Blood

1. Blood
Tempat : epidural, subdural, intraparenchymal, intraventricular, and subarachnoid
Hyperdense (bright): Acute blood
Isodense (similar to brain tissue): Subacute (at approximately 1 week)
Hypodense (darker than brain tissue): Subacute to chronic (at approximately 2 weeks)
Cisterns
2. Cisterns
Cari darah di cisterns dan liat terbuka atau ga = Circummesencephalic (ambient) ; Suprasellar ;
Quadrigeminal ; Sylvian

3. Brain
Liat kedua hemispheres
Cek diferensiasi dan compare kedua dr grey-white buat tahu early signs of stroke
1. Simetris ga
2. Pastiin ga ada midline shift (indikasi intracerebral mass, edema, or a herniation)
3. Liat parenkim cari anatomical distortion or altered attenuation indicative of a mass, bleed,
or vascular malformation

Ventricles
4. ventricle
liat ventrikel third, forth, and lateral ventricles buat tau dilation, compression, shift, and
bleeding. Compare ukuran ventrikel sama umur.

Young Patient Ventricles Elderly Patient Ventricles

Bone
5.bone
liat fractures, and evaluate the sinuses for fluid or soft tissues accumulation
Fluid in the sinus may be a clue to a facial injury.

Bone Windows on CT

Additional Areas to Examine

- venous sinuses to detect hypo density which is indicative of thrombosis
 - Soft tissues and skin sekitar parenchymal window buat lesions or hematomas
- Check the orbits
- Look at every image from base to vertex of skull
o sagittal and coronal reformats
o Small extra axial hemorrhages, particularly along the tentorium are better seen on
the reformatted images
How to Determine the Appropriate Brain Imaging Study in the Emergency
Suspected Diagnosis: Epidural hematoma
• Blood – look for hemorrhage – subdural, epidural, subarachnoid, cerebral contusion
• Cisterns – look to see if they are open or compressed
• Brain – look for midline shift
• Ventricles – look for compression or blood in them
• Bone – look for skull fractures in the area of the blood on the bone window

• Classic epidural hemorrhage (EDH) = biconvex/lenticular shape

• Pendarahan dari the middle meningeal artery
• Epidurals do not cross sutures, because this is where the Dura attaches to the skull. Thus
epidurals result in medial bowing of the Dura, with Dura remaining fixed at its attachment
sites

• Classic subdural hemorrhage (SDH) = Semilunar , or Crescent-shaped

• pendarahan dr bridging veins that cross the subdural space
• It’s found along the cerebral convexity and bilateral tentorium cerebelli

Suspected Diagnosis: Subarachnoid hemorrhage

• Blood – look for hemorrhage – subdural, epidural, subarachnoid, cerebral contusion
• Cisterns – look to see if they are open or compressed
• Brain – look for midline shift
• Ventricles – look for compression or blood in them
• Bone – look for skull fractures in the area of the blood on the bone window

• Subarachnoid Hemorrhage (SAH) = hyperdensity in the Sulci, cisterns or ventricles.

• Kalo bukan krn head trauma berarti dr aneurysms, arteriovenous malformation (AVM), Cocaine,
vasculopathy, or coagulopathy
• Penyebab tersering = Aneurysms of the anterior communicating artery are the most common Circle of
Willis
• Below are the vessels commonly associated with the Circle of Willis:

Alternate Diagnosis: Intraparenchymal Hemorrhage

• Intraparenchymal hemorrhage
• Penybab Non traumatic: Hypertensive Hemorrhage, aneurysm, AVM, drug induced, and Tumor necrosis
• Hypertensive Hemorrhage typical places: Basal Ganglia (80%) ; Pontine (10%) ; Cerebellar
Hemispheres (10%)

Potential Complication: Brain Herniation

Koplikasi dari swelling or bleeding in the intracranial space is herniation.
• Brain herniation occurs when the intracranial pressure (ICP) increases to the degree that the
brain in the affected area attempts to extend into a separate compartment. Supratentorial
herniation ; Uncal ; Descending Transtentorial ; Subfalcine ; Extracranial
Infratentorial herniation = Ascending Transtentorial ; Tonsillar

• Uncal herniation is when the medial portion of the anterior temporal lobe is shifted into the
suprasellar cistern. It is a subset of descending transtenorial herniation, which is when
the cerebral hemisphere crosses the tentorium at the level of the incisura. It can result in
Infarct in the PCA distribution
• Subfalcine herniation is when the brain is shifted underneath the falx. It is the same thing as
midline shift. It can result in hydrocephalus resulting from ventricular compression;
infarct in the ACA distribution due to ACA compression
Tonsillar herniation occurs when cerebellar tonsils move downward through the foramen magnum
possibly causing compression of the lower brainstem and upper cervical spinal cord