Depressed Skull Fracture — CT Brain (Non-contrast)

 

Depressed Skull Fracture — CT Brain (Non-contrast)

Key radiological features:

1. Bony Abnormality

• Inward displacement of skull fragment(s) below adjacent inner table
• Step defect in calvarium
• Often comminuted fragments
• Best seen in bone window

2. Depth Criteria (Clinical relevance)

• Depression > thickness of adjacent skull → significant
• Associated with higher risk of dural tear & brain injury

3. Intracranial Complications

• Underlying contusion / intracerebral hemorrhage
• Extradural hematoma (EDH)
• Subdural hematoma (SDH)
• Subarachnoid hemorrhage (SAH)
• Pneumocephalus (air entry)

4. Soft Tissue Findings

• Scalp swelling / hematoma
• Possible foreign body (in compound fractures)

5. Dural / Brain Involvement

• Dural breach (suggested by pneumocephalus or deep fragment)
• Brain laceration in severe cases

6. Special Situations

• Open (compound) fracture → air, contamination
• Over venous sinus → risk of sinus injury/thrombosis
• Frontal sinus involvement → CSF leak risk

One-line summary:

Inwardly displaced skull fragment(s) on bone window + frequently associated underlying intracranial injury (contusion/hematoma ± pneumocephalus).

Skull Fracture (Non-depressed) — CT Brain Features

Skull Fracture (Non-depressed) — CT Brain Features 

1. Linear (most common)

• Thin radiolucent line in bone window
• Sharp, non-sclerotic margins
• Often crosses vascular grooves (vs grooves: branching, sclerotic margins)
• May cross sutures (vs sutures: serrated, symmetric)
• No displacement or depression

2. Diastatic fracture

• Widening of cranial sutures beyond normal
• Common in children
• Typically along coronal, sagittal, lambdoid sutures

3. Comminuted (non-depressed)

• Multiple intersecting fracture lines
• Bone fragmented but no inward displacement

4. Basilar skull fracture

• Often indirect signs predominate:
  • Pneumocephalus
  • Air-fluid levels in paranasal sinuses
  • Opacification of mastoid air cells
• Fracture line may be subtle (bone window essential)
• Common sites: temporal bone, sphenoid, occipital base

General CT Clues (All Types)

• Best seen in bone window
• Look for overlying scalp swelling/hematoma
• Assess for associated intracranial injury (EDH, SDH, contusion)
• Use multiplanar reconstructions (MPR) for subtle fractures

Quick Differentiation

• Fracture line → sharp, straight, may cross sutures
• Suture → zig-zag, symmetric, sclerotic edges
• Vascular groove → branching, tapered

Intracerebral Hemorrhage (ICH) — CT Brain (Non-contrast)

 

Intracerebral Hemorrhage (ICH) — CT Brain (Non-contrast)

Key radiological features (concise):

1. Hyperdense Intraparenchymal Lesion

• Acute blood = hyperdense (bright) (≈60–80 HU)
• Common sites: basal ganglia (putamen), thalamus, lobar, cerebellum, brainstem

2. Surrounding Edema

• Hypodense rim around hematoma (perihematomal edema)
• Develops within hours → increases over days

3. Mass Effect

• Effacement of sulci, ventricles
• Midline shift (quantify if needed)
• Compression of adjacent structures

4. Intraventricular Extension

• Hyperdense blood in ventricles
• May show fluid–fluid level / layering
• Risk of acute hydrocephalus

5. Shape & Margins

• Typically irregular or round/oval
• May have heterogeneous density (active bleed, clot retraction)
• “Swirl sign” → hypodense areas within clot (ongoing bleeding)

6. Location Clues (Etiology hint)

• Deep (putamen/thalamus) → hypertensive
• Lobar → amyloid angiopathy, tumor, AVM
• Multiple → metastasis, coagulopathy

7. Evolution (brief)

• Hyperacute (0–6 h): hyperdense ± swirl
• Subacute (days): density ↓ (isodense ~1–2 weeks)
• Chronic: hypodense cavity ± encephalomalacia

Mnemonic: “HEMATOMA”

• Hyperdensity
• Edema
• Mass effect
• Atypical density (swirl)
• Topography (site clues)
• Outflow into ventricles
• Margins irregular
• Age-dependent change

Subarachnoid Hemorrhage (SAH) — CT Brain (Non-contrast)

Core radiological features (concise):

1) Hyperdensity in subarachnoid spaces

• Acute blood appears hyperdense (bright)
• Typical locations:
  • Basal cisterns (suprasellar, interpeduncular, ambient)
  • Sylvian fissures
  • Interhemispheric fissure
  • Cortical sulci

2) “Star sign” (basal cistern pattern)

• Star-shaped hyperdensity in basal cisterns around Circle of Willis
• Classic for aneurysmal SAH

3) Sulcal effacement with hyperdense sulci

• Blood outlines sulci → prominent hyperdense cortical sulci
• May coexist with early cerebral edema → sulcal effacement

4) Intraventricular extension (common)

• Hyperdensity within ventricles (especially occipital horns)
• May show fluid–fluid levels

5) Hydrocephalus

• Acute obstructive or communicating hydrocephalus
• Findings:
  • Ventricular dilatation
  • Periventricular lucency (transependymal CSF seepage)

6) Loss of gray–white differentiation (severe cases)

• Due to global cerebral edema (esp. massive SAH)

7) Distribution clues to etiology

• Aneurysmal SAH → basal cistern dominant
• Traumatic SAH → cortical sulci over convexities
• Perimesencephalic SAH → localized around midbrain, limited spread

One-line mnemonic

“Bright blood in cisterns, sulci, fissures ± ventricles + hydrocephalus”

Subdural Hematoma (SDH) — CT Brain (Non-contrast) Key Features

 

Subdural Hematoma (SDH) — CT Brain (Non-contrast) Key Features

Typical Appearance

1. Shape & Location

• Crescent-shaped (concavo-convex) extra-axial collection
• Lies between dura and arachnoid
• Crosses sutures, but does NOT cross midline (limited by falx/tentorium)

2. Density (depends on age)

• Acute (0–3 days): Hyperdense (bright)
• Subacute (3–21 days): Isodense → may be subtle (“CT occult”)
• Chronic (>3 weeks): Hypodense (dark)
• Mixed density: Rebleed → fluid-fluid levels / layering

3. Mass Effect

• Sulcal effacement
• Midline shift
• Compression of ventricles
• Possible subfalcine / transtentorial herniation

4. Internal Characteristics

• Homogeneous (acute) or heterogeneous (chronic/rebleed)
• May show septations/membranes (chronic SDH)

5. Associated Findings

• Underlying cerebral edema
• Cortical contusions
• Skull fracture less common than in EDH

High-yield Differentiation (SDH vs EDH)

• SDH: Crescentic, crosses sutures
• EDH: Biconvex (lens-shaped), does NOT cross sutures

Rapid Mnemonic

“SDH = Sickle, Spreads, Slowly changes density”

• Sickle (crescent)
• Spreads across sutures
• Slow evolution → density changes

Normal CT Brain (Non-contrast) — Key Radiological Features (Concise)

 

1. Symmetry

• Bilateral cerebral hemispheres symmetrical
• No midline shift
• Falx cerebri in midline

2. Grey–White Matter Differentiation

• Clear distinction:
  • Grey matter (cortex, basal ganglia) → slightly hyperdense
  • White matter → slightly hypodense
• Preserved corticomedullary junction

3. Ventricular System

• Lateral, 3rd, 4th ventricles:
  • Normal size and configuration
  • Symmetrical
• No dilatation or compression

4. Cisterns & Sulci

• Basal cisterns (suprasellar, ambient, quadrigeminal) → open and well-defined
• Cortical sulci:
  • Normal for age
  • No effacement (→ edema) or prominence (→ atrophy)

5. Basal Ganglia & Thalami

• Normal density and symmetry
• No focal hypo/hyperdense lesions

6. Brainstem & Cerebellum

• Normal size, contour, and density
• No focal lesion or compression

7. No Abnormal Densities

• No:
  • Hyperdensity → hemorrhage
  • Hypodensity → infarct/edema
• No calcification (except physiological: pineal, choroid plexus)

8. Midline Structures

• Falx, septum pellucidum → central
• No mass effect or shift

9. Bone & Extra-axial Structures

• Skull vault intact (no fracture)
• No:
  • Extradural/subdural collection
  • Scalp swelling

10. Orbits & Sinuses (Screening)

• Orbits normal
• Paranasal sinuses:
  • Air-filled (no fluid level or opacification)

Ultra-short Mnemonic: “S G V C B B M B O”

• Symmetry
• Grey–white differentiation
• Ventricles
• Cisterns/sulci
• Basal ganglia
• Brainstem/cerebellum
• Midline
• Bones/extra-axial
• Orbits/sinuses

Epidural Hematoma (EDH) — CT Brain (Non-contrast)

Core CT Features (Acute EDH)

• Shape: Biconvex / lentiform (lens-shaped)
• Density: Homogeneous hyperdense (acute blood)
• Location: Extra-axial, between skull and dura
• Suture relation: Does NOT cross sutures (tight dural attachment)
  (may cross dural reflections rarely if large)
• Midline shift / mass effect: Common → sulcal effacement, ventricular compression
• Underlying skull fracture: Frequently present (esp. temporal bone)

Additional Signs

• “Swirl sign” → hypodense areas within hematoma (active bleeding)
• Lucid interval correlation (clinical, not CT but supportive)
• Effacement of cisterns if severe

Evolution

• Acute (0–3 days): Hyperdense
• Subacute: Isodense → may be missed without contrast
• Chronic (rare for EDH): Hypodense

Key Differentiation (vs SDH)

• EDH → Biconvex, limited by sutures
• SDH → Crescentic, crosses sutures but not midline (falx limit)

Rapid Mnemonic

“EDH = Egg-shaped, Does NOT cross sutures, High density”