imaging of intracranial bleeds - lieberman's...

Head TraumaHead Trauma Imaging of Intracranial BleedsImaging of Intracranial Bleeds

Srishti Gupta, Harvard Medical School – Year IIIGillian Lieberman, MD

November 2000Srishti GuptaGillian Lieberman, MD

November 2000

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Our PatientOur Patient

• 85 y/o woman fell at home, hitting R temple on corner of table

• ambulated then became unresponsive• In the ED . . .

– Patient lethargic– No external signs of injury– pupil size R 3.5 L 2.5 responsive to light– BP 208/palpable HR 112

Srishti GuptaGillian Lieberman, MD

November 2000

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Menu of tests for imaging head traumaMenu of tests for imaging head trauma

1. Head CT2. Head MRINoncontrast Head CT is the test of choice as:• The patient is accessible if emergency resuscitation is needed• IV contrast is not needed• Fast• Great for identifying fractures and bone fragments• Great for identifying acute bleeds; they appear hyperdense• Great for evaluating edema and shift/herniation


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Bone is whiteCalcium is white;Acute hemorrhage is usually white

Brain parenchyma is light grey;White matter is darker than grey matter

CSF is very dark grey;Sulci, cisterns and ventricles

Air is black;Nasal cavity, sinuses, mastoid air cells

White

Light Grey

Charcoal Grey

Black

In order to recognize the abnormal, you first need to know the appearance of the normal.

On non-contrast head CT:


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Normal AnatomyNormal Anatomy• Ca caudate• WM white matter• GM grey matter• SP septum pellucidum• CP choroid plexus• LV lateral ventricles• Me medulla• FV fourth ventricle• CB cerebellum • FC falx cerebri

LV

FC

CP

WM

GM

BIDMC


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Normal AnatomyNormal Anatomy• Ca caudate• WM white matter• GM grey matter• SP septum pellucidum• CP choroid plexus• LV lateral ventricles• TV Third Ventricle• Me medulla• FV fourth ventricle• CB cerebellum • FC falx cerebri• Ci Cisterns

CaSP

TV

Ci

BIDMC


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Normal AnatomyNormal Anatomy• Ca caudate• WM white matter• GM grey matter• SP septum pellucidum• CP choroid plexus• LV lateral ventricles• Third Ventricle• Me medulla• FV fourth ventricle• CB cerebellum• FC falx cerebri

Me

CB FV

BIDMC


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Normal AnatomyNormal Anatomy• Sutures• Sinuses

– FS Frontal– EA Ethmoid Air Cells– SS Sphenoid– MS Maxillary– MA Mastoid Air Cells

• NA Nasal Airway• EC Ear Canal

FS

MA

BIDMC


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Normal AnatomyNormal Anatomy

• Sutures• Sinuses



EA

SS

MA

NA

EC

BIDMC


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Normal AnatomyNormal Anatomy

• Sutures• Sinuses



MS

SS

BIDMC


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Systematic Approach to reading a Systematic Approach to reading a Head CTHead CT

I. Quality Control– Check patient name, study date, time– Check standard views are included

• properly positioned contiguous images from foramen to cranial vertex

• correct scanner settings; Brain W/L: 80/40 Bone W/L: 2000/350

– Determine if IV contrast was given


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Systematic Approach to reading a Systematic Approach to reading a Head CT (cont’d)Head CT (cont’d)

II. Check Brain Parenchyma• Check grey/white differentiation• Gyri• Look for blood• Surgeons need to know . . . (size of hematoma, extent of midline shift,

herniation)

III. Check CSF spaces: Ventricles, Cisterns and Sulci• CSF spaces (ventricles and cisterns)

– size, symmetry, midline shift– herniation

• Subfalcine – cingulate gyrus crosses falx• Transtentorial – temporal lobe into tentorial notch • Cerebellar – cerebellum into foramen magnum


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Systematic Approach to reading a Systematic Approach to reading a Head CT (cont’d 2)Head CT (cont’d 2)

IV. Check face and skull bones on bone windows– Do not confuse sutures with fracture especially in

pediatric patients

V. Check “air spaces”– Sinuses– Nasal airway– Ear Canals and Mastoid air cells


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A Head CT with out IV contrast was obtained on our patient. Let’s review it

first fast and then systematically.


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Emergency Head CT w/o contrast 2h s/p fall. W/L: 80/40


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BIDMC

Emergency Head CT w/o contrast 2h s/p fall.W/L: 2000/350


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Our Patient’s Head CTOur Patient’s Head CT

• R frontoparietal subdural hematoma (6 mm)

• Midline marker• R temperoparietal epidural

hematoma (1.8 cm)• 6 mm leftward shift of lateral

ventricles• Right lateral ventricle• Left lateral ventricle• Effacement of R sulciBIDMC


Film findings:

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Locations for intracranial blood include:1. Epidural hemorrhage2. Subdural hemorrhage3. Subarachnoid hemorrhage4. Intraparenchymal hemorrhage

Differentiation between epidural and subdural maybe difficult


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Anatomy of intracranial bleedsAnatomy of intracranial bleeds

Woo and Nesathurai, 2000


Epidural Subdural

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Epidural Epidural • “classic” brief LOC, lucid

interval, deteriorating mental status

• most commonly middle meningeal artery, vein, venous sinus

• biconvex and confined by intracranial sutures

• craniotomy to evacuate hemorrhage and for hemostasis

http://www.rad.uab.edu


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Subdural HematomaSubdural Hematoma• altered consciousness, pupil

abnormalities• shearing of bridging veins• concave, not confined by

sutures• mass effect can cause

herniation or reduced perfusion

• blood toxic effect on tissue• monitor ICP, high mortality

rate• acute, subacute, chronic or

combination depending on time of presentation

http://www.med.wayne.edu/diagRadiology/TF/Neuro/


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Subarachnoid HemorrhageSubarachnoid Hemorrhage• shearing of microvessels in

subarachnoid space• often benign in trauma• most commonly associated

with ruptured aneurysm “worst headache of my life”

• hyperdensities indicate blood in– interhemispheric fissure– suprasellar cistern– sylvian cistern– perimesencephalic cistern– ambient cistern– quadrageminal plate cistern

Araiza & Araiza, 1997


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ParenchymalParenchymal HemorrhageHemorrhage

• presents with behavioral and cognitive changes

• round or irregular high density lesions

• damage to small arterioles in brain parenchyma

• result from lacerations or coalescence of contusions

• often associated with coup countrecoup injuries

• most common in frontal and temporal lobes

http://www.xray2000.f9.co.uk/Ibase2/Brain/


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Potential Shortcomings of CT in the Potential Shortcomings of CT in the Imaging of Head TraumaImaging of Head Trauma

• Location of pathology– Temporal– Posterior Fossa

• Isointense bleeds– anemia– coagulopathies– dilution of blood with

CSF

http://www.med.wayne.edu/diagRadiology/TF/Neuro/


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Management PrioritiesManagement Priorities

Medical Therapy– diuretics– blood pressure control– elevation of head– seizure prophylaxis– sedation– mild hypothermia

Surgical– Ventriculostomy– Evacuation– Craniotomy

Maintain perfusion and oxygenation of brainICP at or below 15 mm Hg


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Patient’s coursePatient’s course

• AD taken emergently to OR for evacuation of R frontal temporal hematomas

• Significant improvement in neurological function post operatively

• Patient discharged to home on POD# 5 in stable condition


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Our Patient’s FollowOur Patient’s Follow--up scansup scans

POD #1

BIDMC BIDMC


s/p

evacuationOn presentation

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FollowFollow--up scansup scans

POD # 1

Craniotomydefects

SurgicalSubdural air

BIDMC BIDMC


s/p

evacuation

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SummarySummaryTYPE Clinical Signs CT signs

EPIDURAL Lucid interval followed by deteriorating mental status

biconvex (lentiform) confined by sutures

SUBDURALAltered consciousness, pupil abnormalities, can be gradual in onset

Bi concave, not confined by sutures

SUBARACHNOID“Worst headache of life” more often associated with aneurysm, HTN

Hyperdensities in cisterns (star pattern)

PARENCHYMALBehavioral and cognitive changes, coup countrecoup injuries

round or irregular hyperdense lesions


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Head Injury FactsHead Injury Facts• 8 million people in the U.S. suffer head

injury each year• 500,000 hospitalized• Leading causes MVA (50%) Falls (21%)• Leading cause elderly falls (75%)

• Please buckle up and wear helmets on bikes, scooters, and rollerblades.


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ReferencesReferences• Grossman R. I., Yousem D. M. Neuroradiology: The Requisites 1st edition, 1994• Woo B.H., Nesathurai S. The Rehabilitation of People with Traumatic Brain Injury 1st edition, 2000• Novelline, R. A. Squire’s Fundamentals of Radiology 5th edition, 1997• Kushner D. “Mild Traumatic Brain Injury: Understanding Manifestations and Treatment” Archives

of Internal Medicine 158 (15) 1617-24• Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PMC “Indications for computed

tomography in patients with minor head injury “ NEJM 343 (2):100, 2000• Araiza J., Araiza B. “Neuroimaging” Emergency Medicine Clinics of North America 15 (3), 1997• http://www.radiology.wisc.edu/Med_Students/neuroradiology/NeuroRad/NeuroRad.htm• http://brighamrad.harvard.edu/education.html• Johnson KA & Becker JA, http://www.med.harvard.edu/AANLIB/home.html• http://www.neuropat.dote.hu/nrad2.htm• Zapawa,JE & Alcantara AL,

http://www.med.wayne.edu/diagRadiology/Anatomy_Modules/brain/brain.html• http://www.med.wayne.edu/diagRadiology/TF/Neuro/NeuroTF.html• http://www.rad.uab.edu• http://www.xray2000.f9.co.uk/Ibase2/Brain/


http://brighamrad.harvard.edu/education.html

http://www.med.harvard.edu/AANLIB/home.html

http://www.neuropat.dote.hu/nrad2.htm

http://www.med.wayne.edu/diagRadiology/Anatomy_Modules/brain/brain.html

http://www.med.wayne.edu/diagRadiology/TF/Neuro/NeuroTF.html

http://www.rad.uab.edu/

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AcknowledgementsAcknowledgements

• Vasant Narasimhan• Daniel Saurborn M.D.• Wayne Monsky M.D.• Beverlee Turner for her support and

PowerPoint expertise.

The end.The end.


imaging of intracranial bleeds - lieberman's...

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