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The mnemonic used by Dr. Andrew Perron who lectures on this topic frequently is: Blood Can Be Very Bad. Content
and images below are taken from his lecture (with his permission).
1. Blood
Step: 1
Look for any evidence of bleeding throughout all slices of the head CT.
Blood will appear bright white and is typically in the range of 50-100 Houndsfield units.
Basic categories of blood in the brain are epidural, subdural, intraparenchymal/intracerebral, intraventricular, and
subarachnoid.
Step: 2
2 Key questions to answer regarding the 4 key cisterns (Circummesencephalic, Suprasellar, Quadrigeminal and
Sylvian)
- Is there blood?
-Are the cisterns open?
Circummesencephalic cistern
Suprasellar cistern
Quadrigeminal cistern
Sylvian cistern
3. Brain
Step: 3
Symmetry - make sure sulci and gyri appear the same on both sides. (easiest when patient not rotated in the
scanner)
Grey-white differentiation - the earliest sign of a CVA on CT scan is the loss of the grey-white interface on CT
scan. Compare side to side.
Shift - the falx should be in the midline with ventricles the same on both sides. Check for effacement of sulci
(unilateral or bilateral).
Hyper/hypodenisty - blood, calcification and IV contrast are hyperdense (appear lighter) and air, fat and areas of
tumor ischemia are hypodense (appear darker).
4. Ventricles
Step: 4
Examine for IIIrd, IVth and lateral ventricles for dilation or compression/shift.
Pathologic processes cause dilation (hydrocephalus) or compression/shift. Communicating vs. Non-communicating.
Communicating hydrocephalus is first evident in dilation of the temporal horns (normally small, slit-like). The
lateral, IIIrd, and IVth ventricles need to be examined for effacement, shift, and blood.
5. Bone
Step: 5
Bone has the highest density on CT scan (whitest in appearance.) Evaluate for fracture.