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

Rad

The Skull
The standard projections are : 1. The lateral view

2. The AP 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.Pineal 2.Habenula 3.Choroid plexus 4.Dura (falx,tentorium). 5.Ligaments (petroclinoid and interclinoid) 6.Pacchionian bodies 7.Basal ganglia and dentate nuclei 8.Pituitary gland 9.Lens

Normal Skull Films

AP Skull-X Ray

Lateral Skull-X Ray

AP view

Lateral view

Abnormal Skull
1.Fracture. 2.Metastasis 3.Congenital disorders 4.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

INDIKASI HEAD SCAN

1.TRAUMA KEPALA 2.KELAINAN CEREBROVASCULER 3.TUMOR OTAK 4.KELAINAN KONGENITAL 5.PENYAKIT INFEKSI 6.ATROFI CEREBRAL ATAU PENYAKIT-PENYAKIT DEGENERATIF

THE BRAIN LAYER ANATOMY

SKIN BONE EPIDURAL DURAMATER

SUBDURAL
ARACHNOID SUBARACHNOID PIAMATER

T H E B R A I N L A Y E R A N A T O M Y

ANATOMY BRAIN

HEAD Scan NORMAL

FRAKTUR KEPALA
-DIHUBUNGKAN DG PENUMOCEPHALY

(udara didalam kepala) jarang tension pneumocephalus - Significan jika Fx terbuka berhub dg udara luar merusak penampilan (secara kosmetik penampilan tdk baik) or

berhubungan udara pd sinus resiko infeksi atau mudah timbul perdarahan (epidural hematom) -Treatment: hanya u kosmetik Atau pencegahan infeksi ( jika fx terbuka berhub dg udara luar atau udara pada 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

E P I D U R A L H E M A T O M

Subdural Hematoma
Occur in the 4 As : alcoholic,anticoagulant-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 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 generallyfeathery in appearance on CT scan, as itsmixed 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

S A H

S A H

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 doesnt)-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

Intraparenchymal hemorrhage

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

Intraventricular hemorrhage

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 brain 2.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)

H Y D R O C E P H A L U S

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
Biaya P.Rad Prinsip Beda CT scan VS MRI CT MRI Mahal Sangat mahal sedang - tinggi (-) X-ray Magnet & gel radio Biasa +/- 5 mnt +/- 30 mnt tidak baik sangat baik Baik tidak baik (-) images beberapa potongan

Waktu Soft tissue Tulang Perub-imag potongan

MRI : Normal brain (axial)

MRI : Normal brain (sagital)

MRI : normal brain (coronal)

MRI ( T 1 and T2)

MRI VS CT Encephalitis :11(MRI) Infarct Acute : 82 %

3 (CT) 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