imaging in head trauma
Post on 14-Jan-2017
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Dr. Sunil Kumar SharmaSenior Resident
Dept. of NeurologyGMC Kota
Aim
To understand Indications and select the appropriate imaging modality
To identify common traumatic emergency abnormalities of brain.
To determine an immediate life threatening abnormality on a CNS imaging
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
OUTLINEClassification of traumatic brain injuryClinical indications for imagingImaging techniqueExtraaxial hemorrhageIntraaxial injuryBrain herniations
Classification of traumatic brain injury
Traumatic Brain Injury
Classification -Primary & Secondary
Mechanism of injury-Penetrating, Blunt
Location-Intraaxial, Extraaxial
Clinical severity, GCS -Mild, Moderate, severe
Classification of TBIPrimary
Injury to scalp, skull fracture
Surface contusion/laceration
Intracranial hematoma
Diffuse axonal injury, diffuse vascular injury
Contd..Secondary
Hypoxia-ischemia
swelling/edema
raised intracranial pressure
Meningitis/abscess
Imaging ModalitiesPlain Radiography
Ultrasound
CT
MRI
Radionuclide studies
Angiography
Conventional X-raysUses a form of Ionizing radiation
Good in evaluating air containing structures, bones and calcifications
Limitations No depth information
Low soft tissue contrast
Radiation
Computed Tomography
Uses Ionizing radiation.Cross-sectional imagePrinciple based on differential x-ray beam
attenuation by tissue Image contrast, displayed as Gray scale –
Density/attenuation Low attenuation-Darker High Attenuation-Whiter
APPROACH TO CT BRAINLook at the scout film: ? Fracture of upper
cervical spine or skullLook at bone windows to see fracturesLook for brain asymmetryLook at sulci, Sylvian fissure and cisterns
to exclude subarachnoid hemorrhageLook for subdural collectionDetermine if mass is intraaxial (in the
brain) or extraaxial (outside)
Advantages of CT
High sensitivity for calcificationEasier and faster to perform.Most sensitive for detection of acute
hemorrhage Increasing availability No contraindications to emergency patient
scanningQuickest & most efficient screening
technique in acute traumatic setting
Disadvantages of CT
High radiation dose per examination
Children are more sensitive to radiation induced cancers than adults
Bone marrow, thyroid, breast, and lung are at greatest risk
Contrast related side effects
Factors to Consider When Determining Need of CT in Patients with Head InjuryIndications for urgent CT scan include:Evidence of skull fracture—basal,
depressed, or open
Abnormal results of neurologic examination
Seizure
Vomiting >1 time
High-risk mechanism (e.g., ejection from vehicle; pedestrian or cyclist versus automobile)
Decreasing GCS score or persistently decreased GCS score of <15.
Indications for lower threshold for CT scan include:Age >60 yr
Persistent anterograde amnesia
Retrograde amnesia >30 min
Coagulopathy
Fall >5 stairs or >3 feet
Cont..Intoxication (examination unreliable)
LOC >30 min
Mechanism and location of injury
Social factors (e.g., abusive situation at home, language barriers preclude accurate history)
Magnetic Resonance Imaging
Advantages of MRIUses non ionizing radiation
Less invasive technique
Multiplanar capability
Excellent soft tissue contrast
Ability to depict flowing blood without the need of IV contrast administration
Disadvantages of MRI
Cost
Limited Availability
Length of the examination time
Physiological motion artifacts
Acoustic noise
Contraindications of MRI
Ferrous object: Oxygen tanks, wheelchairs in the scan room is extremely dangerous
Pts. who have electrically &/or magnetically activated implants: Cardiac pace makers, Implanted defibrillators
Pts. with intracranial aneurysm clipsMetal within the eyeSome decorative tattoos
Indications for CT, MRI Scanning of BrainGeneral rules in brain imaging-Acute neurological illness-Start with CT Sub acute/ ChronicStart with MRIMRI is the imaging study of choice in
evaluating most brain abnormalitiesHead CT is the 1st line modality for brain
emergency
Cont…
General rule in Spine imaging -Bony spine-CT, Conventional radiograph Marrow replacing diseases-MRI Intervertebral Disc-MRI, CT MyelographyContents : Spinal cord, nerve roots, ligaments- MRI
Extraaxial Injury
Skull fracture
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Skull Fracture
Not predictive of intracranial injury
Absence does not exclude intracranial injury
Types-Linear, depressed, basal, comminuted
Risk of brain injury increases with the depth of depression
Skull x-ray findings-
Linear fracture-• Lucent sharply
defined line without sclerotic margin
Mimics-Vascular groove , sutures
Depressed fracture –
• Increased or double density on x-ray
• Best evaluated by CT
• >5mm, elevation indicated
Epidural Hematoma
Blood collection within potential space between skull
inner table & dura mater75 % at the temporal region Usually (99%)at the coup side Majority have Skull fracture 85-95% ; In
children often absent Mostly arterial bleed ,Due to laceration of the
middle meningeal artery or dural veinsExpands and present rapidly -Tense distension
Radiological signs
Biconvex with a sharply defined margin Does not cross suture line unless there is
fracture/diastasisMass effect +/-brain herniationDisplacement of sinus, falx from the skull Adjacent skull fracture
MANAGEMENT OF EDH
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
SUBDURAL HEMATOMAOccurs between the dura and arachnoid
Can cross the sutures but not the dural reflections
Due to disruption of the bridging cortical veins
hyperdense(acute), isodense(subacute) Hypodense(chronic),
Radiological signsCrescent shape The most common locations are the frontal
and parietal convexities.Countercoup Unlike an EDH, its spread is not limited by
suture lines; it can spread over the whole convexity, but it almost never crosses the midline
Mass effect +/-brain herniationSkull fracture in < 50 %
SUBDURAL HEMATOMA
MANAGEMENT OF SDH
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.
SUBARACHNOID HEMORRAGECan originate from direct vessel injury, contused cortex
or intraventricular hemorrhage.In contrast to aneurysmal SAH, the blood is superficial
in the cortex and not present in the basal cisterns.Usually focal (but diffuse from aneurysm)In some instances, for example, if blood is found in the sylvian fissure, a vascular study (CTA,DSA) is needed to rule out an aneurysm rupture.Can lead to communicating hydrocephalus
Intraventricular hemorrhageMost 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
Intraaxial injury Surface
contusion/lacerationIntraparenchymal
hematomaWhite matter shearing
injury/diffuse axonal injury
Post-traumatic infarctionBrainstem injury
CONTUSION/LACERATIONSMost common source of traumatic SAHContusion: must involve the superficial
gray matterLaceration: contusion + tear of pia-
arachnoidAffects the crests of gyriHemorrhage present ½ cases and occur at
right angles to the cortical surfaceLocated near the irregular bony contours:
poles of frontal lobes, temporal lobes, inferior cerebellar hemispheres
Intraparenchymal hematomaFocal collections of blood that most
commonly arise from shear-strain injury to intraparenchymal vessels.
Usually located in the frontotemporal white matter or basal ganglia
DDx: DAI, hemorrhagic contusion
DIFFUSE AXONAL INJURYDIFFUSE AXONAL INJURY
Rarely detected on CT ( 20% of DAI lesions are hemorrhagic)
MRI: T1, T2, T2 GRE, DWI
DAIDue 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
DTI
Traumatic cerebral infarctBest diagnosed by: Restricted diffusionLocation- Most commonly occur in PCA vascular distribution,
MCA, ACA, vertebrobasilar relatively common
Other: Lenticulostriate, thalamoperforating; cortical/subcortical; cerebellar
Traumatic cerebral infarct
SUBFALCIAL HERNIATIONSubfalcial: displacement of the cingulate gyrus
under the free edge of the falx along with the pericallosal arteries.
Can lead to anterior cerebral artery infarction
DESCENDING HERNIATION
Herniation:Ascending TranstentorialCranial shift of
vermis and parts of superomedial cerebellar hemisphere through tentorium incisura
Compressed superior cerebellar, vermian cisterns and forth ventricle
TONSILLAR HERNIATION
Inferior displacement of the cerebellar tonsils through the foramen magnum
Can lead to posterior cerebellar artery infarction
EXTERNAL HERNIATIONDue to a defect in the
skull in combination with elevated ICP
Venous obstruction can occur at the margins of the defect.
Conclusions
CT = primary modality for head trauma, enough for
most parts Skull x-rays still used in penetrating trauma, suspected child abuseMRI to help predicting prognosis by detection of subtle injuries i.e., contusion and DAI Primary vs secondary lesion. Often, secondary lesion more important
ConclusionsWhile checking the scan, make sure to think if the patient needs CTA or other CTs (C-spine, facial bones, etc) Coup-contrecoup mechanism helps confirm acute trauma nature and search for subtle lesions
Thank you
Thank you
References
Osborn Diagnostic Imaging Brain-2004
Bradley’s Neurology in Clinical Practice 6’th edition 2012
Slideshare.com
Radiopedia.com
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