Dr Hj Asmah Yusuf Sp.RadDr Evo Elidar Hrp Sp.Rad

The Skull

The standard projections are : 1. The lateral view

2. The PA view

Routine method of study of Skull X –ray

• Examine : the inner and outer table• Examine trabeculasi and densitas bone• Examine: Sutures• Examine :Vascular markings• Examine : sella• Examine : intracranial kalsifikasi

Normal intracranial kalsifikasi

1.Pineal2.Habenula3.Choroid plexus4.Dura (falx,tentorium).5.Ligaments (petroclinoid and interclinoid)6.Pacchionian bodies7.Basal ganglia and dentate nuclei8.Pituitary gland9.Lens

Normal Skull Films

AP Skull-X Ray Lateral Skull-X Ray

AP view

Lateral view

Abnormal Skull

1.Fracture.2.Metastasis

3.Congenital disorders4.Kalsifikasi

5.Raised intracranial pressure

Metastasis

Lesi lytik

Lesi lytik luas

Multiple Myeloma

Congenital disorders

Scaphocephaly

Scaphocephaly

Scaphocephaly

Raised intracranial pressure

Hydrocephalus

Raised intracranial pressure

Computed tomography

CT schematic

INDICATION

• 1.HEAD INJURY• 2.CEBROVASLULAR DISEASES (CVD)• 3.BRAIN TUMOR• 4.CEREBRAL INFECTION• 5.CONGENITAL DISORDER• 6.CEREBRAL ATROPHY OR 7.DEGENERATIVE

DISEASES

THE BRAIN LAYER ANATOMY

• SKIN• BONE EPIDURAL• DURAMATER SUBDURAL• ARACHNOID SUBARACHNOID• PIAMATER

THE

BRAIN

LAYER

ANATOMY

ANATOMY BRAIN

HEAD Scan NORMAL

High density (hiperdens) : densitas lesilebih tinggi dari jaringan normal.

Isodens :densitas lesi sama dengan jaringan sekitarnya

Low density(hipodens): densitas lesi lebihrendah dari jaringan normal

Skull Fractures

• -Associated with pneumocephaly (air in head) rarely can develop tension pneumocephalus• -Only significant if open to air,cosmetically disfiguring(greater than full thickness displacement) or

associate with air sinus (for risk of infection) or underlying bleed (epidural hematom)-Treatment ONLY for cosmetic orprevention of infection ( if open to air or to an air sinus

Fracture

Intracranial Hemorrhage

• Intracranial hemorrhage can be classified according to the space occupied by the blood:

– Epidural Hemorrhage– Subdural Hemorrhage– Subarachnoid Hemorrhage– Intraparenchymal Hemorrhage– Intraventricular Hemorrhage

Intracranial Hemorrhage: Types

Epidural Hemorrhage

• Between skull and dura, limited by periosteal layer so stops at sutures of skull and thus biconvex (lens) shaped

• Due to middle meningeal artery tear,often associated with skull fracture

EPIDURAL

HEMATOM

Subdural Hematoma

• Occur in the 4 A’s : “alcoholic,anti- coagulant-treated,aged and abuse victims (shaken

baby syndrome)• Between dura and archnoid of brain Follow contour of brain so “ Crescent Shape”.• Due to cortical bridging vein tear as hemoglobin

broken down,blood changes color on CT scan and can be easily mised

(see sub acute )

•Usually patients with subdural hematoma have worse Brain injury than epidural hematoma•Small size bleeds can be spontaneusly absorbed by the body,but if midline shift is presentSurgical evacuation

Subdural Hemorrhage

ACUTE SUB ACUTE CHRONIC

Subarachnoid Hemorrhage

• Subarachnoid hemorrhage is generally feathery in appearance on CT scan, as it’smixed in with cerebrospinal fluid

•The MOST COMMON cause of subarachnoid haemorrhage is 1.Trauma 2.The 2 nd and 3 rd most common causes are aneurysms or arteriovenous malformations• No intervention is generally performed for subarachnoid hemorrhage alone.

•However ,subarachnoid hemorrhage can cause hydrocephalus (due to obstruction of CSF flow) or vasospasm (due to ? blood product irritating a vessel) in delayed fashion

SAH

SAH

Intraparenchymal Hemorrhage

• Called ‘’ Contusions “ in trauma bruising of the brain• Coup ( direct injury of brain impact) or

contrecoup (injury due to brain hitting skull opposite side as skull decelerates but brain doesn’t)-usualy

temporal/frontal.

-Can develop extreme amount of edema or blossom,so must follow closely with repeat CT scans-Can be caused by hypertensive hemorrhage in characteristic locations (basal ganglia,thalamus pons, cerebellum) or arteriovenous malformations

-In older patients (> 60 ) can be caused by cerebral amyloid angiopathy, usually in a lobar location-Surgical evacuation if excessive mass effect

Intraparenchymalhemorrhage

Intraventricular Hemorrhage

-Usually due to extension of intraparenchymal bleed (most

Commonly from hypertension-Treatment depends on whether hydrocephalus develops – then patients may need ventriculostomy placement

Intraventricularhemorrhage

STROKE

• Stroke is disease cerebrovasculer (venous of brain) which marked with death tissue brain (infarct cerebral) happened because the less of oxygen and blood strem to brain.

Stroke divided to become two type

1.Stroke ischaemi blood stream to brain is desisted by

artherosclerotic (heaping of cholesterol at venous wall) or blood clot which have corking an vein to brain2.Stroke hemorrhage venous

broken causing pursue normal blood stream and blood seep into area brain in the

breakdown

Cerebral infarct

Infarct pons

Cerebral hemorrhage

Hydrocephalus

Normal CSF flow is from lateral ventricles to third ventricle, via aquaduct silvii to fourth V, then through foramina of magendieand luschka to subarachnoid space,then absorption via arachnoid granulations into the superior sagittal sinus

-Any obstruction on this pathway can cause hydrocephalus -Treatment is temporarily by diverting spinal fluid via ventriculostomy catheter permanently,a shunt ( e.g. ventriculoperitoneal , or VP shunt)

HYDROCEPHALUS

BRAIN TUMOURS

BRAIN TUMOURS

Brain Tu (pylocytic astrocytoma)

Brain tumors

Cerebral abscess

Pada kontras tampak ring enhancement

Encephalitis

• OLEH : Dr Hj. Asmah Yusuf Sp.Rad Dr. Elidar Hrp Sp.Rad

MRI Beda CT scan VS MRI

CT MRIBiaya Mahal Sangat mahalP.Rad sedang - tinggi (-)Prinsip X-ray Magnet &

gel radioWaktu Biasa +/- 5 mnt +/- 30 mntSoft tissue tidak baik sangat baikTulang Baik tidak baikPerub-imag (-) images beberapa potongan potongan

MRI : Normal brain (axial)

MRI : Normal brain (sagital)

MRI : normal brain (coronal)

MRI ( T 1 and T2)

MRI VS CTEncephalitis :11(MRI) 3 (CT)Infarct Acute : 82 % 58 %

CT : -Beberpa jam pertama normal pada : 60 % pasien walau klinis sdh ada -Scan ulang 48 jam setelah stroke area hypodense ( dark)

MRI lebih sensitif dibanding CT,Beberaoa menit setelah klinis /sympton Gambaran MRI (+)

Cerebral Infarct

CT T1 MRI T2 MRI

Cerebral infract

Encephalitis

Encephalitis

Subarachnoid hemorrhage

Brain tumor (sagital)

MRI : Brain tumor

Dandy Walker malformation

Chiari Malformation type II