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Part 2: Pathology
Rathachai Kaewlai, MD www.RadiologyInThai.com
Created: December 2006
Checklist for Trauma Brain CT
Have 3 different windows to look for different pathology (brain, subdural and bone windows) First image includes foramen magnum Look first for the pathology that needs emergent Rx
Look for primary pathology (hemorrhage in different compartments) Look for secondary pathology (brain herniation, midline shift) Look at the mastoid and sphenoid sinuses for hemorrhage which implies skull base fractures Look at temporomandibular joints for fracture and/or dislocation (this pathology causes significant long
Direct blow to the skull Skull vault has 3 layers (outer table, diploe, and inner table) but
diploe does not form where skull is covered by muscles (thin area, prone to fracture) Areas prone to fracture:
Squamous temporal/parietal bones (most common) Foramen magnum, skull bases, cribiform plates, orbital roofs
Fracture (fx) present in majority of severe head injury cases Skull fx absent in 1/4 of fatal injuries at autopsy. Absence of
skull fracture not excludes brain injury
1/3 of severely injured patients do not have skull fx Concomitant cervical spine injury is 15% (cervical spine
radiograph or CT may be needed)
Skull Fracture Fracture • Smooth or jagged edge • Straight line • Angular turn • Darker on X-ray • Greater in width • Any locations Suture • Serrated edge • Curvilinear • Curvilinear • Lighter • Lesser width • Specific anatomic location 5 .
Edge enhancement algorithm is useful to detect bony lesions (in bone window). and edge enhancement algorithm*) AND Scout CT (to look for fracture ‘in plane’ with axial scan) Coronal and sagittal reformation is proven to be useful only when the scans were performed in helical mode (most hospitals scan the brain in conventional mode) * Consult your radiologist about the different CT algorithm.Skull Fracture Imaging recommendation When suspects skull fracture Head CT (in bone window. 6 .
venous sinus thrombosis and occlusion) Almost always overlying soft tissue edema Associated with extra-axial hematoma Axial images of CT may miss fx that is ‘in plane’. venous sinus. Always check scout CT for obvious fx 7 .Skull Fracture Linear. non-depressed Run through the entire thickness of bone Look if the fx line runs through a vascular channel. (This can cause epidural hematoma.
8 Retrospective review of the skull x-ray shows faint fracture line.34-year-old man. fell from 10ft height Axial CT: linear non-depressed fracture (red arrows) of left parietal bone. . Note soft tissue hematoma overlying the fracture.
middle ear structures Potential surgical elevation in Depressed > 5 mm and overlies motor or speech areas Depressed > skull thickness Causes laceration of dura. arachnoid and possible brain parenchyma 9 .Skull Fracture .Depressed Fragment (s) depressed inward Consider open when Skin laceration over the fracture Through paranasal sinuses.
severe head injury Axial CT (bone window) shows open depressed fractures (red arrows) of the right frontoparietal bone and presence of pneumocephalus (blue arrow). 10 . Severe soft tissue edema or hematoma. although not needed for diagnosis. MVA. helps radiologists and clinicians ‘see’ the complexity of fractures and plan for treatment. 3D CT.Middle age man.
1-2 mm more than normal contralateral side Coexisting linear fracture possible May tear dural venous sinus. causing venous epidural hematoma (venous EDH).Diastatic Spreading of suture.Skull Fracture . venous sinus thrombosis or occlusion 11 .
12 . pedestrian hit by a car Axial CT image shows diastasis fractures (red arrows) through left coronal suture and posterior portion of the sagittal suture.35-year-old man. Severe soft tissue swelling or hematomas overly the fractures. Normal suture is shown (blue arrow).
bruising around the eyes (raccoon eyes) 13 . cranial nerve (V. VI. carotid-cavernous fistula Presentations: Temporal bone fx.CSF otorrhea. bruising over mastoid (Battle sign) Anterior cranial fossa fx.Skull Fracture . dissection.Basilar Clue: opacified sphenoid or mastoid Problem associated: Dural tear (patients come with CSF otorrhea or rhinorrhea) Ear ossicles. VII) involvement Vascular injury. infarction.CSF rhinorrhea. occlusion.laceration. labyrinth.
There is no fracture through the right carotid canal (C). Blood in bilateral sphenoid sinuses imply fractures through the sinuses. Axial CT image shows the most common type of skull base fx. If there is a suspicion of fracture through the carotid canal. 14 .Young man in high velocity MVA with bleeding from the right ear. longitudinal fx (blue arrows) through the right temporal bone. Note disruption of the right ear ossicles (red arrow). CT angiography should be performed to rule out vascular injury.
Skull Fracture Pneumocephalus Presence of air or gas in the cranial cavity Principal cause = trauma Indicates communication between intracranial and extracranial spaces. CSF otorrhea or 15 . paranasal sinuses or ambient air rhinorrhea Significant complications: meningitis.g. e.
16 . This patient had right frontal sinus fracture as a source of pneumocephalus.Small pneumocephalus (red arrows) is seen in the subarachnoid space of the right frontal convexity. Presence of pneumocephalus should raise the suspicion of sinus fracture or open fracture to the ambient air.
venous EDH) Hematoma between inner table of the skull and dura Underlying brain usually minimally injured. large EDH) Most common location = squamous part of temporal bone 17 .Epidural Hematoma (EDH) Etiology-pathogenesis Source of bleeding most commonly middle meningeal artery (85-90%) > others (dural sinus . Good prognosis if treated aggressively May cross midline and dural attachment Not cross sutures (exception: diastatic fx.
older people dura strongly adheres to inner table of the skull Majority has skull fx Clinical features: Significant trauma Loss of consciousness. Lucid interval found in 40% of patients Delayed development 10-25%. within the first 36 hours 18 .Epidural Hematoma (EDH) Epidemiology: Young men (20-40’s) .
Epidural Hematoma (EDH) CT findings Hyperdense biconvex extra-axial mass Low density area inside hematoma represents active bleeding (swirl sign) Common to have herniation Potential indications for surgery Size > 2 cm Active bleeding Pending herniation Corresponding neurological deficit 19 .
subacute presentation. giving potential space for blood accumulation Tear of venous sinus (lhigh flow. low pressure) More benign course.Epidural Hematoma (EDH) Venous EDH Usually in posterior fossa Depressed skull fx causes strip of the dura. usually not required surgery 20 .
Nonvisualized temporal horn of the right lateral ventricle implies mass effect from the hematoma and degree of brain edema.Young patient in MVA Axial CT image shows a large lentiform-shaped homogeneous hyperdense mass in the right temporal convexity. consistent with epidural hematoma (red arrows). 21 . Fracture is identified at the right squamous temporal bone (not shown).
Subsequent MRV and CTV show no evidence of venous sinus injury. The patient was discharged home. consistent with epidural hematoma (red arrows). The proximity of the hematoma to the transverse sinus raises the possibility of dural venous sinus injury. 22 . fall from 12ft Axial CT image shows a small lentiform-shaped homogeneous hyperdense mass in the left parieto-occipital convexity.35-year-old man.
Subdural Hematoma (SDH) Etiology-pathogenesis: Blood collects between dura and arachnoid Source of blood . i. subarachnoid hemorrhage 23 .torn cortical bridging veins.e. artery may also be torn Epidemiology: Extremes of age .infant or elderly Usually coexists with other brain injuries.
displacing the cerebral cortex medially arachnoid) Usually hyperdense (can be mixed due to unclottted blood or torn Can be isodense if patients are anemic or blood mixes with CSF Can cross suture Can extend into interhemispheric fissure (thick falx).Subdural Hematoma (SDH) CT findings: Acute SDH . along tentorium 24 .crescent blood collection over hemisphere.
representing subdural hematoma (red arrows). 25 . fall from height Axial CT image shows a thin concave hematoma along the left temporal convexity.35-year-old man.
fall from height Axial CT image (subdural window) shows thin bilateral hyperdense blood along the right parietal and left temporal convexities. representing acute subdural hematoma (red arrows). Bilateral subdural hematoma can be subtle and easily missed on ‘brain window’.35-year-old man. 26 . Small subarachnoid hemorrhage is also noted in the sulci of the right parietal lobe (blue arrow).
Nearly all cases of tSAH have other lesions to suggest traumatic cause Isolated SAH in trauma patients. SDH. there is a possibility of ruptured aneurysm causing sudden loss of consciousness and then later trauma (ruptured aneurysm while driving. or other lesions.Traumatic Subarachnoid Hemorrhage (tSAH) Etiology-pathogenesis: Tear of veins in subarachnoid space Epidemiology: Most common cause of subarachnoid hemorrhage is trauma tSAH usually associated with cerebral contusion. or having activities) 27 .
Traumatic Subarachnoid Hemorrhage (tSAH) CT findings: High density blood in sulci/cisterns Location . look similar to aneurysmal SAH) Seen as blood-CSF level in the ventricles Traumatic intraventricular hemorrhage (tIVH) can coexist Subtle tSAH Blood in the interpeduncular fossa may be the manifestation of subtle SAH 28 .next to contusion or under SDH/skull fx/scalp laceration (otherwise.
found down at home Coronal reformatted CT image shows subarachnoid hemorrhage insinuated in the cerebral sulci of left parietal and right temporal lobes.58-year-old man. 29 . Ruptured cerebral aneurysm is the main differential diagnosis in the patients presenting with pure subarachnoid hemorrhage with equivocal history of trauma.
Cerebral Contusion Etiology-pathogenesis: Initial injury causes the contusion due to cerebral gyri impact inner table of the skull (rough edges and ridges) Evolve from petechial hemorrhage -> small hemorrhage -> large hematoma (imaging worsened with time) More evident after 24h Epidemiology: Most common parenchymal lesion in head trauma 30 .
delineating extents of contusions 31 . bilateral Can be normal early Can be non-hemorrhagic MRI is better for detection.Cerebral Contusion CT findings Low density cortex (edema) mixed with high density blood (petechial hemorrhage) Classic location: anterior base of frontal and temporal lobes Multiple.
a typical location of this nonhemorrhagic contusion. Contusion without hematoma is difficult to appreciate on CT scan.38-year-old man. 32 . fall from height Axial CT image shows an illdefined area of hypodensity and loss of grey-white matter differentiation in the tip of the left temporal lobe (red arrows). MRI is more sensitive.
right more than left.Middle age man. 33 . is noted as an ill-defined area of hypodensity in CT and high signal intensity zone in MRI T2-WI. fall from height Hemorrhagic contusion (red arrows) at the frontal bases. MRI is more sensitive to depict the extent of this injury.
Diffuse Axonal Injury (DAI) Frequent cause of persistent vegetative state and morbidity in traumatic brain injury patients Etiology-pathogenesis Traumatic deceleration injury: shearing/rotational forces in areas of greater density differential in the brain (= grey-white matter interface) Can be an isolated finding in traumatic brain injury No (or little) association with presence of subarachnoid. or skull fracture 34 . subdural hemorrhage.
corpus callosum Number and location of lesions predict prognosis (worst when multiple.Diffuse Axonal Injury (DAI) Clinical features Usually results in instantaneous loss of consciousness. and in supratentorial location) 35 . brain stem. Clinical symptoms worse than CT findings Most patients (90%) remains in vegetative state (rarely causes death because brainstem function typically unaffected) General imaging features Can be either hemorrhagic or non-hemorrhagic (the latter is more common) Grey-white matter interface.
or T2*). Hemorrhagic lesions will be dark. nonhemorrhagic lesions can be missed by CT) Small hemorrhagic foci in typical locations MR findings MRI is the imaging of choice to detect DAI Susceptibility sequence needed for detection of hemorrhagic DAI (called T2 GRE. Non-hemorrhagic lesions are bright on T2-WI and FLAIR 36 .Diffuse Axonal Injury (DAI) CT findings May be normal (microscopic.
Diffuse Axonal Injury (DAI) Imaging recommendation for suspected DAI When initial brain CT is normal but the patient is in vegetative state MRI with susceptibility sequence OR Follow up brain CT in 24 hours (1/6 of DAI will evolve. may be seen in subsequent CT) 37 .
Same day MRI (Susceptibility sequence) shows multiple tiny areas of blood products (red arrows) in the greywhite matter junctions and deep grey nuclei consistent with DAI. severe head injury. GCS 4T Axial CT image shows mild diffuse brain swelling without intracranial hemorrhage. Blue star is an artifact. 38 .24-year-old woman. Small subgaleal hematoma is present (red arrow). MVA. Blue arrow represents a vascular flow void.
infarction Pseudoaneurysm.Vascular Effects of Trauma Hemodynamic alterations common with traumatic brain injury Spectrum of vascular abnormalities due to trauma Vasospasm. dissection Ischemia/infarction due to… Vasospasm Embolism from vascular injury Secondary to brain herniation 39 . ischemia. arterio-venous fistula Laceration.
39-year-old man. 40 . fall from height Axial CT image done at day 2 after the injury shows a large right middle cerebral artery territory infarction (red arrows). in conjunction with acute subdural (blue star) and intraparenchymal hemorrhage in the right frontal base. The high density structure in the left parasagittal region is a part of an intracranial pressure monitoring device.
Cerebral Edema Increased brain water (astroglial swelling) Two types (vasogenic and cytotoxic edema) often coexists In trauma: Vasogenic edema occurs immediately then cytotoxic edema within hours Usually adjacent or mixed with brain contusion Generally resolves within 2 weeks 41 .
23-year-old woman. MVA Axial CT image shows edematous brain with loss of grey/white matter interface (red stars). 42 . compressed ventricle (arrow) and effacement of the sulci (not seeing any cerebral sulci) in this patient who had DAI confirmed by MRI.
brain death 43 .Herniations Usually more deteriorating than primary injury Etiology-pathogenesis Hemorrhage accumulates within closed space. CSF spaces compressed then mechanical displacement of brain occurs May cause secondary ischemia or infarction If not correct.
and vice versa. Subfalcine herniation is defined as herniation of cingular gyrus (blue star) underneath the falx cerebri.Midline Shift & Subfalcine Herniation Axial CT image shows a midline shift to the left due to large right extra-axial hemorrhage (red stars) and intraparenchymal hemorrhage. 44 . ACA occlusion may become occluded. Presence of midline shift usually signify subfalcine herniation. The degree of midline shift (red line) is usually measured at the level of maximal deviation of the midline structure (septum pellucidum is a useful anatomy).
because it is treatable. Central herniation is defined as both temporal lobes descend through the tentorial incisura. which can be seen as effacement of the cistern around the midbrain (star). This patient had dilated left lateral ventricle from asymmetric brain edema (right more than left). 45 .Obstructive Hydrocephalus & Descending (central) transtentorial herniation Hydrocephalus is one of the most emergent finding to look for.
Tonsils can be low lying as a normal variation or a Chiari malformation. 46 . cerebellar tonsils (red stars) in the same cut as foramen magnum.Tonsillar Herniation Make sure the lowest cut of CT image includes foramen magnum! Presence of space-occupying lesion in the brain. obliteration of CSF space and displaced portions of cervicomedullary junction (M) are signs of tonsillar herniation.
then irreversible loss of brain function Clinical criteria: coma + absent brainstem reflexes + apnea test Imaging may confirm but does not substitute for clinical criteria CT findings: No flow in intracranial arteries/venous sinuses Diffuse cerebral edema Hyperdense cerebellum (much denser than cerebrum) 47 .Brain Death Etiology-pathogenesis: Severe increased ICP decreases cerebral blood flow.
diffuse cerebral edema. ruptured cerebral aneurysm Contrast-enhanced axial CT (Left) shows diffuse SAH (blue stars) in the cerebral cisterns.49-year-old woman. 48 . The patient had bilateral ventricular shunt placement. Both images show normal enhancement of extracranial vessels (red arrows). There is no intracranial blood flow either in arteries or venous sinuses.
Is designed to assist emergency practitioners in providing appropriate radiologic care for patients. Is flexible and not intended. MGH Radiology. nor should they be used to establish a legal standard of care. The information provided in this presentation… Is intended to be used as educational purposes only. for cases I’ve seen and things I’ve learned. 49 . Thanks.
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