CT Head Protocolls

Slide 1: HEAD , FACIAL BONES, SINUSES, AND ORBITS

Slide 2: CRANIAL NERVES

Slide 3: 1.I - Olfactory 2.II - Optic 3.III - Oculomotor 4.IV - Trochlear 5.V - Trigeminal 6.VI - Abducens 7.VII - Facial 8.VIII - Auditory 9.IX - Glossopharyngeal 10.X - Vagus 11.XI - Accessory 12.XII - Hypoglassal

Slide 4: I. Olfactory: Sensory nerves for smell

Slide 6: II. Optic: Sensory nerve for vision.

Slide 8: III. Oculomotor: control of extrinsic eye muscles and pupil dilation.

Slide 10: IV. Trochlear: control of muscles that surround the eye

Slide 12: V. Trigeminal: control of facial nerves and muscles for chewing.

Slide 14: VI. Abducens: muscle control of lateral movement of the eyeball

Slide 16: VII. Facial: control over facial expression and taste

Slide 18: VIII. Vestibulocochlear or Auditory Nerve: Sensory nerve for hearing

Slide 21: PATHOLOGY

Slide 22: SINUSITIS Sinusitis is the name given when the lining of one or more of these sinuses is red, swollen, and tender, the opening is blocked, and the sinus is at least partially filled with fluid (mucus and/or pus).

Slide 23: SINUS POLYP

Slide 24: ORBITAL FRACTURE Demonstrates a superior orbital fracture on the left with fragments of bone extending toward the frontal lobe. There was no evidence of an optic canal fracture.

Slide 25: ORBITAL ROOF FRACTURE

Slide 26: TRIPOD FRACTURE

Slide 27: MANDIBULAR FRACTURE

Slide 28: Types of skull fracture

Slide 29: Although the skull is tough, resilient, and provides excellent protection for the brain, a severe impact or blow can result in fracture of the skull and may be accompanied by injury to the brain. Some of the different types of skull fracture include: Simple: a break in the bone without damage to the skinLinear or hairline: a break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone Depressed: a break in a cranial bone (or "crushed" portion of skull) with depression of the bone in toward the brainCompound: a break in or loss of skin and splintering of the bone. Along with the fracture, brain injury, such as subdural hematoma (bleeding) may occur.

Slide 30: OPEN FRACTURE- COMPOUND

Slide 31: CLOSED FRACTURE

Slide 32: HEMORRHAGE • INTRACEREBRAL • SUBDURAL • EPIDURAL • SUBARACHNOID

Slide 33: INTRACEREBRAL

Slide 34: FETAL INTRACEREBRAL BLEED

Slide 35: SUBDURAL

Slide 36: EPIDURAL

Slide 37: SUBARACHNOID

Slide 38: Rupture of an intracranial aneurysm is the most common cause of nontraumatic subarachnoid hemorrhage. 90-95% of all intracranial aneurysms are located in the carotid system. The anterior communicating artery is the most common site (30%), followed by the posterior communicating artery (25%) and the middle cerebral artery (20%).

Slide 39: HYDROCEPHALUS

Slide 41: BRAIN CYST

Slide 42: CEREBRAL INFARCT

Slide 43: INFARCT + BLEED

Slide 44: CEREBRAL ANEURYSM

Slide 47: ARTERIO-VENOUS MALFORMATION

Slide 48: What is a brain AVM? Normally, arteries carry blood containing oxygen from the heart to the brain, and veins carry blood with less oxygen away from the brain and back to the heart. When an arteriovenous malformation (AVM) occurs, a tangle of blood vessels in the brain or on its surface bypasses normal brain tissue and directly diverts blood from the arteries to the veins

Slide 49: BRAIN METS

Slide 50: CVA

Slide 52: This is a CAT scan of a patient with a bleeding stroke caused by CAA. The two bright areas represent recent areas of bleeding into the brain. Both areas are in the outer part of the brain that is characteristic for CAA-related strokes.

Slide 53: BRAIN INFECTIONS • MENINGITIS • ENCEPHALITIS • ABSCESS

Slide 54: MENINGITIS Subdural empyema and diffuse cerebral edema in a patient with bacterial meningitis (same patient as in Image 18). Obtained 1 week after Image 18, this contrast-enhanced CT scan shows diffuse cerebral edema and lacunar infarcts in the thalamus.

Slide 55: ENCEPHALITIS Encephalitis Encephalitis is an inflammation (irritation and swelling with presence of extra immune cells) of the brain, usually caused by infections.

Slide 56: BRAIN ABSCESS

Slide 57: MULTIPLE SCLEROSIS Multiple Sclerosis (MS) is a disease of the central nervous system (brain and spinal cord) which in its most serious form can be very disabling. The central nervous system (CNS) bodily functions serves as the body’s control center, meaning it’s responsible for controlling all involuntary and voluntary functions of the body such as breathing, body movements, vision, etc. To be able to fully grasp the nature of this disease it’s important to understand the roles and functions of the CNS, specifically the means by which the brain and spinal cord send messages throughout the body.

Slide 58: PARKINSON’S DISEASE Parkinson's disease is caused by the progressive impairment or deterioration of neurons (nerve cells) in an area of the brain known as the substantia nigra. When functioning normally, these neurons produce a vital brain chemical known as dopamine. Dopamine serves as a chemical messenger allowing communication between the substantia nigra and another area of the brain called the corpus striatum. This communication coordinates smooth and balanced muscle movement. A lack of dopamine results in abnormal nerve functioning, causing a loss in the ability to control body movements

Slide 59: ALZHEIMER’S DISEASE One of the hallmarks of Alzheimer's disease is the accumulation of amyloid plaques between nerve cells (neurons) in the brain. Amyloid is a general term for protein fragments that the body produces normally. Beta-amyloid is a fragment of a protein that is snipped from another protein called amyloid precursor protein (APP). In a healthy brain, these protein fragments would be broken down and eliminated. In Alzheimer's disease, the fragments accumulate to form hard, insoluble plaques.

Slide 60: PET images show the metabolic degeneration of the brain of a patient with Alzheimer's as it progressively reduces brain function. In the early stages of the disease, limited areas of the brain are dysfunctional (arrows in upper image), but in late stages of Alzheimer's, larger brain areas are affected (arrows in upper and lower images). The structures that are spared and remain functioning (dark blue images) are the portions of the cortex that control the motor systems such as the legs, arms and hands (upper image), the internal structures (center structures that are dark blue in lower image) and the visual cortex at the back (bottom of the lower image). Notice that the metabolic function of the brain with late stage Alzheimer's resembles that of a child. This correlates with the child-like functional behavior of these patients.

Slide 61: BRAIN TUMORS • ASTROCYTOMAS • GLIOMAS • PINEAL REGION TUMORS • LIPOMA • ACOUSTIC NEUROMA • MENINGIOMA

Slide 62: •astrocytomas Astrocytomas are glial cell tumors that are derived from connective tissue cells called astrocytes. These cells can be found anywhere in the brain or spinal cord. Astrocytomas are the most common type of childhood brain tumor.

Slide 63: •Brain stem gliomas are tumors found in the brain stem. Most brain stem tumors cannot be surgically removed because of the remote location and delicate and complex function this area controls. Brain stem gliomas occur almost exclusively in children; the group most often affected is the school-age child. The child usually does not have increased intracranial pressure, but may have problems with double vision, movement of the face or one side of the body, or difficulty with walking and coordination

Slide 64: •optic nerve gliomas Optic nerve gliomas are found in or around the nerves that send messages from the eyes to the brain. They are frequently found in persons who have neurofibromatosis, a condition a child is born with that makes him/her more likely to develop tumors in the brain. Persons usually experience loss of vision, as well as hormone problems, since these tumors are usually located at the base of the brain where hormonal control is located. These are typically difficult to treat due to the surrounding sensitive brain structures.

Slide 65: •medulloblastomas Medulloblastomas are one type of PNET that are found near the midline of the cerebellum. This tumor is rapidly growing and often blocks drainage of the CSF (cerebral spinal fluid, which bathes the brain and spinal cord), causing symptoms associated with increased ICP. Medulloblastoma cells can spread (metastasize) to other areas of the central nervous system, especially around the spinal cord. A combination of surgery, radiation, and chemotherapy is usually needed to control these tumors

Slide 66: •pineal region tumors Many different tumors can arise near the pineal gland, a gland which helps control sleep and wake cycles. Gliomas are common in this region, as are pineal blastomas (PNET). In addition, germ cell tumors, another form of malignant tumor, can be found in this area. Tumors in this region are more common in children than adults, and make up 3 to 8 percent of pediatric brain tumors. Benign pineal gland cysts are also seen in this location, which makes the diagnosis difficult between what is malignant and what is benign. Biopsy or removal of the tumor is frequently necessary to tell the different types of tumors apart. Persons with tumors in this region frequently experience headaches or symptoms of increased intracranial pressure. Treatment depends on the tumor type and size.

Slide 67: GLIOMA

Slide 68: ACOUSTIC NEUROMA

Slide 69: ACOUSTIC NEUROMA

Slide 70: PITUITARY GLAND TUMOR

Slide 71: CT PROTOCOLS • HEAD • HEAD VASCULAR ( CIRCLE OF WILLIS) • PITUITARY & SELLA TURCICA • INTERNAL AUDITORY CANAL • ORBITS • PARANASAL SINUSES • TMJ • FACIAL BONES • DENTAL

Slide 72: HEAD/BRAIN • Indications – Headache – Mass ( sol ) – Seizure disorder – Trauma – CVA – Hydrocephalus – Syncope – TIA

Slide 73: • Parameters set by the institution • Routine brain should display – Differentiation of Gray and white matter – Corpus callosum – Ventricles – lateral , 3rd, 4th and cerebral aqueduct – Basal ganglia • Caudate nucleus • Lentiform nucleus – Putamen – Globus pallidus – Thalamus – Medulla and pons – Structure above tentorium (supratentorial) – Structures below tentorium (infratentorial) Posterior Fossa

Slide 74: Parameters Single Slice Fixed Matrix Adaptive Array PATIENT HEAD FIRST. SUPINE SAME SAME SCANNING AREA BASE TO VERTEX SAME SAME CONTRAST 100ML AT 1ML/SEC SAME SAME DETECTOR COLLI NA 4X5MM 4X1POST FOSSA/4X2.5 DFOV 23-25 CM SAME SAME SLICE THICKNESS 5 MM SAME SAME ANGLE PARALLEL TO SKULL SAME SAME BASE TABLE FEED/ROT NON SPIRAL SAME SAME PITCH NA NA NA ROT TIME 2 SEC 1SEC 1 SEC RECON SOFT TISSUE/BONE SAME SAME WINDOW 80/30B.250/50SD,4000/30 SAME SAME 0B

Slide 75: With Contrast • 60% ionic or 300mgL/mL nonionic • 60 cc • Hand inject or 1cc/sec on power injector • Scan following total injection of contrast volume • Do not inject if hemorrhage , contusion, or hydrocephalus

Slide 76: 2 1 4 8 3 7 6 5 1- Eye 5- Beam Hardening 2- Lens 6- Mastoid air cells 3- Optic nerve 7- Sphenoid bone 4- Nasal septum 8- Sphenoid sinus

Slide 77: 4 7 6 1 3 5 2 1- Mastoid 5- 4th Ventricle 2- Occipital bone 6- Pituitary Gland 3- Temporal bone 7- Falx cerebri 4- Frontal bone

Slide 78: 1 3 4 2 1- Brain stem 4- 4th ventricle 2- internal occipital protuberance 3- 3rd ventricle

Slide 79: 5 1 4 2 6 3 7 1- Anterior horn of lateral ventricle 6- Lentiform nucleus 2- Caudate nucleus 7- Thalamus Gland 3- Third ventricle 4- Internal Capsule 5- White matter

Slide 80: Bone Window 3 2 1 1- Occipital bone 2- Condyle 3- Sphenoid sinus 4- Foramen Magnum

Slide 81: BRAIN ANGIO SCOUT: LATERAL LANDMARK: OML SLICE PLANE: AXIAL I.V. CONTRAST: 100-140 ML- 3-5 ml /sec BREATH HOLD: NONE SLICE THICKNESS: 1-2 MM START LOCATION: BELOW SELLAR FLOOR END LOCATION: 4-5 CM ABOVE SELLA RECON: 50% OVERLAP FILMING: 3 D RECON

Slide 84: PITUITARY AND SELLA TURCICA • Indications – Visual problems – Hormone imbalance – Scan head first and supine • Coronal images can be done , we can also target recon in the coronal plane • Pituitary exam should show – Pituitary gland – Sella turcia – Optic chiasm

Slide 85: Parameters Single Slice Fixed Matrix Adaptive Array PATIENT Axial Same same SCANNING AREA Base of skull to Same Same CONTRAST 100-150ml 1ml/sec 40 sec delay same same DETECTOR COLLI 3mm 4x1.25 4x1mm DFOV 10-12cm same same SLICE THICKNESS 3mm 2mm 1-3mm ANGLE Parallel to skull base Same same TABLE FEED/ROT 1mm 0.75-1.5mm 4.5mm PITCH 1 0.75-1.5 0.75-1.25 ROT TIME 1 sec 0.5-0.8sec 0.5sec RECON Standard/high resolution same Same WINDOW 250/20 2500/100 same same

Slide 87: IAC • Indications – Hearing loss – Vertigo – Tinnitus – Mastoiditis – Acoustic neuroma • Axial and coronal images • IAC study should show – External and Internal auditory canal – Mastoid air cells – Ossicles ( mallus,incus, stapes )

Slide 88: Parameters Single Slice Fixed Matrix Adaptive Array PATIENT Axial and coronal Same same SCANNING AREA Mastoid to petrous ridge Same Same CONTRAST None / if mass 30ml 1ml/sec same same DETECTOR COLLI 3mm 2x.625mm 2x.5mm DFOV 23cm same same SLICE THICKNESS 1mm Less than 1mm Less than 1mm ANGLE none Same same TABLE FEED/ROT 1mm 0.75mm 1mm PITCH 1 0.75 1 ROT TIME 1 sec 0.5sec 0.5sec RECON high resolution same Same WINDOW 2500/100 same same

Slide 89: 2 1 1- Ossicles 2- EAM

Slide 90: 1-Ossicals 1

Slide 91: Semicircular Duct Mastoid air cell Ossicals

Slide 92: SCANNED RECON: R & L SIDE 10 CM FOV

Slide 93: ORBITS • Indication – Trauma – Mass – Inflammatory disease – Optic nerve damage • Scan in the axial and coronal planes • 150 cc of contrast injection can be 100cc for the axial and 50cc for the coronal • Orbit exam should show – Eye ( lens, globe ) – Optic nerve ( 4mm / with sheath 6mm ) – Rectus muscles

Slide 94: Parameters Single Slice Fixed Matrix Adaptive Array PATIENT Coronal and axial Same same SCANNING AREA Hard palate to above the frotal sinuses Same Same CONTRAST 100-150ml 1ml/sec same same DETECTOR COLLI 3mm 4x1.25 2x.05mm DFOV 14-16cm same same SLICE THICKNESS 3mm same same ANGLE Parallel to oml for axail Same same Perp to oml for coronal TABLE FEED/ROT 3mm 0.75-1.5mm 0.8mm PITCH 1 0.75-1.5 0.75 ROT TIME 0.8 sec 0.8sec 0.5sec RECON Standard/high resolution same Same WINDOW 250/20 2500/100 same same

Slide 96: Optic Nerve

Slide 97: PATIENT CAN’T ASSUME PRONE POSITION SUPINE-CORONAL

Slide 98: DENTAL ARTIFACT OMISSION- MULTIANGULATION

Slide 99: DENTAL ARTIFACT OMISSION- DENTURE REMOVAL

Slide 101: FACIAL BONES • Indications are trauma, congenital or mass • Patient supine and mandible perpendicular to table • Facial bones should display – Mandible, nasal bones, zygoma, lacrimal, orbits, ethmoid and vomer.

Slide 102: Parameters Single Slice Fixed Matrix Adaptive Array PATIENT Head first supine and prone.Mandible Same same perp to table SCANNING AREA Mandible to top of head Same Same CONTRAST None same same DETECTOR COLLI 3mm 4x1.25 4x1mm DFOV 15-18cm same same SLICE THICKNESS 3mm 3mm ANGLE Parallel to hard palate Same same TABLE FEED/ROT 3mm 1.25mm 1mm PITCH 1 0.75-1.5 0.75 ROT TIME 0.8 sec 0.5sec 0.5sec RECON Standard same Same WINDOW 2500/100 same same

Slide 103: 7 4 1 2 3 6 5 1- Frontal sinus 2- Nasal Bone 3- Crista Galli 4-Frontal Bone 5- Maxillary Bone 6- Sphenoid Bone 7- Optic Nerve

Slide 104: FACIAL BONES INCLUDE MANDIBLE!!!!!!

Slide 105: • Indications PNS – Sinusitis – Mucosal disease – Mass • Patient is scanned supine and coronal • Supine – hard palate – above frontal sinuses • coronal – posterior to the sphenoid sinus – anterior to the frontal sinus • No angle for axial images , angel for coronal • Sinus scans should show – Frontal, maxillary, ethmoid , and sphenoid sisnues

Slide 106: Parameters Single Slice Fixed Matrix Adaptive Array PATIENT Head first supine and prone Same same SCANNING AREA Hard palate – frontals Same Same Sphenoid - frontals CONTRAST Can be used for mass 30ml same same DETECTOR COLLI 3mm 4x1.25 2x0.5 DFOV 14-16 cm same same SLICE THICKNESS 3mm 3mm 3mm ANGLE Parallel to hard palate Same same TABLE FEED/ROT 3mm 0.75mm 0.8mm PITCH 1 0.75-1 1 ROT TIME 1 sec 0.5sec 0.5sec RECON Standard/soft tissue same Same WINDOW 250/50 s, 2500/100 st same same

Slide 107: 1 2 4 3 5 1- Ethmoid Air cells 4- Condyle 2- Zygomatic Arch 5- Mastoid Air Cells 3- EAM

Slide 108: 1-Ethmoid Air Cell 4 2- Maxillary Sinus 3- Hard Palate 4- Sphenoid Bone 1 2 3

Slide 109: TMJ SCOUT: LATERAL LANDMARK: OML SLICE PLANE: CORONAL & AXIAL I.V. CONTRAST: NONE BREATH HOLD: NONE SLICE THICKNESS: 1 - 3 MM START LOCATION: CORONAL: POSTERIOR TO JOINT AXIAL: POSTERIOR TO JOINT END LOCATION: CORONAL: THROUGH THE ENTIRE JOINT AXIAL: THROUGH THE ENTIRE JOINT FILMING: BONE & SOFT TISSUE

Slide 111: DENTAL

Slide 112: STEREOTACTIC