Project: Ghana Emergency Medicine Collaborative
Document Title: Systematic Evaluation to Non-Traumatic Head CTs
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Systematic Evaluation to
Non-Traumatic Head CTs

Source Undetermined

Rashmi U. Kothari, MD
KCMS/MSU
Why do you need to be able to
evaluate a CT
Ø  Radiology

report is not
immediately available

Ø  Need

immediate
interv...
Course Outline
Ø  Basic

principles of CT

Ø  Basic

anatomy

Ø  Systematic
Ø  CT

approach

Potpourri
Course Goals
Ø  Learn

“Blood Can Be Very
Bad” approach to reading CTs

Ø 

Identify classic CT findings
Disclaimer
Ø  Make

you a neuroradiologist

Ø  Teach

you cause of finding
of abnormality

Ø  Help

you with contrast C...
Source Undetermined

Basic Principles of CT Imaging
X-rays Absorbed Differently by
Different Tissues
Radiolucent

Radiodense

Air

Bone

Spinal fluid
Source Undetermined

Met...
Attenuation
(amount of radiation blocked by tissue)
50-100 HU

Air

Blood

-1000 HU

Bone
+1000 HU

HU=Hounsfield Units
Windowing
Ø  Blood

Source Undetermined

Source Undetermined
Source Undetermined

Brain

Blood

Bone
CT Anatomy

Source Undetermined

Ø  Six levels of cuts
Ø  Cortical sulci
Ø  Lateral Ventricles
Ø  Basal Ganglia
Ø  3 ...
CT Anatomy: Cortical Sulci & Lat. Ventricle

Falx
Cortical sulci
Source Undetermined
Source Undetermined

Frontal lobe
Par...
CT Anatomy: Basal Ganglia & 3rd Ventricle

Anterior horns
.

Choroid plexus

Source Undetermined
Source Undetermined

Ante...
CT Anatomy: Midbrain & Pons
Sylvian fissure
Insular ribbon
Ambient cistern
(cirummesenphalic cistern)
Source Undetermined
...
Systematic Approach to Head CTs
Ø P erron

et al: Carolina’s Medical Center

Ø “ Blood

Can Be Very Bad” pnemonic

Ø C ...
“Blood Can Be Very Bad”
Ø  Blood
Ø  Cisterns
Ø  Brain
Ø  Ventricles
Ø  Bone
Perron et al: Ann Emerg Med 1998:32:554-5...
“Blood Can Be Very Bad”
Ø  Acute

blood = hyperdense (white)

Ø  50-100
Ø  As
Ø  At

HU

it ages it becomes hypodense
...
“Blood Can Be Very Bad”

Source Undetermined
Source Undetermined

Source Undetermined
“Blood Can Be Very Bad”
Ø  4

cisterns:

Suprasellar
Ø  Quadrigeminal
Ø  Slyvian
Ø  Ambient
Ø 

Source Undetermined

...
Cisterns: Is there blood?

Source Undetermined
Source Undetermined

Are they open?
21

Andrew D. Perron, MD, FACEP
“Blood Can Be Very Bad”

Source Undetermined

Source Undetermined

Brain
Source Undetermined
“Blood Can Be Very Bad”

Source Undetermined

Source Undetermined

Source Undetermined

Ventricle
Source Undetermined
“Blood Can Be Very Bad”

Source Undetermined

Bone

Source Undetermined

Andrew D. Perron, MD, FACEP
Source Undetermined

Source Undetermined

Classic CT Findings

Source Undetermined

Source Undetermined
Source Undetermine...
Epidural

•  Lens shape
•  85% arterial bleeds
•  Middle meningeal art
• Lucid period
Source Undetermined

Subdural

•  Co...
Intracerebral Hemorrhage
q  10% of all strokes

Source Undetermined

Source Undetermined

q  2 major causes
q  Hyperten...
Subarachnoid Hemorrhage
q  5-10% of all strokes
q  Aneurysms, AVMs,

trauma
q  Hyperdense, fuzzy
q  Locations of blood...
ICH

Source Undetermined

Source Undetermined

SAH

Normal

Source Undetermined

Source Undetermined

SAH

ICH

Source Und...
Findings Suggestive of ICH
Ø N ormal Calcification
Ø  Basal ganglia
Ø  Choroid plexus
Ø  Pineal gland

CSource Undeter...
Findings Suggestive of ICH
Ø Metal
Ø  Very hypodense
Ø  “Sparks”
Ø  Clips, bullets,
metallic catheters

CSource Undete...
Findings Suggestive of ICH
?

CSource Undetermined
Volume Averaging
(Technical Issues Mimicking ICH)
Ø  Orbital roof
Ø  Petrous portion of

temporal bone
Ø  Pituitary fos...
Findings Suggestive of ICH/SAH

?

?

CSource Undetermined
Motion Artifact
(Technical Issues Mimicking ICH or SAH)

Ø Streaky
Ø Hyperdense
Ø Boney prominence

Source Undetermined...
Evolution of an Infarct

Source Undetermined

Source Undetermined

Ultra-Acute Acute-Subacute
0-3 hours

6hrs-days

Source...
Ultra-Early CT Findings
Ø  Normal
Ø  Sulcal effacement
Ø  Loss of insular ribbon
Ø  Loss of grey-white

interface
Ø  ...
Sulcal Effacement

Source Undetermined

Source Undetermined
Loss of Insular Ribbon

Source Undetermined
Loss of Sulci & Acute Hypodensity

Source Undetermined
Acute Hypodensity

Source Undetermined

Source Undetermined
Acute-Subacute Stroke
(hours-days)

Ø  Hypodense
Ø  Well demarcated
Ø  Mass effect
Ø  Midline shift
Ø  Loss of sulci
...
Old Infarct
(months to years)

Ø  Density of CSF
Ø  Well demarcated
Ø  Ventrical enlargement
Ø  Sulci enlargement
Ø  ...
Suggestive of an Infarct?

Source Undetermined
Suggestive of an Infarct?

Source Undetermined

Tumor

Source Undetermined

Stroke
Case Presentations
Thalamic ICH

Source Undetermined
Normal

Source Undetermined
Chronic Frontal Subdural

Source Undetermined
Subacute Right Parietal Infarct

Source Undetermined
Source Undetermined

continued
Source Undetermined

SAH

Source Undetermined

Normal
Acute Subdural

Source Undetermined
Normal

Source Undetermined
Closed Ventricles

Source Undetermined
Cisterns: Are they open?

Source Undetermined

Source Undetermined

Andrew D. Perron, MD, FACEP
Metallic Artifact

Source Undetermined
Brainstem SAH

Source Undetermined
Chronic MCA Infarct

Source Undetermined
Left IVH

Source Undetermined
Epidural

Source Undetermined
Rt Subacute Epidural

Source Undetermined
Sagital Sinus

Source Undetermined
Subacute Infarct

Source Undetermined
Renal Cell Metastasis

Source Undetermined
Source Undetermined

continued
Source Undetermined

SAH

Source Undetermined

Normal
48 hr old Right Temporal Infarct

Source Undetermined
Acute on Chronic Subdural

Source Undetermined
Source Undetermined
Source Undetermined

Source Undetermined

SAH

Source Undetermined

Source Undetermined
Rt Parietal Fx with Air

Source Undetermined
Source Undetermined
Brain Abscess

Source Undetermined
Calcification Basal Ganglia

Source Undetermined
Source Undetermined
Source Undetermined

continued
hours

3-4 days

Source Undetermined

Source Undetermined

months

7-10
days

Source Undetermined

Source Undetermined
Trauma with Air

Source Undetermined
Dense MCA Sign

Source Undetermined
Subacute Brainstem Infarct

Source Undetermined
Atrophy

Source Undetermined
Trauma with SAH

Source Undetermined
Bitemporal Edema (Herpes)

Source Undetermined
Meningioma

Source Undetermined
Caudate Infarct

Source Undetermined
IVH Left Lateral Horn

Source Undetermined
Ultra-Early Right Parietal Infarct
Right Sulcal Effacement

Source Undetermined
Source Undetermined

Continued
Source Undetermined

Source Undetermined

Source Undetermined

Source Undetermined

Source Undetermined

Source Undetermin...
Subacute Infarct
(Rt Temporal Lobe)

Source Undetermined

Source Undetermined
Periventricular White
Matter Disease

Source Undetermined

Source Undetermined
Chronic Rt Occipital Infarct

Source Undetermined

Source Undetermined

Source Undetermined
Subacute Subdural

Source Undetermined
Traumatic Petechae

Source Undetermined
Loss of Sulci & Sylvian Fissure

Source Undetermined
Old Lt Lacunar Infarct

Source Undetermined
Subacute Lt Subdural

Source Undetermined
Rt MCA Infarct with Hemorrhage

Source Undetermined
Lt Sagital Vein Thrombosis

Source Undetermined
Source Undetermined
SAH with Blood along Falx
& in Ventricle

Source Undetermined
Tumor

Source Undetermined
Tumor

Source Undetermined
CT Ground Rule
Radiolucent

Radiodense

Spinal fluid

Bone

Ischemic
infarct

Blood

Source Undetermined

Edema

Calcium

...
“Blood Can Be Very Bad”
Ø  Blood
Ø  Cisterns
Ø  Brain
Ø  Ventricles
Ø  Bone
Perron et al: Ann Emerg Med 1998:32:554-5...
Intracerebral Hemorrhage
q A ppearance
q Hyperdense
q Well demarcated
q Globular

q L ocation
q Intraparenchymal

So...
Subarachnoid Hemorrhage
q  Appearance
q  Hyperdense
q  Fuzzy

q  Locations of blood

q  Mimics
q  Contrast
q  Calci...
Ultra-Early Infarct

Old Infarcts

Normal

Density of CSF

Sulcal effacement

Well demarcated

Loss of insular ribbon

Ven...
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GEMC: Systematic Evaluation to Non-Traumatic Head CTs: Resident Training

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This is a lecture by Dr. Rashmi U. Kothari from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC: Systematic Evaluation to Non-Traumatic Head CTs: Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Systematic Evaluation to Non-Traumatic Head CTs Author(s) Rashmi U. Kothari, MD (KCMS/MSU), 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for selfdiagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2 To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Systematic Evaluation to Non-Traumatic Head CTs Source Undetermined Rashmi U. Kothari, MD KCMS/MSU
  4. 4. Why do you need to be able to evaluate a CT Ø  Radiology report is not immediately available Ø  Need immediate intervention Ø  Don’t trust anyone
  5. 5. Course Outline Ø  Basic principles of CT Ø  Basic anatomy Ø  Systematic Ø  CT approach Potpourri
  6. 6. Course Goals Ø  Learn “Blood Can Be Very Bad” approach to reading CTs Ø  Identify classic CT findings
  7. 7. Disclaimer Ø  Make you a neuroradiologist Ø  Teach you cause of finding of abnormality Ø  Help you with contrast CTs
  8. 8. Source Undetermined Basic Principles of CT Imaging
  9. 9. X-rays Absorbed Differently by Different Tissues Radiolucent Radiodense Air Bone Spinal fluid Source Undetermined Metal Ischemic infarct Calcium Edema Blood White matter Grey matter Source Undetermined
  10. 10. Attenuation (amount of radiation blocked by tissue) 50-100 HU Air Blood -1000 HU Bone +1000 HU HU=Hounsfield Units
  11. 11. Windowing Ø  Blood Source Undetermined Source Undetermined Source Undetermined Brain Blood Bone
  12. 12. CT Anatomy Source Undetermined Ø  Six levels of cuts Ø  Cortical sulci Ø  Lateral Ventricles Ø  Basal Ganglia Ø  3 rd Ventricle Ø  Midbrain Ø  Pons Source Undetermined
  13. 13. CT Anatomy: Cortical Sulci & Lat. Ventricle Falx Cortical sulci Source Undetermined Source Undetermined Frontal lobe Parietal lobe Lateral ventricles Occipital lobe Source Undetermined Source Undetermined
  14. 14. CT Anatomy: Basal Ganglia & 3rd Ventricle Anterior horns . Choroid plexus Source Undetermined Source Undetermined Anterior horns Insular ribbon Sylvian fissure 3rd ventricle Quadrigeminal cistern Source Undetermined Source Undetermined
  15. 15. CT Anatomy: Midbrain & Pons Sylvian fissure Insular ribbon Ambient cistern (cirummesenphalic cistern) Source Undetermined Source Undetermined Frontal sinus Suprastellar cistern Pons 4th ventrical Source Undetermined Source Undetermined
  16. 16. Systematic Approach to Head CTs Ø P erron et al: Carolina’s Medical Center Ø “ Blood Can Be Very Bad” pnemonic Ø C ourse reviewing 12 scans & short histories Ø P re-test 60% to Post-test 78% Ø h ttp://www.uic.edu/com/ferne/pdf/acep_2005 _peds/perron_ich _acep_2005_peds_ course.pdf
  17. 17. “Blood Can Be Very Bad” Ø  Blood Ø  Cisterns Ø  Brain Ø  Ventricles Ø  Bone Perron et al: Ann Emerg Med 1998:32:554-562
  18. 18. “Blood Can Be Very Bad” Ø  Acute blood = hyperdense (white) Ø  50-100 Ø  As Ø  At HU it ages it becomes hypodense 1-2 weeks it is isodense with brain
  19. 19. “Blood Can Be Very Bad” Source Undetermined Source Undetermined Source Undetermined
  20. 20. “Blood Can Be Very Bad” Ø  4 cisterns: Suprasellar Ø  Quadrigeminal Ø  Slyvian Ø  Ambient Ø  Source Undetermined Source Undetermined Source Undetermined
  21. 21. Cisterns: Is there blood? Source Undetermined Source Undetermined Are they open? 21 Andrew D. Perron, MD, FACEP
  22. 22. “Blood Can Be Very Bad” Source Undetermined Source Undetermined Brain Source Undetermined
  23. 23. “Blood Can Be Very Bad” Source Undetermined Source Undetermined Source Undetermined Ventricle Source Undetermined
  24. 24. “Blood Can Be Very Bad” Source Undetermined Bone Source Undetermined Andrew D. Perron, MD, FACEP
  25. 25. Source Undetermined Source Undetermined Classic CT Findings Source Undetermined Source Undetermined Source Undetermined
  26. 26. Epidural •  Lens shape •  85% arterial bleeds •  Middle meningeal art • Lucid period Source Undetermined Subdural •  Concave shape •  Venous bleeds •  Crosses suture line Source Undetermined
  27. 27. Intracerebral Hemorrhage q  10% of all strokes Source Undetermined Source Undetermined q  2 major causes q  Hypertension q  Blacks & Asians q  50% basal ganglia q  Pons q  Cerebellum q  Amyloid q  Caucasians q  Lobar q  Recurrent
  28. 28. Subarachnoid Hemorrhage q  5-10% of all strokes q  Aneurysms, AVMs, trauma q  Hyperdense, fuzzy q  Locations of blood C- Source Undetermined – Sulci – Sylvian fissure – Circle of Willis – Falx – Tentorium
  29. 29. ICH Source Undetermined Source Undetermined SAH Normal Source Undetermined Source Undetermined SAH ICH Source Undetermined Source Undetermined SAH
  30. 30. Findings Suggestive of ICH Ø N ormal Calcification Ø  Basal ganglia Ø  Choroid plexus Ø  Pineal gland CSource Undetermined
  31. 31. Findings Suggestive of ICH Ø Metal Ø  Very hypodense Ø  “Sparks” Ø  Clips, bullets, metallic catheters CSource Undetermined
  32. 32. Findings Suggestive of ICH ? CSource Undetermined
  33. 33. Volume Averaging (Technical Issues Mimicking ICH) Ø  Orbital roof Ø  Petrous portion of temporal bone Ø  Pituitary fossa Ø  Brainstem Source Undetermined Source Undetermined Source Undetermined
  34. 34. Findings Suggestive of ICH/SAH ? ? CSource Undetermined
  35. 35. Motion Artifact (Technical Issues Mimicking ICH or SAH) Ø Streaky Ø Hyperdense Ø Boney prominence Source Undetermined Source Undetermined
  36. 36. Evolution of an Infarct Source Undetermined Source Undetermined Ultra-Acute Acute-Subacute 0-3 hours 6hrs-days Source Undetermined Chronic 1 year
  37. 37. Ultra-Early CT Findings Ø  Normal Ø  Sulcal effacement Ø  Loss of insular ribbon Ø  Loss of grey-white interface Ø  Acute hypodensity Source Undetermined
  38. 38. Sulcal Effacement Source Undetermined Source Undetermined
  39. 39. Loss of Insular Ribbon Source Undetermined
  40. 40. Loss of Sulci & Acute Hypodensity Source Undetermined
  41. 41. Acute Hypodensity Source Undetermined Source Undetermined
  42. 42. Acute-Subacute Stroke (hours-days) Ø  Hypodense Ø  Well demarcated Ø  Mass effect Ø  Midline shift Ø  Loss of sulci Source Undetermined
  43. 43. Old Infarct (months to years) Ø  Density of CSF Ø  Well demarcated Ø  Ventrical enlargement Ø  Sulci enlargement Ø  No sulcal effacement Ø  No mass effect Source Undetermined
  44. 44. Suggestive of an Infarct? Source Undetermined
  45. 45. Suggestive of an Infarct? Source Undetermined Tumor Source Undetermined Stroke
  46. 46. Case Presentations
  47. 47. Thalamic ICH Source Undetermined
  48. 48. Normal Source Undetermined
  49. 49. Chronic Frontal Subdural Source Undetermined
  50. 50. Subacute Right Parietal Infarct Source Undetermined
  51. 51. Source Undetermined continued
  52. 52. Source Undetermined SAH Source Undetermined Normal
  53. 53. Acute Subdural Source Undetermined
  54. 54. Normal Source Undetermined
  55. 55. Closed Ventricles Source Undetermined
  56. 56. Cisterns: Are they open? Source Undetermined Source Undetermined Andrew D. Perron, MD, FACEP
  57. 57. Metallic Artifact Source Undetermined
  58. 58. Brainstem SAH Source Undetermined
  59. 59. Chronic MCA Infarct Source Undetermined
  60. 60. Left IVH Source Undetermined
  61. 61. Epidural Source Undetermined
  62. 62. Rt Subacute Epidural Source Undetermined
  63. 63. Sagital Sinus Source Undetermined
  64. 64. Subacute Infarct Source Undetermined
  65. 65. Renal Cell Metastasis Source Undetermined
  66. 66. Source Undetermined continued
  67. 67. Source Undetermined SAH Source Undetermined Normal
  68. 68. 48 hr old Right Temporal Infarct Source Undetermined
  69. 69. Acute on Chronic Subdural Source Undetermined
  70. 70. Source Undetermined
  71. 71. Source Undetermined Source Undetermined SAH Source Undetermined Source Undetermined
  72. 72. Rt Parietal Fx with Air Source Undetermined
  73. 73. Source Undetermined
  74. 74. Brain Abscess Source Undetermined
  75. 75. Calcification Basal Ganglia Source Undetermined
  76. 76. Source Undetermined
  77. 77. Source Undetermined continued
  78. 78. hours 3-4 days Source Undetermined Source Undetermined months 7-10 days Source Undetermined Source Undetermined
  79. 79. Trauma with Air Source Undetermined
  80. 80. Dense MCA Sign Source Undetermined
  81. 81. Subacute Brainstem Infarct Source Undetermined
  82. 82. Atrophy Source Undetermined
  83. 83. Trauma with SAH Source Undetermined
  84. 84. Bitemporal Edema (Herpes) Source Undetermined
  85. 85. Meningioma Source Undetermined
  86. 86. Caudate Infarct Source Undetermined
  87. 87. IVH Left Lateral Horn Source Undetermined
  88. 88. Ultra-Early Right Parietal Infarct Right Sulcal Effacement Source Undetermined
  89. 89. Source Undetermined Continued
  90. 90. Source Undetermined Source Undetermined Source Undetermined Source Undetermined Source Undetermined Source Undetermined
  91. 91. Subacute Infarct (Rt Temporal Lobe) Source Undetermined Source Undetermined
  92. 92. Periventricular White Matter Disease Source Undetermined Source Undetermined
  93. 93. Chronic Rt Occipital Infarct Source Undetermined Source Undetermined Source Undetermined
  94. 94. Subacute Subdural Source Undetermined
  95. 95. Traumatic Petechae Source Undetermined
  96. 96. Loss of Sulci & Sylvian Fissure Source Undetermined
  97. 97. Old Lt Lacunar Infarct Source Undetermined
  98. 98. Subacute Lt Subdural Source Undetermined
  99. 99. Rt MCA Infarct with Hemorrhage Source Undetermined
  100. 100. Lt Sagital Vein Thrombosis Source Undetermined
  101. 101. Source Undetermined
  102. 102. SAH with Blood along Falx & in Ventricle Source Undetermined
  103. 103. Tumor Source Undetermined
  104. 104. Tumor Source Undetermined
  105. 105. CT Ground Rule Radiolucent Radiodense Spinal fluid Bone Ischemic infarct Blood Source Undetermined Edema Calcium White matter Grey matter Air Metal Source Undetermined
  106. 106. “Blood Can Be Very Bad” Ø  Blood Ø  Cisterns Ø  Brain Ø  Ventricles Ø  Bone Perron et al: Ann Emerg Med 1998:32:554-562
  107. 107. Intracerebral Hemorrhage q A ppearance q Hyperdense q Well demarcated q Globular q L ocation q Intraparenchymal Source Undetermined q M imics q Normal Calcification q  Basal ganglia q  Choroid plexus q  Pineal gland q Artifacts q  Metal q  Catheters q  Volume Averaging q  Motion
  108. 108. Subarachnoid Hemorrhage q  Appearance q  Hyperdense q  Fuzzy q  Locations of blood q  Mimics q  Contrast q  Calcified Falx q  Normal Tentorium q  Motion artifact q  Sulci q  Sylvian fissure q  Circle of Willis q  Falx q  Tentorium Source Undetermined
  109. 109. Ultra-Early Infarct Old Infarcts Normal Density of CSF Sulcal effacement Well demarcated Loss of insular ribbon Ventrical enlargement Loss of grey-white interface Sulci enlargement Acute hypodensity Source Undetermined No sulcal effacement No mass effect Acute-Subacute Hypodense Well demarcated Mass effect Midline shift Loss of sulci Source Undetermined Source Undetermined

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