stroke
and transient ischemic attack (TIA), especially
prior to initiating treatment
• The primary goal of imaging patients with
acute stroke symptoms is to distinguish
between hemorrhagic and ischemic stroke.
 WHAT imaging technique
• NCCT.
• Contrast CT.
• MRI .
• MRI & MRA.
• perfusion CT/MRI.
• Sensitivity of imaging modality is variable and
depends in time window between imaging and onset
of symptoms , location of affected area ( low
sensitivity of CT in posterior fosse) and size of area
involved. But as general role :
– Non contrast CT has low sensitivity in acute stroke ~35%.
– MRI has higher sensitivity for acute stroke when using DWI
reaching 99% .
Imaging characteristics CT MRI
Availability in the acute setting (0–6 hours) ++ −
Rapid image acquisition ++ +
Lack of vulnerability to motion artifact + −
Accessibility for patients with monitors and/or ventilators ++ −
Feasibility and safety for patients with metallic implants ++ −
(pacemakers, implantable defibrillators)
Lower cost + −
Lack of ionizing radiation − ++
Renal toxicity associated with contrast administration + +
Time for post-processing angiography and perfusion − −
imaging
Sensitivity to lacunar and posterior fossa infarcts − ++
Differentiation between acute and chronic ischemia − ++
Ability to assess causes of ICH or SAH while in the + +
scanner
Detection of chronic hemorrhage including microbleeds − +
• The accuracy of MRI techniques for detection
of intracranial hemorrhage in the acute stroke
setting (within 6 hours) has been reported as
likely equivalent to NCCT .
• But T2*-weighted sequences (including
gradient-recalled echo [GRE] and
susceptibility-weighted imaging [SWI]
sequences) have superior accuracy in the
detection of chronic microhemorrhages
• NCCT is the accepted standard-of-care
imaging modality for exclusion of intracranial
hemorrhage and has been incorporated in the
inclusion criteria in randomized clinical trials
evaluating the efficacy of IV thrombolysis.
• NCCT is often referred to as the “reference
standard” for detection of acute intracranial
hemorrhage based on reports describing its
accuracy with early CT scanners.
• The primary goals of imaging during the 0–
4.5-hour time window are to exclude the
presence of intracranial hemorrhage and assess
the presence and extent of ischemic changes.
• The presence of intracranial hemorrhage
(excluding microbleeds) is an absolute
contraindication to administering IV
thrombolytic therapy.
• Early signs of ischemia involving more than
one-third of the middle cerebral artery (MCA)
territory in the 0–6-hour time window have
been associated with large infarcted regions,
increased risk of hemorrhagic transformation,
and poor outcomes, and thus constitute a
relative contraindication to IV thrombolysis.
• NCCT is also used to assess for early signs of
infarction, including :
– loss of gray-white differentiation.
– Sulcal effacement.
– Hyperdense clot in the proximal vessels.
• The middle cerebral artery can be classified
into 4 parts:[2]
– M1: The sphenoidal segment, so named due to its
origin and loose lateral tracking of the sphenoid
bone. Although known also as
the horizontal segment, this may be misleading
since the segment may descend, remain flat, or
extend posteriorly the anterior (dorsad) in different
individuals. The M1 segment perforates the brain
with numerous anterolateral central (lateral
lenticulostriate) arteries, which irrigate the basal
 Alberta stroke program early CT
score (ASPECTS)
• Scoring system
• Segmental assessment of the middle cerebral
artery (MCA) vascular territory is made and 1
point is deducted from the initial score of 10
for every region involved:
– caudate
– putamen
– internal capsule
– insular cortex
– M1: "anterior MCA cortex," corresponding to
• The initial paper 1 specifically referred to the
internal capsule only involving the posterior
limb, however, subsequent articles indicate any
portion of the internal capsule may be included
• M1 to M3 are at the level of the basal ganglia
• M4 to M6 is at the level of the ventricles
immediately above the basal ganglia
• Clinical use
– An ASPECTS score less than or equal to 7 predicts
a worse functional outcome at 3 months as well as
symptomatic hemorrhage.
– According to the study performed by R I Aviv et
al., patients with ASPECTS score less than 8
treated with thrombolysis did not have a good
clinical outcome .
 Posterior circulation
pc-ASPECTS
• thalami (1 point each)
• occipital lobes (1 point each)
• midbrain (2 points)
• pons (2 points)
• cerebellar hemispheres (1 point each)
BRAIN TUMORS
Meningioma
Schwanoma
Glioblastoma multi formi
 hydrocephalus
• Communicating
• Non communicating
• communicating (i.e. CSF can exit the
ventricular system)
• without obstruction to CSF absorption
particular group of conditions with disparate,
and often poorly understood, abnormal CSF
dynamics, including:
– normal pressure hydrocephalus (NPH)
– choroid plexus papillomas (part of the associated
hydrocephalus is thought to be due to
overproduction of CSF 1. An obstructive
component in larger masses is often also present).
• non-communicating (i.e. CSF cannot exit the
ventricular system, and thus there is by
definition obstruction to CSF absorption)often
merely referred to as obstructive
hydrocephalus
• upstream ventricles are dilated and exert mass
effect upon adjacent brain (e.g. effacement of
sulci)
• numerous causes including:
– foramen of Monro: colloid cyst
– aqueduct of Sylvius: aqueduct stenosis, tectal
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