Skull and Scalp Lesions Skull fractures Linear fracture Comminuted fracture Depressed fracture Compound fracture Diastatic fracture
Skull and Scalp Lesions “SCALP” S : skin C : connective tissue A : [galea] aponeurosis L : loose connective tissue P : periosteum
Skull and Scalp Lesions Bilateral subgaleal hematoma
Skull and Scalp Lesions Acute and chronic cephalohematoma; a crescent-shaped soft-tissue mass in the periosteum of the left parietal and a partially calcified mass in the periosteum of the left parietal bone. The mass originated from a cephalohematoma. Radiographics 2004; 24:1655–1674
Epidural Hematoma (EDH) Classic arterial epidural hematoma; a lentiform, high attenuation collection adjacent to the right temporal lobe, caused by skull fracture with middle meningeal artery injury. Neurotherapeutics 2011; 8:
Epidural Hematoma (EDH) Neurotherapeutics 2011; 8: Venous epidural hematoma; scalp soft tissue swelling with lentiform EDH and pneumocephalus indicated an associated skull fracture. CT venogram was obtained as the fracture line extended over the expected location of the right transverse sinus. The opacified transverse sinuses are patent with compression and displacement from the inner table by the EDH caused by injury to the transverse sinus.
Subarachnoid Hemorrhage (SAH) Moderate to severe head trauma Superficial sulci CSF cisterns
Subarachnoid Hemorrhage (SAH) Common causes Head trauma Intracranial aneurysm Perimesencephalic hemorrhage Less frequent etiologies Arteriovenous malformation Arterial dissection Extension from intracerebral hemorrhage
Subarachnoid Hemorrhage (SAH) Pseudo-subarachnoid hemorrhage Severe diffuse brain edema Relatively hyperdense vasculatures A 34-year-old man with cardiac arrest. A, On the first day, no abnormal finding is seen. B, On the 8 th day, the brain shows diffuse low attenuation with obliteration of cisterns-sulci and narrowed ventricles. High-attenuation areas along sylvian fissures and tentorium cerebelli. C, On the 129th day, brain edema becomes more severe with more prominent high attenuation areas.
Cortical Contusions Locations Cerebellum 10% Superior vermis Tonsils Inferior hemisphere Gliding contusion Parasagittal region emedicine.medscape.com
A typical coup-contrecoup pattern of injury with an extracranial/skull injury at the point of direct impact and a more pronounced area of intracranial contusions at the directly opposite side of the head.
Cortical Contusions Evolve with time Early Ill-defined low density Small petechial hemorrhage hours More lesions 20% delayed hemorrhage
Cortical Contusions Blossoming of hemorrhagic contusions. (a)Multiple intracranial hemorrhages including a subtle left temporal hemorrhagic contusion, SDH along the right tentorium and SAH in the basilar cisterns and Sylvian fissure. (b) CT scan 6 hours later demonstrates expansion of the left temporal contusion. Neurotherapeutics 2011; 8:
Intraventricular Hemorrhage (IVH) 1-5% close head injury Other primary intraaxial lesions Etiology Disrupted subependymal veins Ruptured intracranial hemorrhage Focal choroid plexus hematoma Isolated IVH better outcome
Deep Gray Matter/Brainstem Injury 5-10% primary brain injury Direct trauma Shearing force Disrupted perforating blood vessels Petechial hemorrhage Locations Dorsolateral brainstem Diffuse axonal injury Duret hemorrhage Periaqueductal region Deep gray matter
Diffuse axonal injuries in classic locations: Gray/white matter interface (predominantly in frontal and temporal lobes), the corpus callosum (especially the splenium) and the dorsolateral midbrain 9-year-old boy with motor vehicle accident. Initial CT showed subcortical hemorrhagic foci in left fronal lobe. Due to persistent reduced vigilance, MRI was ordered
Diffuse Brain Swelling Diffuse cerebral swelling in this 32-year-old patient who sustained head trauma: diffuse sulcal effacement but relative preservation of gray-white differentiation. Neurotherapeutics 2011; 8:
Diffuse Brain Swelling Twofold higher in children More prone to dysautoregulation Vasodilatation and hyperemia Cerebral swelling
Neurotherapeutics 2011; 8: Large left holohemispheric and parafalcine subdural hematoma results in midline shift and subfalcine herniation.
Uncus protrudes into suprasellar cistern.
Subacute subdural hematoma producing extensive midline shift with subfalcine and right uncal herniation. There is trapping of the ventricles with acute ependymal cerebrospinal fluid seepage, predominantly in the left periatrial and occipital regions.
Cerebral Herniations Descending transtentorial herniation due to massive subdural hematoma radiologyimages.blogspot.com
Secondary Hemorrhage Large left holohemispheric and parafalcine subdural hematoma results in midline shift and uncal herniation. Downward brainstem herniation has led to classic Duret hemorrhage. Neurotherapeutics 2011; 8:
Secondary Hemorrhage Extensive cerebral edema with descending transtentorial herniation and a relatively large hemorrhage in brainstem. Because there is brain herniation, this hemorrhage is most likely Duret hemorrhage.
Secondary Hemorrhage Thin chronic subdural hematoma with abnormal signal in the contralateral crus cerebri; Kernohan’s notch phenomenon. m
Traumatic Ischemia/Infarction Right-sided holohemispheric subdural hematoma results in subfalcine and uncal herniation with subsequently developed infarcts in ACA and PCA distributions with infarction of the posterior limb of the right internal capsule due to compression of the anterior choroidal artery with uncal herniation. Neurotherapeutics 2011; 8: