Neuro Radiology

ALGORITHMIC EVALUATION OF
COMPLEX NEUROLOGIC INJURIES
Advances in Emergency
Neuroradiology:
An Algorithmic Approach
I.
II.
Introduction
Neurologic Injury: Catastrophic and Critical
Diagnoses
III. Strategic Pathways for Diagnostic Imaging
Martin Kernberg, MD, Asst. Clinical Professor

Steve Polevoi, MD, Assoc. Clinical Professor
IV:
V.
VI.
Craniofacial
Axial Skeleton and Spinal Cord Injuries
Appendicular Skeleton and Peripheral Neural Injuries
Case Illustrations
Conclusions
References
Division of Emergency Medicine

Department of Medicine
University of California, San Francisco
Div. of Emergency Medicine, UCSF
Neurologic Injury: Parallel Processing of
Introduction
Neurologic injury remains one of the leading causes of death and long term
functional deficits despite recent advances in management. The
contemporary evaluation and management of the neurologic patient
require parallel efforts to assess the patient clinically and radiologically.
The timing and selection of radiological investigations remains a source
of controversy. Advancing imaging modalities yield diagnoses previously
overlooked; medicolegal concerns influence clinical decisions; decision
rules and protocols designed to reduce unnecessary costs, radiation
exposure, and clinical delays can seem complex, contradictory, and
excessively rigid; resources are progressively limited. In reviewing these
issues, a system is described that may prove useful in clinical practice,
with a critical review of the advantages and disadvantages of various
radiological modalities. While a set of algorithms is advocated, it is
underscored that this will vary depending on the facilities available. It is
appropriate however to be aware of the limitations of the radiological
techniques that are utilized on a daily basis and to have a knowledge of
how selective use of advanced imaging modalities will improve patient
care.
Information
1.
2.
3.
Consider the high risk differential diagnosis, on

the basis of clinical history, physical
examination, and laboratory studies.
Concurrently stabilize, initiate imaging
sequence, and/or contact appropriate surgical
consultants.
Confirm benign etiologies directly, or indirectly
after formal exclusion of the catastrophic
differential diagnosis.
Modified from P Jaye, ME Kernberg, and T Green, Trauma Radiology, The Lancet,
in press, 2007.
How are neurologic catastrophic

conditions defined?
Catastrophic conditions are those which

have a significant risk of mortality, if the
diagnosis is emergently missed.
Critical traumatic conditions are those
which have a significant risk of morbidity,
if the diagnosis is delayed (e.g., cervical
spine injuries, subacute hemorrhage, or
transient cerebral ischemia).
Emergency Chest Radiology
3 Catastrophic conditions
Intracranial hemorrhage
Traumatic
Vascular etiologies
Subdural hematoma
Epidural hematoma
Intraventricular hemorrhage
Aneurysm rupture
Hemorrhagic arterio-venous malformation
Hemorrhagic Venous angioma
Acute intra-axial ischemia and infarction

Intracranial and axial infection
Meningitis
Diskitis
Abscess
2 Critical Injuries:
Axial and Intra-axial Trauma
Axial fractures
C-spine
T-spine
Lumbosacral
Intra-axial
Contusions
Concussions
Petechial hemorrhage
General Vital Sign Indications for

Catastrophic Differential Diagnosis
Local Vital Sign Indications for

Neurologic Differential Diagnosis
1.
Glasgow Coma Score

1.
2.
2.
2.
3.
3.
4.
5.
Clinical Catastrophic Criteria
Acuity, severity, progression, persistence,

refractory, atypical or unexplained:
Adult
Pediatric
Cranial nerve functional deficits

1.
1. Tachycardia or bradycardia (heart rate <50)

2. Tachypnea or bradypnea (respiratory rate
<7)
3. Significant pyrexia or hypothermia
4. Hypotension and hypertension
5. Acute hypoxia
6. Pain severity
7. Weight loss
Visual acuity
Hearing loss
Anosmia
Motor strength
Reflex changes
Peripheral sensory deficits
Critical acute symptoms (e.g., severe headache, neck

pain, back pain; palpitations or respiratory
irregularity; nausea, vomiting, distension; paresthesia,
weakness, or paralysis)
Selective physical findings (neurologic deficits; blood
pressure fluctuation, rhythm disorders, bradypnea or
tachypnea; altered bowel or urinary function
(incontinence or retention); loss of reflexes, motor
function, or sensation; hemotympanum, periorbital
ecchymosis).
Aberrant laboratory, electrocardiographic, or plain
radiographic abnormalities (e.g., axial imaging).
Craniofacial Injury: Strategy
Imaging Modalities
Catastrophic
Craniofacial Findings
Conventional Radiographs and Special Views
CT: Incremental, Spiral, Angiographic
US: Gray Scale, Color Doppler, Amplitude

Angiography
MR: MRI and MRA
Arterial Catheterization
Standard
Diagnostic Testing
Clinical Information
Advanced Imaging
Options
Vital Signs
1. Laboratory
1. CT/CTA
History
2. XR
2. MRI
Neurologic
Examination
3. Angiography
Principles of facial imaging
If you can name the particular bone, plain film imaging is

appropriate:
Nasal spine
Mandible series (preferred: orthopantomogram)
If two or more bones are involved, CT is indicated. Do not

order (but your institution may require):
Facial films
Sinus series
Orbit series
TMJ series
Skull series
Case 1
30 year old homeless

male, intoxicated, is
involved in fistfight,
with multiple facial
abrasions, and
paranasal sinus
tenderness.
Case 1
Case 1
Case 1
Case 1
Principles of Cranial Imaging
Universal decision rule:
Acuity, severity, progression, persistence, refractory,

atypical and unexplained
Symptoms
Physical findings
Headache, nausea and vomiting, confusion, vertigo,

sensory deficit; weakness, paresthesia, ataxia; bleeding
from the ear, new rhinorrhea.
GCS decline
Neurologic deficits
Supraclavicular injuries
CT versus MRI: Controversy

CT vs. MR
MRI
CT
Sensitivity (ICH)
100%
97%
Radiation dose
1/1000 cancer rate
IQ impact
No known change
Diminished IQ
HS graduation rate
No known change
Diminished rate
Laboratory, electrocardiographic, or plain film findings,

such as
Respiratory acidosis
ST segment depression or elevation
Associated injuries: C-spine fractures
CT versus MRI: Controversy
SAH: Emerging controversy
CT versus MRI
MRI
CT
Imaging sequence
CT
MRI
Sedation
Often in children
Often in children
1. Non-contrast CT
1. MRI
Cost per machine
0.25 million
1.0 million
2. Lumbar puncture
2. CTA if MRI + ICH.
Cost per study
High
Intermediate
3. CTA if LP + ICH.
After hours access
Difficult
Easy
Types of Intracranial Hemorrhage
Epidural hematoma
Intraparenchymal hematoma
Common mechanism: meningeal artery laceration,

often associated with temporo-parietal fractures
Common mechanism: contusion with potential for
progression
Subdural hematoma
Subarachnoid hemorrhage
Intraventricular hemorrhage
Common mechanism: injury to bridging dural veins

Common mechanism: traumatic aneurysm rupture
Common mechanism: extension of intraparenchymal
hematoma
Case 2
75 yo ChineseAmerican male, with

no prior medical
history, awoke at
2300 hours with n/v
and left sided
weakness,
progressing to
witnessed seizures.
Case 2: CT and MRI
Case 3
Case 3
61 year old Hispanic

female with severe
headache and
nausea, become
apneic in transport,
with run of
ventricular
tachycardia.
Case 3
Case 3
Contusions and Intracerebral

Hematomas
Contusions can, in a period of hours or

days, evolve or coalesce to form an
intracerebral hematoma requiring
immediate surgical evacuation.
This occurs in approximately 20% of
patients and is best detected by
repeating the head CT scan within 12 to
24 hours after the initial scan. ATLS
C-spine interpretation:
Architectural principles
Axial Skeletal Trauma: Diagnostic Strategy

Catastrophic
Axial Skeletal Findings
Standard
Diagnostic Testing
Advanced Imaging
Options
Lateral projections
Counting (Marshalls law)
Vital Signs
1. Laboratory
1. CT/CTA
History
2. XR
2. MRI
Neurologic
Examination
3. Angiography
Are anatomic curves

continuous?
Conformance
Anterior projections
Are all the vertebral

bodies visible, including
T1?
Continuity
Are the transitions

between vertebral bodies
regular, with respect to
size and intervertebral
spaces?
Symmetry
Dens and C1
C1 and C2
Sinusoidal configuration
Scoliosis
Lateral masses
Muscle spasm
Ligamentous injury
Occult fracture
C-spine interpretation
guidelines
Prevertebral STS
Anterior longitudinal
line
Posterior longitudinal
line
Spinolaminar line
Posterior process line
Dens-basion distance
C-spine: the lateral view of

the lateral masses
Contour transitions
C-spine: the AP view of the

dens
Symmetry

dens
Indications for C-spine Films:

lateral masses
Symmetry
Severe pain
Midline tenderness*
Unrestrained occupant
Sinusoidal contour
Ejection
Neurologic deficit*
Radiculopathy
Intoxication*
Altered level of consciousness*
Mechanism
Velocity
Intrusion
Rollover
Other injuries
Brain
Distracting pain*
*= NEXUS exclusion criteria (NEJM Jul,

2000): implicit indications for imaging.
NEXUS
NEXUS
N Engl J Med 2000 Jul 13;343(2):94-9.

Validity of a set of clinical criteria to rule
out injury to the cervical spine in patients
with blunt trauma. National Emergency
X-Radiography Utilization Study Group.
Hoffman JR, Mower WR, Wolfson AB,
Todd KH, Zucker MI.
34,069 patients
Five criteria to be classified as low probability of

injury:
no midline cervical tenderness

no focal neurologic deficit
normal alertness
no intoxication
no painful, distracting injury
Individual criteria not compared

NPV 99.8%
Nexus Study
Canadian C-Spine Rule (I)
34,000 Patients, 23 Centers

5 Criteria: No posterior midline tenderness,
intoxication, altered consciousness,
neurological deficits, distracting injuries.
99.6% Sensitivity, but 12% Specificity.
Canadian C-Spine Rule (II)
3) Is the patient able to actively rotate

neck 45 degrees to left and right
regardless of pain?
C-spine: dens injury
Technique:
Asymmetry
CT C-spine: the lateral view of

the dens
8924 Adults
100% Sensitivity and 42.5% Specificity
1) Is there any high-risk factor that mandates
radiography (i.e. age > 65, dangerous
mechanism of injury, or paresthesias)?
2) Is there any low-risk factor present that
allows safe assessment of range of motion (i.e.
simple rear-end motor vehicle collision, sitting
position in ED, ambulatory at any time since
injury, delayed onset of neck pain, or absence
of midline tenderness?
CT C-spine: the axial view of

the dens
Asymmetry
Finest possible cuts of

level of abnormality
Beware of motion
artifacts
Cortical discontinuity
Double density sign
CT of C1-C2 More Sensitive Than

Plain Films
Study of 202 patients with traumatic brain

injury, Link, et al, found 5.4% of patients had
C1 or C2 fractures and 4% had occipital condyle
fractures not visualized on three-view
radiographs.
Blacksin and Lee evaluated 100 consecutive
trauma patients, found 8% frequency of
fractures of the occipital condyle (3%) and C1C2 (5%) not detected on cross-table lateral cspine.
http://www.east.org
Flexion-extension Films: ATLS

guidelines
Persistent neck pain, without

radiographic changes
Non-acute CT scan, with suspected
degenerative or chronic spondylolisthesis
The degree of angulation must be
determined by the patient, and limited by
level of tolerance.
Thoracic Imaging: Radiologic

Sequence
Imaging evaluation of acute chest trauma divides

into five typical paths:
1. Chest Radiograph: general survey
2. Thoracic spine series
3. US (e.g., myocardial contusion and pericardial
effusions)
4. CT/CTA (e.g., pulmonary contusion, aortic
transection, pericardial injury)
5. MRI: assessment of cord injury
PEDIATRIC C-SPINE
Increased cranial size, with increased

ligamentous laxity
Pseudosubluxation of C2 on C3 and C3
on C4 OK below age 8. Use posterior
cervical line to rule out pathology
Thoracic and Neurologic Trauma: Strategy

Catastrophic Chest
Findings
Standard
Diagnostic Testing
Advanced Imaging
Options
Vital Signs
1. Laboratory
1. US
Cardiovascular and
Pulmonary History
2. ECG
2. CT/CTA
Auscultation
3. CXR
3. Angiography
T and LS-spine interpretation:

Architectural principles
Lateral projections
Counting (Marshalls law)
History and PDx
Vertebral bodies
Transverse processes
Posterior processes
Are the transitions between

vertebral bodies regular, with
respect to size and intervertebral
spaces?
Laboratory
Conventional Imaging
Symmetry
Are anatomic curves continuous?

Assess subluxation.
Conformance
Acute Abdomen
Anterior projections
Continuity
Are all the vertebral bodies visible

for the selected level?
Are the vertebral bodies the same
height anteriorly and posteriorly?
Are the vertebral bodies the same
density throughout?
Classical Algorithm for Abdominal Trauma
Consultation
Regular transitions
Bifid artifacts
Initial X-sectional
Imaging
CT
Scoliosis
Muscle spasm
Ligamentous injury
Occult fracture
Nuclear Medicine
Angiography
Case 4
Acute Abdomen
Laboratory
GI Contrast Studies
Parallel Algorithm for Abdominal

Trauma
History and PDx
US
Secondary Imaging
Conventional Imaging
1. CXR
2. Abdominal Series
Imaging
US
1. Color Doppler
2. Power Doppler
Consultation
71 year old with hx of

chronic back pain,
depression, and seizures,
increasing over the past
several months, and
worse today.
PDx: extreme weakness.
CT
1. IV, Oral, Rectal
2. CT Angiography
Case 4
Case 4
Universal Decision Rule in Axial and

Extremity Injuries
Severe Pelvic Fractures
If focal skeletal tenderness is demonstrated, conventional

radiographs.
Comparison view in children (or use of Keats).

CT (or MRI) for atypical, asymmetric, askew, or avulsed findings.
Advise patients that occult fractures and internal derangements
cannot be excluded, and interval evaluation may be required.
Early transfer to
a Trauma Center
Strongly
recommended
(ATLS)
Splint
Formal radiologic interpretation in less than 24 hours.

Formal follow-up:
Hard collar for cervical spine strain.

Appropriate splint for extremity injuries.
Diminished or asymmetric range of motion in children, concurrent

orthopedic discussion or consultation.
Neurologic deficits, central or peripheral: emergent consultation.
Instability: concurrent orthopedic discussion or consultation.
Interval evaluation in adults in <7 days with appropriate specialist
(e.g., orthopedist, maxillofacial, neurosurgical, or otolaryngologist).
Appendicular Skeletal Trauma
2 Catastrophic neurologic
injuries
Catastrophic
Appendicular Findings
Standard
Diagnostic Testing
Advanced Imaging
Options
Vital Signs
1. Laboratory
1. CT/CTA
History
2. XR
2. MRI
Extremity
Examination
3. Angiography
Critical Injuries:
Axial and Extremity Trauma
Fractures
Dislocations
Subluxation
Child abuse, with potential fatal outcome

Neurologic compromise from fracturedislocations
Local Vital Sign Indications for

Traumatic Differential Diagnosis
1.
2.
3.
4.
5.
Injury site related pain or tenderness

Aberrant range of motion
Aberrant muscle strength (scale of 5)
Aberrant sensation
Aberrant pulses
1.
2.
3.
Diminished pulse to palpation

Peripheral capillary refill
Peripheral pulse oximetry
Imaging Modalities
Clinical Catastrophic Criteria
Acuity, severity, progression, persistence,

refractory, atypical or unexplained:
Critical acute symptoms (i.e., pain at rest, pain with

motion, immobility, subjective paresthesia)
Selective physical findings (diminished range of
motion, severe tenderness to palpation, loss of motor
function, loss of sensation, loss of pulses, pallor,
presence of extensive hematoma).
Aberrant laboratory (declining Hematocrit, aberrant
peripheral or central pulse oximetry; plain radiographic
abnormalities).
Conventional Radiographs and Special Views
CT: Incremental, Spiral, Angiographic
US: Gray Scale, Color Doppler, Amplitude

Angiography
MR: MRI and MRA
Arterial Catheterization
Appendicular Skeletal Trauma
Universal Decision Rule in Axial and

Extremity Injuries
Comparison view in children (or use of Keats).

CT (or MRI) for atypical, asymmetric, askew, or avulsed findings.
Advise patients that occult fractures and internal derangements
cannot be excluded, and interval evaluation may be required.
Hard collar for cervical spine strain.
Appropriate splint for extremity injuries.
Formal radiologic interpretation in less than 24 hours.

Formal follow-up:
Diminished or asymmetric range of motion in children, or

neurovascular compromise, concurrent orthopedic discussion or
consultation.
Instability: concurrent orthopedic discussion or consultation.
Interval evaluation in adults in <7 days with appropriate specialist
(e.g., orthopedist, maxillofacial, neurosurgical, or otolaryngologist).
1. Laboratory
1. CT/CTA
History
2. XR
2. MRI
3. Angiography
Trauma: Universal Diagnostic Strategy

Catastrophic
Findings
References
Standard
Diagnostic Testing
Advanced Imaging
Options
1. Laboratory
1. US
History
2. ECG
2. CT/CTA
Physical
Examination
3. XR
3. MRI
1. Kernberg ME, Polevoi SK, Lewin M, and Murphy C,

Catastrophic errors: algorithmic solutions, 3rd
Mediterranean Emergency Medicine Conference, Nice,
France, September 4, 2005 (Catastrophic errors
evaluated in a consecutive case series of 125,000

emergency room patients).
Vital Signs
Advanced Imaging
Options
Vital Signs
Extremity
Examination
Standard
Diagnostic Testing
Splint
Catastrophic
Appendicular Findings
If focal skeletal tenderness is demonstrated, conventional

radiographs.
2. P Jaye, ME Kernberg, and T Green, Trauma

Radiology, The Lancet, in press, 2007.
3. Scott A. Hoffinger, Pediatric Emergency Radiology,
Topics in Emergency Medicine, (ME. Kernberg, MD,
Editor), 2004
4. Radiation Risks and Pediatric Computed Tomography
(CT): A Guide for Health Care Providers, National Cancer
Institute (USA) and Society for Pediatric Radiology, 2002
(modified for Table 1).
5. Weissleder R, Rieumont MJ, and Wittenberg J, Primer
of Diagnostic Imaging, MGH, 1997
Discussion Slides
1. Craniofacial
Nexus rules
Canadian c-spine rules
Head CT scanning
2. Appendicular
skeleton
Ottawa rules
Ankle
Knee
Hip
Pelvis
Shoulder
Other lumbo-sacral
spine
After a closed head injury, with transient loss of

consciousness, a 2 year old female infant has
persistent nausea and vomiting. Imaging should
include:
1.
2.
3.
4.
None
Skull films
Head CT scan
Head MRI

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ALGORITHMIC EVALUATION OF

COMPLEX NEUROLOGIC INJURIES

Martin Kernberg, MD, Asst. Clinical Professor

Division of Emergency Medicine

Div. of Emergency Medicine, UCSF

Neurologic Injury: Parallel Processing of

Consider the high risk differential diagnosis, on

How are neurologic catastrophic

Catastrophic conditions are those which

Div. of Emergency Medicine, UCSF

Emergency Chest Radiology

Div. of Emergency Medicine, UCSF

Acute intra-axial ischemia and infarction

Div. of Emergency Medicine, UCSF

General Vital Sign Indications for

Div. of Emergency Medicine, UCSF

Local Vital Sign Indications for

Glasgow Coma Score

Div. of Emergency Medicine, UCSF

Clinical Catastrophic Criteria

Acuity, severity, progression, persistence,

Cranial nerve functional deficits

1. Tachycardia or bradycardia (heart rate <50)

Div. of Emergency Medicine, UCSF

Critical acute symptoms (e.g., severe headache, neck

Div. of Emergency Medicine, UCSF

Craniofacial Injury: Strategy

Conventional Radiographs and Special Views

CT: Incremental, Spiral, Angiographic

US: Gray Scale, Color Doppler, Amplitude

MR: MRI and MRA

Div. of Emergency Medicine, UCSF

Emergency Chest Radiology

Div. of Emergency Medicine, UCSF

Principles of facial imaging

If you can name the particular bone, plain film imaging is

If two or more bones are involved, CT is indicated. Do not

30 year old homeless

Div. of Emergency Medicine, UCSF

Emergency Chest Radiology

Principles of Cranial Imaging

Universal decision rule:

Acuity, severity, progression, persistence, refractory,

Headache, nausea and vomiting, confusion, vertigo,

CT versus MRI: Controversy

1/1000 cancer rate

Laboratory, electrocardiographic, or plain film findings,

Div. of Emergency Medicine, UCSF

Div. of Emergency Medicine, UCSF

CT versus MRI: Controversy

SAH: Emerging controversy

Cost per machine

2. CTA if MRI + ICH.

Cost per study

After hours access

Div. of Emergency Medicine, UCSF

Div. of Emergency Medicine, UCSF

Types of Intracranial Hemorrhage

Common mechanism: meningeal artery laceration,

Common mechanism: injury to bridging dural veins

Div. of Emergency Medicine, UCSF

Emergency Chest Radiology

Div. of Emergency Medicine, UCSF

75 yo ChineseAmerican male, with