di-imaging of head traum 2009 (tn)
TRANSCRIPT
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IMAGING OF HEAD TRAUMA
Dr. Thanh Binh Nguyen
University of Ottawa, CanadaJuly 2009
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OUTLINE
Clinical indications for imaging
Imaging technique
Extraaxial hemorrhage
Intraaxial injury
Brain herniations Skull fractures
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INTRODUCTION
Head trauma is the leading cause of
death in people under the age of 30.
Males have 2-3 x frequency of braininjury than females
Due mainly to motor vehicle accidents
and assaults
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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
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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
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IMAGING TECHNIQUE
CT without contrast is the modality of
choice in acute trauma (fast, available,
sensitive to acute subarachnoidhemorrhage and skull fractures)
MRI is useful in non-acute head trauma
(higher sensitivity than CT for corticalcontusions, diffuse axonal injury,
posterior fossa abnormalities)
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APPROACH TO CT BRAIN
Look at the scout film: ? Fracture of uppercervical 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)
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SCALP INJURY
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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.
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Extraaxial fluid collections
Subarachnoid hemorrhage(SAH)
Subdural hematoma(SDH)
Epidural hematoma
Subdural hygroma
Intraventricular hemorrhage
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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 fromaneurysm)
Can lead to communicatinghydrocephalus
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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)
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W=33 L=41
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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.
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EPIDURAL HEMATOMA
Located between the skull andperiosteum
Due to laceration of the middlemeningeal artery or dural veins
Can cross dural reflections but is limitedby suture lines
Lentiform shape (but concave shape inSDH)
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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
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Intraventricular hemorrhage
Most commonly due to rupture of
subependymal vessels
Can occur from reflux of SAH orcontiguous extension of an intracerebral
hemorrhage
Look for blood-cerebrospinal fluid levelin occipital horns
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INTRA-AXIAL INJURY
Surface contusion/laceration
Intraparenchymal hematoma
White matter shearing injury/diffuse
axonal injury
Post-traumatic infarction
Brainstem injury
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CONTUSION/LACERATIONS
Most common source of traumatic SAH
Contusion: must involve the superficial graymatter
Laceration: contusion + tear of pia-arachnoid Affects the crests of gyri
Hemorrhage present ½ cases and occur atright angles to the cortical surface
Located near the irregular bony contours:poles of frontal lobes, temporal lobes, inferiorcerebellar hemispheres
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Fromhttp://neuropathology.n
eoucom.edu/
Dr.Agamanolis
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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 brainDDx: DAI, hemorrhagic contusion
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DIFFUSE AXONAL INJURY
Rarely detected on CT ( 20% of DAI
lesions are hemorrhagic)
MRI: T1, T2, T2 GRE, SWI
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DAI
Due to acceleration/deceleration towhtie matter + hypoxia
Patients have severe LOC at impactGrade 1: axonal damage in WM only -
67%
Grade 2: WM + corpus callosum(posterior > anterior) – 21%
Grade 3: WM + CC + brainstem
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DAI
Hours:
hemorrhages and tissue tears
Axonal swellings Axonal bulbs
Days/weeks: clusters of microglia and
macrophages, astrocytosisMonths/years: Wallerian degeneration
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From
http://neuropathology.neou
com.edu/
Dr.Agamanolis
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Sagittal T1-W images
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Axial FLAIR images
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AXIAL FLAIR
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AXIAL T2 GRADIENT-ECHO
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BRAINSTEM INJURY
By direct or indirect forces
Most commonly associated with DAI
Involves the dorsolateral midbrain and upperpons and is usually hemorrhagic
Duret hemorrhage is an example of indirectdamage: tearing of the pontine perforators
leading to hemorrhage in the settingtranstentorial herniation
<20% of brainstem lesions are seen on CT
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18 biker hit by a car
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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
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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 pontineangle
Compression of the posterior cerebral artery
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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
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UPWARD HERNIATION
Due to posterior fossa mass causingsuperior displacement of the vermisthrough the tentorial incisura
Compression of the 4th ventricle andeffacement of the quadrigeminal platecistern.
Compression of the superior cerebellarartery
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TONSILLAR HERNIATION
Inferior displacement of the cerebellar
tonsils through the foramen magnum
Can lead to posterior cerebellar arteryinfarction
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EXTERNAL HERNIATION
Due to a defect in the skull in
combination with elevated ICP
Venous obstruction can occur at
the margins of the defect.
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SIGNIFICANT SKULL
FRACTURES “Depressed”: inner table is depressed
by the thickness of the skull.
Overlie major venous sinus, motorcortex, middle meningeal artery
Pass through sinuses
Look for sutural diastasis (lambdoid)
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TEMPORAL BONE
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TEMPORAL BONE
FRACTURES Look for opacification of the mastoid
Longitudinal: 70%, parallel to long axis
of petrous bone, conductive hearingloss (from ossicular dislocation), facialnerve paralysis (20%)
Transverse: 20%, sensorineural hearing
loss, facial nerve paralysis (50%)Complex
Complications: meningitis, abscess
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POST TRAUMATIC
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POST TRAUMATIC
SEQUELAECarotid-cavernous fistula(CCF)
Dissection/pseudoaneurysm
Infarction
Atrophy/encephalomalacia
Infection
Leptomeningeal cyst
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