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31 Emergency Cranial Radiological Assessment The Society of Neurological SurgeonsBootcamp
32 Objectives Identify basic intracranial structures Identify brain shift, intracranial hemorrhage, and skull fracturesBe able to communicate accurately to the chief resident or attending the important findings that may impact clinical decision making and emergent patient management.The Society of Neurological Surgeons
34 Foramen ovale Foramen spinosum Carotid canal Jugular fossa # Left sphenoid bone – medial to foramen ovale, extends across carotid canal. Mastoids O.K.Mastoid air cellsThe Society of Neurological Surgeons
35 Sphenoid sinus Carotid canal The Society of Neurological Surgeons # Left sphenoid bone – medial to foramen ovale, extends across carotid canal. Mastoids O.K.The Society of Neurological Surgeons
38 CT ScanComputerized Axial Tomography or CT scan is the most often used emergency imaging study in neurosurgery. A CT scan is an excellent study for identifying intracranial hemorrhage and skull fractures.Calcified structures such as bone or the pineal gland appear white or hyperdense.Acute blood clot appears white or hyperdense. Chronic hematomas appear dark or hypodense.Ischemic strokes are hard to identify on CT until they are about 6 – 12 hours old.
40 Epidural Hematoma Between the skull and the dura. Biconvex or lens shaped.More common in children and young adults. Uncommon in the elderly since the dura is very adherent to the skull.Over 90% are associated with a skull fracture. Classically due to laceration of the middle meningeal artery.Initial concussion - “lucid interval” - deteriorationTreatment is usually emergent surgery.
41 Case Example: 6 year old girl, MVA, GCS 7T, LOC at scene, lucid interval, now with lethargy and left side weaknessTaken to OR for emergent evacuation of EDHThe Society of Neurological Surgeons
42 Acute SDH More likely to be “crescent shaped” than “lens shaped”. Often holohemispheric.Can extend along falx or tentorium.Does not cross the midline.Higher morbidity and mortality than EDH due to additional underlying brain injury.50-90% mortality.
43 Subdural Hematoma: Clot age and CT Imaging Characteristics AcuteSubacuteChronic
44 Chronic SDH 50% without significant history of trauma Hypodense/isodense crescent shaped collectionEvacuate if symptomaticLooks like motor oilOften occurs in the elderly on aspirin, plavix, or coumadinCan be treated by twist drill craniostomy, burr hole or craniotomy
54 Traumatic Contusions Coup or contra-coup contusion Hemorrhagic contusions can enlarge or “blossom” as well as develop extreme edema, so must follow examination closely and consider repeat CT scansSurgical evacuation if there is excessive mass effect
55 47 year old gentleman, was inebriated, fall, LOC, GCS 7T (E2, M4, V1T), PERRL, In cervical collarEVD placed, Medical management of ICP, gradually improved over several days, neck cleared after extubation and improvement in neuro statusThe Society of Neurological Surgeons
56 18 year old male, shot in head while sitting in car, GCS 15 with no focal deficits, open scalp wound over skull fractureScalp debrided, bullet fragment extracted, wound closed
57 Acute Hydrocephalus7 year old boy with posterior fossa tumor, drowsy, less responsive through the dayEVDEVD placed, immediately better
58 Ischemic StrokeTypically follow a vascular distribution such as the territory of the MCA, PCA or ACA.A stroke may take several hours before it is apparent on a CT scan.Typically is seen earlier on an MRI
71 Basilar Skull Fracture of the Temporal Bone Seen on Bone Windows
72 Basic Principles of MR Imaging Images are created based on signals returning from spinning protonsNot based on densityObjects are described in terms of intensity (hypointense, isointense, hyperintense)T1 and T2 Weighted ImagingT1 Post Contrast Enhancement