Table Of ContentAtlas of Pathological Computer Tomography
Volume 1
A.Wackenheim L. Jeanmart A.L. Baert
Craniocerebral
Computer Tomography
Confrontations with Neuropathology
With Collaboration of
D. Baleriaux, D. Crolla, 1. Dietemann, R. Dom, 1. Flament, N. Heldt,
Y Palmers, and 1. Termote
With 112 Figures in 498 Separate Illustrations
Springer-Verlag Berlin Heidelberg New York 1980
ISBN -13 :978-3-642-67567-6 e-ISBN -13:978-3-642-67565-2
DOl: 10.1007/978-3-642-67565-2
Library of Congress Cataloging in Publication Data
Wackenheim. Auguste.
Craniocerebral computer tomography. Bibliography: p. Includes index. 1. Brain-Radiography. 2. Tomo
graphy. I. Jeanmart, L., 1929- joint author. II. Baert, A., 1931- joint author. III. Title. [DNLM:
1. Brain-Radiography. 2. Skull-Radiography. 3. Tomography, Computerized axial. WE705 W1l5cl
RC386.6.I64W32 616.8'047572 79-29673 ISBN 0-387-09879-8
This work is subject to copyright. All rights are reserved, whether the whole or part of the material
is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduc
tion by photocopying machine or similar means, and storage in data banks. Under § 54 of the German
Copyright Law where copies are made for other than private use, a fee is payable to the publisher,
the amount of the fee to be determined by agreement with the publisher.
© by Springer-Verlag Berlin Heidelberg 1980
Sof tcover reprint of the hardcover 1s t edition 1980
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence
of a specific statement, that such names are exempt from the relevant protective laws and regulations
and therefore free for general use.
Reproduction of the figures: Gustav Dreher GmbH, Stuttgart
2121/3\30-543210
Introduction
In this monography we report some confrontations of CT and ana
tomical data recorded during the last years in Leuven, Bruxelles
and Strasbourg, three neighbouring universities.
This material represents only a small part of our cases, but we have
selected those which seemed the most suited for didactic purposes.
This study is made in the traditional european way and confronts
the data of an investigation with the examination of the corresponding
anatomic specimen. Obviously this is only possible in very few cases.
But then, these cases provide a striking demonstration of the morphol
ogy of lesions seen at CT.
Our aim was to provide material for teaching. This book is the first
part of a trilogy; the two others deal with the pathology of the
trunk.
A. WACKENHEIM, L. JEANMART, A.L. BAERT
(Strasbourg, Bruxelles, Leuven)
Contents
1 Malformations . . . 1
1.1 V en tric1es . . . 1
1.2 Hydrocephalus . 1
1.3 Bourneville Disease . 1
1.4 Aneurysms. . . . . 1
1.5 Arteriovenous Aneurysms (Angiomas) . 1
2 Infections . . . . . . . . . 13
2.1 Abscesses and Empyema. 13
2.2 Abscesses and Hematoma 13
2.3 Ventriculitis . . . . . 13
2.4 Tuberculous Meningitis 14
3 Hematomas . . . . . . . . . . . 27
3.1 Intracerebral Hematomas . . . 27
3.1.1 Chronic Vascular Disease 27
3.1.2 Multiple Hematoma. . 27
3.1.3 Coffee Bean Hematoma . 27
3.1.4 Septate Hematoma . . . 27
3.1.5 Cockade-Shaped Hematoma 28
3.1.6 "Geometric" Hematoma. . 28
3.1.7 Associated Intra- and Extracerebral Hematomas 28
3.1.8 Cortical Rupture . . . . . . . . 28
3.1.9 Hematomas of the Posterior Fossa . . . . . 28
3.1.10 Edema Surrounding the Hematoma. . . . . 28
3.1.11 Supracallosa1 or Butterfly-Shaped Hematomas 29
3.1.12 Unexplained Phenomena. 29
3.2 Intraventricular Hemorrhage. . . . . 29
3.2.1 Origin of the Hemorrhage . . . 29
3.2.2 Direction of the Blood Diffusion:
Craniocaudal or Caudocranial? 29
3.2.3 Intraventricular Blood
Density Determination. . . . 29
VII
3.3 Subarachnoid Hemorrhage. . . . . . . . . . . 30
3.3.1 Intracerebral Hematoma with Subarachnoid
Hemorrhage . . . . . . . . . . . . . . 30
3.3.2 Hemorrhage in the Optochiasmatic Cistern. 30
3.3.3 Hemorrhage in the Cisterns of the Fissure of Bichat 30
3.4 Subdural and Extradural Hematomas 30
3.5 Hematoma and Tumor 30
4 Ischemias . . . . . . . 65
4.1 Temporal Herniation . 65
4.2 "Luxury Perfusion" 65
4.3 Postischemic Cerebral Atrophy . 66
4.4 Multiple Ischemic Lesions 66
5 Atrophies 73
6 Gliomas . 77
7 Metastases 93
8 Tumor of the Pituitary Area 105
9 Reticulosarcomas . 113
10 Ependymomas 117
11 Pinealomas . 119
12 Meningiomas. 123
References . . . 129
VIII
Authors and Collaborators
Wackenheim, Auguste
Professor and Chairman of Department of Diagnostic Radiology,
CHU Strasbourg, 1, Place de l'Hopital, F-67005 Strasbourg Cedex
J eanmart, Louis
Professor and Chairman of Department of Diagnostic Radiology,
Institut Jules Bordet, 1, Rue Heger-Bordet, B-1000 Bruxelles
Baert, Albert L.
Professor and Chairman of Department of Diagnostic Radiology,
Universitaire Ziekenhuizen, Capucijnenvoer 35, B-3000 Leuven
Baleriaux, D.
Premiere Assistante, Department of Diagnostic Radiology,
Universite Bordet (Prof. L. Jeanmart), Centre Anticancereux
de l'Universite Libre de Bruxelles, B-1000 Bruxelles
Crolla, D.
Resident, Department of Diagnostic Radiology (Prof. A. Baert),
Universitaire Ziekenhuizen, Capucijnenvoer 35, B-3000 Leuven
Dietemann, J.
Service de Neuroradiologie (Prof. A. Wackenheim), CHU Strasbourg,
1, Place de I'Hopital, F-67005 Strasbourg Cedex
Dom, R.
Docent Unit. of Neuropathology, Department of Neurology and
Neurosurgery (Prof. R. van den Bergh), University of Leuven,
B-3000 Leuven
Flament, J.
Chairman of Department of Neuropathology, Service d'Anatomie
Pathologique de I'Universite Libre de Bruxelles (Prof. P. Dustin),
B-I000 Bruxelles
IX
Heldt, N.
Institut d' Anatomie Pathologique (Prof. Y. Legal), CHU Strasbourg,
1, Place de I'Hopital, F -67005 Strasbourg Cedex
Palmers, Y.
Resident, Department of Radiology (Prof. A. Baert),
Universitaire Ziekenhuizen, Capucijnenvoer 35, B-3000 Leuven
Termote, J.
Resident, Department of Radiology (Prof. A. Baert),
Univcrsitairc Zickenhuizen, Capucijnenvoer 35, B-3000 Leuven
Photographs:
J. Gintzburger, F-67005 Strasbourg
M . Verheyden, B-I000 Bruxelles
W. Demedt, B-3000 Leuven
x
Malformations
In the absence of any ependymal disease, adherence of opposite ventricular 1.1 Ventricles
walls is responsible for narrow and deformed ventricles. This could be
verified in two cases (Fig. 1). Let us recall that at the level of the occipital
horn, narrowness may be due to hypertrophy of the calcar avis. These
asymmetries of the occipital horn were already well known by gas-mye
lographic techniques [24]. In the example in Fig. 1, there is no image of
the occipital horn, though the horn does exist: it is very narrow and has
an axially oriented lumen.
In cases of congenital hydrocephalus it is very difficult to recognize the 1.2 Hydrocephalus
anatomic structures on a conventional CT scan. It is only possible to differ
entiate the parenchymatous parts from the CSF (Fig. 2).
Thc contribution of CT in the diagnosis of Bourneville discase may be 1.3 Bourneville Disease
fundamental. Indeed, in a patient whose clinical picture suggests Bourneville
disease, CT may demonstrate paraventricular tumors (astrocytomas with
moderate contrast uptake) especially of the foramen of Monro (Fig. 3).
The association of the clinical and the CT data is then very characteristic
of Bourneville disease.
A large thrombosed aneurysm is readily demonstrated on CT, even without 1.4 Aneurysms
contrast enhancement (Fig. 4). Nevertheless, the large size of the hyperdense
area may mislead the radiologist; on the other hand, the round shape
and preferential location are clues suggesting an aneurysm.
A nonthrombosed aneurysm enhances clearly. If the margins of its image
are irregular, that will be due to partial thrombosis (Fig. 5). Hematomas
due to a ruptured aneurysm have quite characteristic locations, i.e., frontal
interhemispheric (Fig. 6), opticochiasmatic (Figs. 6, 7, and 58), sylvian
(Figs. 7 and 10), or peripeduncular (Fig. 51).
Thc walls of a calcified aneurysm are only rarely visible on a plain CT
scan. However, when they are visible, as in Fig. 8, the diagnosis is easy.
Especially in young patients, evidence of a hematoma on CT should lead 1.5 Arteriovenous Aneurysms
one to search for a vascular malformation. The latter may be obvious (Angiomas)
and easily recognized in cases such as the one shown in Figs. 9 and 10,
1
in which intravenous injection of contrast medium enhances linear high
densities that undulate and resemble venous pathways from the area of
the hematoma toward a sinus. Nevertheless, these features cannot be consid
ered specific, since they may also be encountered, for instance, in lymphomas
[15] and even in the neighborhood of trivial hematomas. They are then
secondary to linear propagations of the bleeding. Though this image is
usually not specific for arteriovenous malformation, the association of the
three signs, localized high densities of the level of clotted blood, presence
of one or several drainage vessels, and contrast enhancement, is characteris
tic for a hemorrhagic lesion with hypertrophied drainage vessels.
Cases with linear high densities (on plain or enhanced CT) and without
hematoma correspond to megadolichoarteries (Fig. 8) or to nonbleeding
arteriovenous aneurysms [16].
There are, however, cases - such as the one shown in Fig. 12 - in which
there are no CT signs that would allow one to suspect the very small
arteriovenous fistula that is responsible for the hemorrhage.
Finally, marked enhancement of an intraventricular choroid mass is a clue
suggesting angioma (Fig. 11).
2
