Set8 20041004

Figures 8.1 through 8.5 represent 5 patients
who presented with focal neurological deficits
and acute change in mental status.

8.1. Non-contrast CT Brain

8.1 Non-contrast CT Brain

CT Density 68.6 HU
Q8.1. Diagnosis Please


8.2. Non-contrast CT Brain

8.2 Non-contrast CT Brain

CT Density 72.9 HU
Q8.2. Diagnosis Please


8.3a. Non-contrast CT Brain

8.3b&c. Non-contrast CT Brain

09/02/2003

CT Density 25.0 HU
09/21/2003

Q8.3. Diagnosis Please

8.4a. Non-contrast CT Brain

8.4b. Non-contrast CT Brain

Q8.4. Diagnosis Please

8.4c. Non-contrast CT Brain


8.5 Non-contrast CT Brain

Q8.5. Diagnosis Please



Figure 1: Acute intracerebral hematoma within the
right temporal lobe (arrow) with surrounding edema
(E).
60 year-old patient with melanoma. Hemorrhage is
from metastatic tumor bleed.

E

8.1 Non-contrast CT Brain

CT Density 68.6 HU
(Hounsfield Units)

Acute Intracerebral hematoma:

Acute hematoma is seen by non-contrast imaging as an area of high density with
density numbers ranging from 40 to 90HU.
CT can detect acute intracerebral blood as small as 2mm, due to contrast between
high-density of blood and low-density of surrounding brain (arrows).


Acute Subdural Hematoma:
Subdural hematoma is located between the layers
of dura and arachnoid mater, covering the cerebral
hemispheres whereas intracerebral hematoma is
localized within the brain substance.

8.2 Non-contrast CT Brain

Acute subdural hematoma is recognized by CT as
an area of peripheral zone of crescentic shaped
increased density, outside the surface of the brain
(arrows).
Most subdural hematoma is caused by tear of
bridging cortical veins.

Acute subdural hematoma covering the right
cerebral hemisphere (arrows), more prominent
posteriorly.
CT density of blood is 74HU consistent with
acute blood. Patient with history of recent fall.

Acute subdural hematoma can evolve over a
period of time and thus classified as acute,
subacute and chronic hematoma.

Acute Subdural Hematoma: Up to 7 day old
High CT density (40-90HU)

Subacute Subdural Hematoma (7 to 21 days old)
The CT density of acute blood gradually
decreases and becomes isodense with adjacent
brain, thus less readily visible and can be easily
overlooked.


A: Left frontal chronic subdural hematoma (arrowheads) seen as an area of low-density with crescentic inter
margin, compressing the adjacent brain.
B: Left frontal subdural hematoma was completely evaluated using burr holes in the skull, but the right
chronic subdural hematoma has increased in size in the follow-up CT done 19 days later (arrows) which was
also subsequently evaluated. 55 year-old patient with chronic myelogenous leukemia with low platelet count.

8.3a. Non-contrast CT Brain
09/02/2003

8.3b&c. Non-contrast CT Brain

CT Density 25.0 HU
(Hounsfield Units)
09/21/2003

Chronic Subdural Hematoma:
Over 21 days old: Acute blood as it evolves, it undergoes liquefaction, and also mixes with
cerebrospinal fluid from adjacent subarachnoid space, thus converting into a serosanguineous fluid.
This fluid has low CT density reaching close or similar to cerebrospinal fluid. Slow movement of
subarachnoid fluid into the subdural hematoma can give rise to gradual expansion of subdural

hematoma that can exert mass effect upon the adjacent brain with or without brain edema. This can
produce herniation of the brain resulting in sudden decompensation of the patient leading to coma.
Thus even a chronic subdural hematoma might need an emergent neurosurgical intervention.


8.4a,b,c. Non-contrast CT Brain

Subarachnoid Hemorrhage:
Subarachnoid blood is recognized by visualizing the high-density of acute blood outlining the cerebral
sulci and subarachnoid cisterns.

Subarachnoid Blood
Subarachnoid blood filling the right cerebral sulci (arrow), related to recent pituitary surgery


Shunt-induced (arrow), intraventricular
blood (v). Intraventricular blood is
recognized by replacement of normal CSF
density by highdensity of blood.

v

Intraventricular Hemorrhage:
Intraventricular blood is easily recognized
by high-density blood outlining the lateral
ventricles, III ventricle and IV ventricle.
8.5 Non-contrast CT Brain


Question

aire
#8.6
Common cause of intracranial hemorrhage in a county hospital emergency
room.
a)

Rupture of arterio-venous malformation

b)

Rupture of cerebral aneurysm

c)

Trauma

d)

Hypertension

e)

Stroke


Question
aire
#8.6
Common cause of intracranial hemorrhage in a county hospital emergency
room.

a)

Rupture of arterio-venous malformation

b)

Rupture of cerebral aneurysm

c)

Trauma

d)

Hypertension

e)

Stroke


Question
aire
#8.7
Likely cause of nontraumatic intracranial hemorrhage in an 8 year-old girl.
a)
b)
c)
d)

Rupture of arterio-venous malformation
Rupture of cerebral aneurysm
Hypertension
Stroke


Question
aire
#8.7
Likely cause of nontraumatic intracranial hemorrhage in an 8 year-old girl.

a)

Rupture of arterio-venous malformation

b)
c)
d)

Rupture of cerebral aneurysm
Hypertension
Stroke


Question
aire
#8.8
35 year-old man developed severe headache and drowsiness while having sex.
The patient was taken to the emergency room and a CT scan showed subarachnoid
hemorrhage. Most likely cause for subarachnoid hemorrhage to be considered is:

a)
Rupture of arterio-venous malformation
b)
Rupture of small vessel within the brain from excitement,
nothing to worry about.
c)
Rupture of cerebral aneurysm
d)
Acute migraine
e)
Stroke


Question
aire
#8.8
35 year-old man developed severe headache and drowsiness while having sex.
The patient was taken to the emergency room and a CT scan showed subarachnoid
hemorrhage. Most likely cause for subarachnoid hemorrhage to be considered is:
a)
Rupture of arterio-venous malformation
b)
Rupture of small vessel within the brain from excitement,
nothing to worry about.

c)

Rupture of cerebral aneurysm

d)

e)

Acute migraine
Stroke


Common Etiology for Nontraumatic
intracranial Hemorrhage
Congenital:
Arterio-venous malformations
Cerebral berry aneurysms

Tumors:
Primary:
Glioblastoma

Vascular:
Embolic Infarction
Venous Sinus Thrombosis

Hypertension
Coagulopathy

Metastasis:
Melanoma
Thyroid Carcinoma

Renal Cell Carcinoma
Chorio Carcinoma