Embed Size (px)
Citation preview
BRAIN CT AND MRI IN ICU
SAMIR EL ANSARY
Global Critical Carehttps://www.facebook.com/groups/1451610115129555/#!/groups/145
1610115129555/ Wellcome in our new group ..... Dr.SAMIR EL ANSARY
A Quick Primer of Brain CT/MRI
Normal CAT of brain
Ventricles are normal sized,
the grey versus white distinction
is clear.
Midline is straight.
Sulci are symmetrical on both sides.
Skull is intact with no
scalp edema.
Severe brain traumaNon-helmeted motorcycle rider
CAT of Skull Fracture
Subarachnoid Hemorrhage
Blood shows white on CT.
Anterior Communicating Artery
aneurysm has burst, flooding the
basal structures under the brain
outside the brain parenchyma, but
will occasionally empty into a
Ventricle as it has on the left here
(see fluid level).
Note typical “bat wing” shape just above the mid-brain (green arrow).
Coiling of anterior cerebral artery rupture and SAH
Coil shown by green arrow.
Note blood load on either
side of the coil (red arrows)
a high risk factor for cerebral
artery spasm and stroke
5 - 8 days post bleed.
Severe Subarachnoid Hemorrhage
Severe hemorrhage and probable
clotting and obstruction at the 3rd
ventricle and /or obstruction at
the formena of Luschka and Magendie
and 4th ventricle causing
hydrocephalus.
Poor outcome Likely.
Acute subdural with contusion and edema on left side
Red arrow- acute blood between dura
and brain.
Green arrow- brain contusion
with subarachnoid features.
Brain bruise with bleeding into the subarachnoid space and into the parenchyma.
Not the same as a burst aneurysm.
Edema shows as shift of midline toward right side.
Chronic Subdural (Hygroma) with new contusion on left parietal
If not resolved, acute subdural turns into chronic hygroma, consistency of crank case oil and shows black on CR
(red arrow).
New contusion with subarachnoid and parenchyma features shown by green arrow.
Previous Prefrontal lobotomy as young adult in 50s
Performed by sticking lance
shaped knife up into pre-frontal brain through thin bone over
eyeball and swishing back
and forth.
Very effective in calming
agitated patients most of whom
assume Hillary Clinton-like smile permanently
Big bland stroke on right and craniotomy for decompression
Other strokes progress to severe brain
edema 3 - 5 days post stroke and
require surgical decompression.
Note cranium removed on right side to
make room for brain edema.
CT shows bland stroke as dark contrast. Temporal lobe is sometimes
also removed on ipsalateral
side to make room for edema.
Humans can live normally with only
one temporal lobe. If you lose
both, you get “Memento”.
Stroke (post craniotomy for decompression)
Big bland stroke on left, with craniotomy and replacement of skull fragment (green arrow).
Intraparenchymal bleed into ventricles
Intraventricular bleed
This was a young
person who eventually
went on to rehab (real rehab-
not the kind Britney goes to)
and back to school.
Normal MRI
MRI shows alterations between water
and fat content of tissues.
Gives a high resolution view of brain, especially stroke, appearing as white contrast
which sometimes can take as long as
8 hours to show up.
Strokes show up faster on MRI than CT
MRI and CAT views of the same whole R. hemispherical infarct
Some very big strokes settle down and don’t require surgical decompression.
This man opens his eyes to verbal on nasal cannula and follows on the
right side 10 days post stroke.
Same bleed into brain stem on CT (right) and MRI (left)
“Normal” view of brain (MRI)
The un-processed view of brain is
obscured by CSF which lights up
like a light bulb, obfuscating
fine detail
T2 FLAIR negates CSF
The T2 FLAIR view negates CSF,
allowing a more accurate view
of brain structure.
However, the T2 shows most pathology in the brain
as white and does not differentiate
well between ischemia, tissue
damage and bleeding.
New stroke on T2 FLAIRNew strokes usually
show up as white on T2.
MPGR shows accumulated blood
Blood shows white on T2 Flair Left).
black on MPGR (Right),
Old stroke
Usually cystify and
develop firm borders
Cerebral abscesses from endocarditis
Brain tumors: Glioblastoma Multiforme
• Glios are rapid growing and cause death by brain compression. They do not usually metastasize, but occasionally can following debulking surgery.
Giant meningioma
• Meningiomas are slow growing and have discrete borders.
• Most amenable to operative resection.
MRI Side views: Chiari malformation
Some believe cranium too small
for brain, Others believe the
foramen magnum is malformed.
Symptoms of headache, ataxia
and nystagmus with progressive
pressure on brain stem.
Bi-temporal distribution is typical.
Thought to occur by re-activation
of herpes virus much like “cold sores”
except through different nerve
distribution
Herpes encephalitis
Hydrocephalus
CT angio of giant unruptured MCA aneurysm
Persistent Vegetative State (Terry Schiavo)
Severe atrophy
of brain tissue
GOOD LUCK
SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO
Global Critical Carehttps://www.facebook.com/groups/1451610115129555/#!/groups/145
1610115129555/ Wellcome in our new group ..... Dr.SAMIR EL ANSARY
