Atlas 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