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IMAGING OF HEAD TRAUMA. Dr. Thanh Binh Nguyen University of Ottawa, Canada July 2009. OUTLINE. Clinical indications for imaging Imaging technique Extraaxial hemorrhage Intraaxial injury Brain herniations Skull fractures. INTRODUCTION.

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IMAGING OF HEAD TRAUMA

Dr. Thanh Binh Nguyen

University of Ottawa, Canada

July 2009


OUTLINE

  • Clinical indications for imaging

  • Imaging technique

  • Extraaxial hemorrhage

  • Intraaxial injury

  • Brain herniations

  • Skull fractures


INTRODUCTION

  • Head trauma is the leading cause of death in people under the age of 30.

  • Males have 2-3 x frequency of brain injury than females

  • Due mainly to motor vehicle accidents and assaults


Classification of TBI

  • Primary

    • Injury to scalp, skull fracture

    • Surface contusion/laceration

    • Intracranial hematoma

    • Diffuse axonal injury, diffuse vascular injury

  • Secondary

    • Hypoxia-ischemia, swelling/edema, raised intracranial pressure

    • Meningitis/abscess


IMAGING TECHNIQUE

  • The presence of a skull fracture increases the risk of having a posttraumatic intracranial lesion.

  • However, the absence of a skull fracture does not exclude a brain injury, which is particularly true in pediatric patients due to the capacity of the skull to bend.

  • NO ROLE FOR PLAIN FILMS IN ACUTE HEAD TRAUMA


IMAGING TECHNIQUE

  • CT without contrast is the modality of choice in acute trauma (fast, available, sensitive to acute subarachnoid hemorrhage and skull fractures)

  • MRI is useful in non-acute head trauma (higher sensitivity than CT for cortical contusions, diffuse axonal injury, posterior fossa abnormalities)


OUR CT PROTOCOLS

  • “ROUTINE”: posterior fossa and supratentorial region (slice thickness = 5mm)

  • “TRAUMA”: posterior fossa (2.5mm), supratentorial region (5mm)

  • “TEMPORAL BONE”: <1mm in axial or coronal plane

  • “ORBITS/FACIAL BONES”: 1.25 mm axial/coronal orbits


APPROACH TO CT BRAIN

  • Look at the scout film: ? Fracture of upper cervical spine or skull

  • Look for brain asymmetry

  • Look at sulci, Sylvian fissure and cisterns to exclude subarachnoid hemorrhage

  • Change windows to look for subdural collection

  • Look at bone windows to see fractures

  • Determine if mass is intraaxial (in the brain) or extraaxial (outside)


SCALP INJURY


SCALP INJURY

  • Cephalohematoma: blood between the bone and periosteum. Cannot cross the suture lines.

  • Subgaleal hematoma: blood between the periosteum and aponeurosis. Can cross the suture lines.

  • Caput Succ: swelling across the midline with scalp moulding. Resolves spontaneously.


Extraaxial fluid collections

  • Subarachnoid hemorrhage(SAH)

  • Subdural hematoma(SDH)

  • Epidural hematoma

  • Subdural hygroma

  • Intraventricular hemorrhage


Subarachnoid hemorrage

  • Can originate from direct vessel injury, contused cortex or intraventricular hemorrhage.

  • Look in the interpeduncular cistern and Sylvian fissure

  • Usually focal (but diffuse from aneurysm)

  • Can lead to communicating hydrocephalus


SUBDURAL HEMATOMA

  • Occurs between the dura and arachnoid

  • Can cross the sutures but not the dural reflections

  • Due to disruption of the bridging cortical veins

  • Hypodense(hyperacute, chronic), isodense(subacute), hyperdense(acute)


W=33 L=41


MANAGEMENT OF aSDH

  • Acute SDH with thickness > 10 mm or midline shift > 5mm should be evacuated

  • Patient in coma with a decrease in GCS by >2 points with a SDH should undergo surgical evacuation.


EPIDURAL HEMATOMA

  • Located between the skull and periosteum

  • Due to laceration of the middle meningeal artery or dural veins

  • Can cross dural reflections but is limited by suture lines

  • Lentiform shape (but concave shape in SDH)


MANAGEMENT OF aEDH

  • EDH > 30 cm3 should be evacuated.

  • EDH < 30 cm3 and <15 mm thickness and < 5 mm midline shift and GCS >8 may be managed nonoperatively with serial CT


Intraventricular hemorrhage

  • Most commonly due to rupture of subependymal vessels

  • Can occur from reflux of SAH or contiguous extension of an intracerebral hemorrhage

  • Look for blood-cerebrospinal fluid level in occipital horns


INTRA-AXIAL INJURY

  • Surface contusion/laceration

  • Intraparenchymal hematoma

  • White matter shearing injury/diffuse axonal injury

  • Post-traumatic infarction

  • Brainstem injury


CONTUSION/LACERATIONS

  • Most common source of traumatic SAH

  • Contusion: must involve the superficial gray matter

  • Laceration: contusion + tear of pia-arachnoid

  • Affects the crests of gyri

  • Hemorrhage present ½ cases and occur at right angles to the cortical surface

  • Located near the irregular bony contours: poles of frontal lobes, temporal lobes, inferior cerebellar hemispheres


From http://neuropathology.neoucom.edu/

Dr.Agamanolis


Intraparenchymal hematoma

  • Focal collections of blood that most commonly arise from shear-strain injury to intraparenchymal vessels.

  • Usually located in the frontotemporal white matter or basal ganglia

  • Hematoma within normal brain

  • DDx: DAI, hemorrhagic contusion


DIFFUSE AXONAL INJURY

  • Rarely detected on CT ( 20% of DAI lesions are hemorrhagic)

  • MRI: T1, T2, T2 GRE, SWI


DAI

  • Due to acceleration/deceleration to whtie matter + hypoxia

  • Patients have severe LOC at impact

  • Grade 1: axonal damage in WM only -67%

  • Grade 2: WM + corpus callosum (posterior > anterior) – 21%

  • Grade 3: WM + CC + brainstem


DAI

  • Hours:

    • hemorrhages and tissue tears

    • Axonal swellings

    • Axonal bulbs

  • Days/weeks: clusters of microglia and macrophages, astrocytosis

  • Months/years: Wallerian degeneration


From http://neuropathology.neoucom.edu/

Dr.Agamanolis


Sagittal T1-W images


Axial FLAIR images


AXIAL FLAIR


AXIAL T2 GRADIENT-ECHO


BRAINSTEM INJURY

  • By direct or indirect forces

  • Most commonly associated with DAI

  • Involves the dorsolateral midbrain and upper pons and is usually hemorrhagic

  • Duret hemorrhage is an example of indirect damage: tearing of the pontine perforators leading to hemorrhage in the setting transtentorial herniation

  • <20% of brainstem lesions are seen on CT


18 biker hit by a car


BRAIN HERNIATIONS


SUBFALCIAL HERNIATION

  • Subfalcial: displacement of the cingulate gyrus under the free edge of the falx along with the pericallosal arteries.

  • Can lead to anterior cerebral artery infarction


UNCAL HERNIATION

  • Displacement of the medial temporal lobe through the tentorial notch

  • Displacement of the midbrain

  • Effacement of the suprasellar cistern

  • Displacement of the contralateral cerebral peduncle against the tentorium

  • Widening of the ipsilateral cerebello pontine angle

  • Compression of the posterior cerebral artery


DOWNWARD HERNIATION

  • Caudal displacement of the thalamus and midbrain

  • Effacement of the perimensencephalic cistern and 4th ventricle.

  • Can cause a 3rd nerve palsy and disrupt pontine vessels leading to brainstem hemorrhage


UPWARD HERNIATION

  • Due to posterior fossa mass causing superior displacement of the vermis through the tentorial incisura

  • Compression of the 4th ventricle and effacement of the quadrigeminal plate cistern.

  • Compression of the superior cerebellar artery


TONSILLAR HERNIATION

  • Inferior displacement of the cerebellar tonsils through the foramen magnum

  • Can lead to posterior cerebellar artery infarction


EXTERNAL HERNIATION

  • Due to a defect in the skull in combination with elevated ICP

  • Venous obstruction can occur at the margins of the defect.


SIGNIFICANT SKULL FRACTURES

  • “Depressed”: inner table is depressed by the thickness of the skull.

  • Overlie major venous sinus, motor cortex, middle meningeal artery

  • Pass through sinuses

  • Look for sutural diastasis (lambdoid)


TEMPORAL BONE FRACTURES

  • Look for opacification of the mastoid

  • Longitudinal: 70%, parallel to long axis of petrous bone, conductive hearing loss (from ossicular dislocation), facial nerve paralysis (20%)

  • Transverse: 20%, sensorineural hearing loss, facial nerve paralysis (50%)

  • Complex

  • Complications: meningitis, abscess


POST TRAUMATIC SEQUELAE

  • Carotid-cavernous fistula(CCF)

  • Dissection/pseudoaneurysm

  • Infarction

  • Atrophy/encephalomalacia

  • Infection

  • Leptomeningeal cyst


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