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Basic Knowledge and Film Practices: Head Trauma Nuttha Sanghan, M.D. Radiology Department Prince of Songkla University.

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Presentation on theme: "Basic Knowledge and Film Practices: Head Trauma Nuttha Sanghan, M.D. Radiology Department Prince of Songkla University."— Presentation transcript:

1 Basic Knowledge and Film Practices: Head Trauma Nuttha Sanghan, M.D. Radiology Department Prince of Songkla University

2 Head Trauma Imaging modalities Primary traumatic lesions Secondary effects

3 Imaging Modalities Skull radiography Calvarial fractures Penetrating injuries Radiopaque foreign bodies Shift away from skull radiography toward CT scan AJNR 2007: 28;

4 Imaging Modalities CT Scan Faster Wide availablility Lack contraindication High accuracy Treatable lesions MRI Longer time Lesser availability Difficult monitoring More sensitive Parenchyma Extraparenchyma Lower accuracy Skull fracture AJNR 2007: 28;

5 Primary Traumatic Lesions Skull and scalp lesions Extraaxial hemorrhage Epidural hematoma (EDH) Subdural hematoma (SDH) Subarachnoid hemorrhage (SAH) Intraaxial lesions Diffuse axonal injury (DAI) Cortical contusion Deep gray matter/brainstem injury

6 Skull and Scalp Lesions Skull fractures Linear fracture Comminuted fracture Depressed fracture Compound fracture Diastatic fracture

7 Skull and Scalp Lesions “SCALP” S : skin C : connective tissue A : [galea] aponeurosis L : loose connective tissue P : periosteum

8 Skull and Scalp Lesions Bilateral subgaleal hematoma

9 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

10 Primary Traumatic Lesions Skull and scalp lesions Extraaxial hemorrhage Epidural hematoma (EDH) Subdural hematoma (SDH) Subarachnoid hemorrhage (SAH) Intraaxial lesions Diffuse axonal injury (DAI) Cortical contusion Deep gray matter/brainstem injury

11 Extraaxial hemorrhage Epidural hematoma (EDH) Subdural hematoma (SDH) Subarachnoid hemorrhage (SAH)

12 Epidural Hematoma (EDH) 1-4% craniocerebral trauma Lucid interval 50% Delay 10-30% hours

13 Epidural Hematoma (EDH) Imaging Displaced dura matter Certain diagnosis Focal biconvex/lentiform configuration Not cross suture Cross dural attachments Falx cerebri Tentorium cerebelli

14 Epidural Hematoma (EDH)

15 Epidural Hematoma (EDH) Arterial origin Laceration: fracture 85-90% Stretching Temporal/temporoparietal region: MMA Venous origin Lacerated dural sinus Posterior cranial fossa

16 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:

17 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.

18 Epidural Hematoma (EDH) Size variable 2/3 hyperdense 1/3 mixed hyper/hypodense Swirl sign Low density: active bleeding Osborn

19 Epidural Hematoma (EDH) Coronal reconstructions Vertex EDH

20 Epidural Hematoma (EDH) Small EDH Not always differentiation SDH Classic shape Fracture

21 Epidural Hematoma (EDH) Mortality 5% Poor outcome Delayed diagnosis Posterior cranial fossa

22 Primary Traumatic Lesions Extraaxial hemorrhage Epidural hematoma (EDH) Subdural hematoma (SDH) Subarachnoid hemorrhage (SAH)

23 Subdural Hematoma (SDH) 10-20% craniocerebral trauma 30% fatal injuries Lack trauma Stretching & tearing of bridging veins Asymptomatic-unconsciousness

24 Subdural Hematoma (SDH) Imaging Crescent shape Cross suture Not cross dural attachment

25 Subdural Hematoma (SDH) Supratentorial convexity Posterior cranial fossa Falx-tentorium Nonaccidental trauma

26 Subdural Hematoma (SDH) Acute (a few days) Hyperdense 60% Mixed 40% Nearly isodense Coagulopathy Severe anemia

27 Subdural Hematoma (SDH) Subacute (a few weeks) Isodense Displaced GW interface Sulci-inner table Contrast administration Cortical vessels Neomembrane

28 Subdural Hematoma (SDH)

29

30 Subdural Hematoma (SDH) Chronic (months) Hypodense Neomembrane Capillary-rich Rebleeding 10-40% Mixed density Fluid-fluid levels Septate-loculation Calcification 1-2%

31 Subdural Hematoma (SDH) AJR 2011: 196;

32 Subdural Hematoma (SDH)

33 Differentiation Epidural hematoma Fracture 85-95% Arterial/venous Biconvex Not cross suture Cross dura Subdural hematoma Stretching/tearing Bridging cortical veins Crescent Cross suture Not cross dura

34 Primary Traumatic Lesions Extraaxial hemorrhage Epidural hematoma (EDH) Subdural hematoma (SDH) Subarachnoid hemorrhage (SAH)

35 Subarachnoid Hemorrhage (SAH) Moderate to severe head trauma Superficial sulci CSF cisterns

36 Subarachnoid Hemorrhage (SAH) Common causes Head trauma Intracranial aneurysm Perimesencephalic hemorrhage Less frequent etiologies Arteriovenous malformation Arterial dissection Extension from intracerebral hemorrhage

37 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.

38 Subarachnoid Hemorrhage (SAH) Pseudo-empty delta sign: SSS thrombosis Posterior parafalcine/interhemispheric SDH SAH around sinus AJR 2007; 189:

39 Primary Traumatic Lesions Skull and scalp lesions Extraaxial hemorrhage Epidural hematoma (EDH) Subdural hematoma (SDH) Subarachnoid hemorrhage (SAH) Intraaxial lesions Diffuse axonal injury (DAI) Cortical contusion Deep gray matter/brainstem injury

40 Intraaxial lesions Diffuse axonal injury (DAI) Cortical contusion Deep gray matter/brainstem injury

41 Diffuse Axonal Injury (DAI) Shear-strain deformation Acceleration/deceleration Rotational force Diffuse, bilateral

42 Diffuse Axonal Injury (DAI) Locations GW interface Corpus callosum Posterior body Splenium Dorsolateral upper brainstem Sequentially deeper with increasing severity

43 Diffuse Axonal Injury (DAI) Imaging Initial normal/subtle Nonhemorrhagic 80% Hypodense foci Site of shearing Petechial hemorrhages 20-50% Tip of the iceberg Delayed scans with new lesions

44 Diffuse axonal injury in a patient who was on anticoagulants: CT scan on day1 and day 2 Diffuse Axonal Injury (DAI)

45 Diffuse axonal injury: small hemorrhagic foci in the right parasagittal posterior frontal lobe and in the splenium of the corpus callosum Neurotherapeutics 2011; 8:

46 Primary Traumatic Lesions Intraaxial lesions Diffuse axonal injury (DAI) Cortical contusion Deep gray matter/brainstem injury

47 Cortical Contusions Second primary intraaxial lesions Less initial loss of consciousness Gray matter More vascularity Likely hemorrhage Variable size

48 Cortical Contusions Locations Temporal lobe Petrous part Greater sphenoid wing Frontal lobe Cribiform plate-orbit Planum sphenoidale Lesser sphenoid wing

49 Cortical Contusions Locations Cerebellum 10% Superior vermis Tonsils Inferior hemisphere Gliding contusion Parasagittal region emedicine.medscape.com

50 Cortical Contusions

51 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.

52 Cortical Contusions Evolve with time Early Ill-defined low density Small petechial hemorrhage hours More lesions 20% delayed hemorrhage

53 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:

54 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

55

56 Primary Traumatic Lesions Intraaxial lesions Diffuse axonal injury (DAI) Cortical contusion Deep gray matter/brainstem injury

57 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

58 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

59 Secondary Effects Diffuse brain swelling Cerebral herniations Secondary hemorrhage Traumatic ischemia/infarct

60 Diffuse Brain Swelling Cerebral hyperemia Increased blood volume Cerebral edema Vasogenic: disrupted BBB Cytotoxic: failured cell membrane pumps

61 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:

62 Diffuse Brain Swelling Twofold higher in children More prone to dysautoregulation Vasodilatation and hyperemia Cerebral swelling

63 Secondary Effects Diffuse brain swelling Cerebral herniations Secondary hemorrhage Traumatic ischemia/infarct

64 Cerebral Herniations Increased intracranial pressure Herniaed brain to another compartment Bony ridges Dural folds

65 Cerebral Herniations Subfalcine Uncal Transtentorial Descending Ascending Tonsillar Central Transcalvarial

66 Neurotherapeutics 2011; 8: Large left holohemispheric and parafalcine subdural hematoma results in midline shift and subfalcine herniation.

67

68 Uncus protrudes into suprasellar cistern.

69 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.

70 Cerebral Herniations Descending transtentorial herniation due to massive subdural hematoma radiologyimages.blogspot.com

71 Descending transtentorial herniation https://www.thieme- connect.de

72 Cerebral Herniations

73 Cerebral Herniations Tonsillar herniation Rare Foramen magnum Compressing medulla Upper cervical spinal cord Early Difficult on axial view Best on sagittal MRI l

74 Secondary Effects Diffuse brain swelling Cerebral herniations Secondary hemorrhage Traumatic ischemia/infarct

75 Secondary Hemorrhage u

76 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:

77 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.

78 Secondary Hemorrhage Thin chronic subdural hematoma with abnormal signal in the contralateral crus cerebri; Kernohan’s notch phenomenon. m

79 Secondary Effects Diffuse brain swelling Cerebral herniations Secondary hemorrhage Traumatic ischemia/infarct

80 Traumatic Ischemia/Infarction 2% traumatic brain injuries Mechanical compression PCA-transtentorial herniation ACA-subfalcine herniation Perforating branches

81 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:

82 Traumatic Ischemia/Infarction Primary vascular injuries Vasospasm Dissection Laceration Occlusion Pseudoaneurysm

83 Traumatic Ischemia/Infarction CT screening-basal skull fracture Carotid canal Sphenoid bone Petrous temporal bone Occipital bone Implement CT angiography Conventional angiography

84 Referrence AJNR 2007: 28; Gentry LR, Knopp EA. Head Trauma. In: Atlas SW, editor. Magnetic resonance imaging of the brain and spine. 4 th ed. Philadelphia: Lippincott Williams & Wilkins;

85 Referrence Neurotherapeutics 2011; 8: Yousem DM, Grossman RI. Head Trauma. In: Neuroradiology. 3 rd ed. Philadelphia: Mosby; p กนกพร โอฬารรัตนชัย. ภาพรังสีกะโหลกศีรษะ. ใน : จันทิมา เอื้อตรง - จิตต์, สนาน สิมารักษ์, บรรณาธิการ. รังสีวิทยาพื้นฐาน. พิมพ์ครั้งที่ 1. เชียงใหม่ : ธนุชพริ้นติ้ง ; หน้า


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