SECOND

 YEAR  
PART  1  
 COMMON  CLINICAL  SYNDROMES  
•  Acute  Trauma  
•  Stroke  
•  Seizure  
•  Infec<on  and  cancer  
•  Headache  
•  Coma  
•  Demen<a    
 CURRENT  NEUROIMAGING  OPTIONS  

1.    Skull  X-­‐ray  
– AP  view  
– Lateral  view  
– Caldwell’s  view  
– Water’s  view  
– Towne’s  view  
– Submento-­‐vertex  view  
 
SKULL  AP-­‐LATERAL  
Caldwell  view  
Townes  view  
Waters  view  
Submentover<cal  view  (SMV)  
 CURRENT  NEUROIMAGING  OPTIONS  
2.    Computed  Tomography  (CT)  
– Axial    
– SagiVal    
– Coronal  
3.  Magne<c  Resonance  Imaging  (MRI)  
4.  Ultrasound  
7.  Angiogram  
– CT/MRI  
 CT  SCAN  

medicinembbs.blogspot.com   prospect.rsc.org  
CT  SCAN  
MRI  

pinterest.com  
MRI  
 ULTRASOUND  OF  THE  BRAIN  

www.ultrasoundcases.info  
 CT  ANGIOGRAM  

clinicaladvisor.com  
MRI  ANGIOGRAPHY  

www.neuroradiologycases.com  
IMAGING  STRATEGY  FOR  COMMON  
CLINICAL  SYNDROMES    
CRANIOFACIAL  TRAUMA  
A.  HEAD  TRAUMA  
B.  FACIAL  TRAUMA  
 HEAD  TRAUMA  
IMAGING  STRATEGIES:  
I.  CONVENTIONAL  RADIOGRAPHY  (FILM  OR  
DIGITAL)    
– first  diagnos<c  procedure  
– Not  sensi<ve  for  detec<on  of  intracranial  
pathology  
– Absence  of  skull  fractures  does  not  exclude  
significant  intracranial  injury.  
 
 IMAGING  STRATEGIES  
II.  CRANIAL  CT  SCAN  
•  Quick,  widely  available  
•   highly  accurate  in  the  detec<on  of  acute  intra-­‐  and  extra-­‐axial  
hemorrhage,  as  well  as  skull,  temporal  bone,  facial  and  orbital  
fractures.  
•  Thinner  sec<ons  are  used  to  evaluate  the  orbits,  facial  skeleton,  
and  skull  base.  
•  Intravenous  contrast  media  is  not  used  in  the  acute  sebng  
because  it  may  mimic  or  mask  underlying  hemorrhage.  
•  Performed  in  unconscious  pa<ents  with  severe  head  injury.  
 IMAGING  STRATEGIES  
III.    MRI  
•  Less  desirable  than  CT  in  acute  sebng  
•  Long  examina<on  <mes  
•  Comparable  to  CT  or  superior  to  CT  in  the  detec<on  of  acute  
epidural  and  subdural  hematomas  and  nonhemorrhagic  brain  
injury.  
•  More  sensi<ve  to  brain  stem  injury  and  to  acute,  subacute,  
and  chronic  hemorrhage,  especially  with  fluid-­‐aVenuated  
inversion  recovery  (FLAIR),  gradient-­‐recalled-­‐echo  (GRE)  T2*-­‐
weighted,  and  suscep<bility-­‐weighted  imaging.  
•  Modality  of  choice  for  pa0ents  with  subacute  and  chronic  
head  injury  
•  Recommended  for  pa<ents  with  acute  head  trauma  when  
neurologic  findings  are  unexplained  by  CT.  
 SCALP  INJURY  
•  Scalp  so?  @ssue  swelling  –  ogen  the  only  
reliable  evidence  of  the  site  of  impact.  
•  Subgaleal  hematoma  –  most  common  
manifesta<on  
–  recognized  on  CT  or  MR  as  focal  sog  <ssue  
swelling  of  the  scalp  localized  beneath  the  
subcutaneous  fibrofaVy  <ssue  and  above  the  
temporalis  muscle  and  calvarium.  
 SKULL FRACTURES
TYPES:  
•  LINEAR  –  sharp,  dark,  translucent  line,  irregular  or  jagged,  
branching  character    
–  Ogens  extend  into  the  base    
–  Versus  vascular  groove:  smooth,  curving  course    
–  Versus  suture  lines:  serrated  edges    
•  DEPRESSED  –  stellate  with  mul<ple  fracture  lines  radia<ng  outward  
from  a  central  point    
–  Secondary  to  severe  trauma    
•  DIASTATIC  –  linear  fracture  extends  into  the  suture  and  separates  
it    
–  Infancy  and  children  –  most  commonly  seen    
–  Lambdoid  and  sagiVal  suture  –  most  commonly  involved    
Linear skull fracture
Linear skull fracture
Linear skull fracture, 3D CT
scan
Depressed skull fracture
Depressed skull fracture
Depressed skull fracture
CT  SCAN  

BONE  WINDOW   BRAIN  WINDOW  

CT  SCAN:  Depressed  skull  fracture  
Diastatic skull fracture
Diasta<c  
skull  
fracture  
 
CT  Scan  
 TEMPORAL  BONE  FRACTURES  
•  Thin-­‐sec<on  (1  to  1.5  mm),  high  resolu<on  CT  scanning  
–  improve  the  ability  to  detect  and  characterize  
fractures.  
•  Presenta<on:    deafness,  facial  nerve  paralysis,  ver<go,  
dizziness,  or  nystagmus.  
•  Physical  signs:    hemotympanum,  CSF  otorrhea,  and  
ecchymosis  over  the  mastoid  process  (“BaVle  sign”).  
•  Head  CT  scan  findings  include:  opacifica<on  of  the  
mastoid  air  cells,  fluid  in  the  middle  ear  cavity,  
pneumocephalus,  occasionally  pneumolabyrinth  
 TEMPORAL  BONE  FRACTURES  
•  TYPES:  
 
a.  Longitudinal  temporal  bone  fracture  
b.  Transverse  temporal  bone  fracture  
c.  Mixed  and  Oblique  fracture  types  
 
 LONGITUDINAL TEMPORAL BONE
FRACTURES
–  70  %  to  90%    
–  Results  from  a  blow  
to  the  side  of  the  
head  
–  Complica<ons:  
conduc<ve  hearing  
loss,  disloca<on  of  
fracture  of  the  
ossicles,  and  CSF  
otorhinorrhea  
TRANSVERSE TEMPORAL BONE
FRACTURES
•  Results  from  blow  to  the  
occiput  or  frontal  region  
•  More  severe  complica<ons,  
includes  sensorineural  
hearing  loss,  severe  ver<go,  
nystagmus,  and  
perilympha<c  fistula.  
•  Facial  palsy  seen  in  30  –  50%  
•  May  involve  the  caro<d  
canal  or  jugular  foramen  
causing  injury  to  the  caro<d  
artery  or  jugular  vein.  
MIXED AND OBLIQUE FRACTURE TYPES

•  O@c  capsule  sparing  fractures  –  run  anterolateral  

to  the  o<c  capsule,  and  are  usually  caused  by  
direct  blows  to  the  temporo-­‐parietal  region.  
•  O@c  viola@ng  fractures  –  cochlea  and  
semicircular  canals  are  damaged  and  results  from  
direct  impact  to  the  occipital  region.  
–  2  to  5  <mes  more  likely  to  develop  facial  nerve  injury  
–  4  to  8  <mes  more  likely  to  develop  CSF  leak  
–  7  to  25  <mes  more  likely  to  experience  hearing  loss  
and  sustain  intracranial  injuries  such  as  epidural  
hematoma  and  subarachnoid  hemorrhage.  
 HEAD  INJURY  CLASSIFICATION  
•  Primary  lesions  
–  Extra-­‐axial  
–  Intra-­‐axial  
•  Secondary  lesions  
 PRIMARY  LESIONS  
•  Occur  as  a  direct  result  of  a  blow  to  the  head  
•  Epidural,  subdural,  subarachnoid,  and  
intraventricular  hemorrhage,  as  well  as  diffuse  
axonal  injury  (DAI),  cor<cal  contusions,  
intracerebral  hematomas,  and  subcor<cal  gray  
maVer  injury.    
 SECONDARY  LESIONS  
•  Cerebral  swelling,  brain  hernia<on,  
hydrocephalus,  ischemia,  or  infarc<on,  CSF  
leak,  leptomeningeal  cyst,  and  
encephalomalacia.  
EPIDURAL  VS  SUBDURAL    
HEMATOMA  

SKIN  
BONE  
EPIDURAL  SPACE  
DURA  
SUBDURAL  
SPACE  
ARCHNOID  
LAYER  
SUBARACHNOID        
     SPACE  
PIA  MATER  
 EPIDURAL  HEMATOMA:  
•  Usually  arterial  in  origin  
–  middle  meningeal  artery  
–  Most  are  temporal  or  temporoparietal  
•  CT:    
–  Acute:  well-­‐defined  high  aVenua<on  len<cular  or  
biconvex  extraaxial  collec<ons  
–  mass  effect  with  sulcal  effacement  and  midline  shig  
–  overlying  skull  fracture  
–  Does  not  cross  sutures  but  can  cross  the  falx  
EPIDURAL  HEMATOMA  

§ len<cular  or  
biconvex  
§ extraaxial  
collec<ons  
§ overlying  skull  
fracture  
§ Does  not  cross  
falx   sutures    
§ can  cross  the  falx  
CT  SCAN:  Epidural  hematoma,  right  
frontal  
high  aVenua<on    
extra-­‐axial  collec<on    
len<cular  or  biconvex  
mass  effect  on  the    
       right  frontal  lobe    
mild  midline  shig    
     (subfalcial  hernia<on)  
does  not  extend  beyond    
the  right  coronal  suture  
 SUBDURAL  HEMATOMA:  
•  Typically  venous  in  origin  
–  stretching  and  tearing  of  cor<cal  veins  in  the  
subdural  space  
–  also  due  to  disrup<on  of  penetra<ng  branches  of  
the  superficial  cerebral  arteries  
•  Extends  over  a  much  larger  space  than  in  
epidural  hematoma  
•  Commonly  seen  ager  acute  decelera<on  
injury  from  a  motor  vehicle  accident  or  fall  
SUBDURAL  HEMATOMA  

• Crescentric    
• Extraaxial  collec<on  
• Does  not  cross  the  falx  
cerebri  and  tentorium    
• can  cross  sutural  
margins  
CT:  Acute  subdural  hematoma,  leg  
parietal  
•  Crescentric    
•  high  aVenua<on  
•  Most  are  
supratentorial  
•  Does  not  cross  
the  falx  cerebri  
and  tentorium    
•  can  cross  sutural  
margins  
Subdural  hematoma,  right  temporal  
 Chronic subdural hematoma

•  Low  aVenua<on  
value  similar  to  
CSF  
•  Crescentric  
•  mass  effect  with  
midline  shig  
 Rebleeding subdural hematoma
•  Heterogeneous  
appearance  from  
a  mixture  of  
fresh  blood  and  
par<ally  liquefied  
hematoma  
•  Sediment  level  or  
“hematocrit  
level”  
 Rebleeding subdural hematoma
•  Crescentric  
•  Sediment  level  or  
“hematocrit  level”  
–  Upper  layer  has  
low  aVenua<on  
represen<ng  old  
blood  
–  Lower  layer  has  
high  aVenua<on  
represen<ng  fresh  
blood  
 Is  this  an  
epidural  or  a  
subdural  
hematoma???  

Acute  or  
chronic???  
ANSWER:  
Subdural  hematoma,  
leg  parietal  
crescent-­‐shaped  high-­‐
aVenua<on  collec<on  
extending  along  the  en<re  
leg  hemisphere    

Epidural  hematoma,  
right  parietal  
Biconvex  extraaxial  
collec<on  with  overlying  
scalp  sog  <ssue  swelling  

BOTH  ARE  ACUTE!  

 SUBARACHNOID  HEMORRHAGE:  
•  disrup<on  of  small  subarachnoid  vessels  or  
direct  extension  into  the  subarachnoid  space  
by  contusion  or  hematoma  
•  May  be  due  to  trauma  or  ruptured  aneurysm    
 SUBARACHNOID  HEMORRHAGE  
•  CT:  
–  Linear  areas  of  
high  aVenua<on  
within  the  
cisterns  and  sulci  

•  high-­‐aVenua<on  
material  within  
the  sulci,  right  
parietal  
 Where  is  the  subarachnoid  
hemorrhage?    
ANSWER:  

CT:  Right  
sylvian  fissure  
 SUBARACHNOID  HEMORRHAGE  
•  MRI:  
–  Isointense  to  T1W  and  T2W  
–  FLAIR  
•  More  sensi<ve  in  detec<ng  acute  subarachnoid  
hemorrhage  
•  High  signal  intensity    
If due to ruptured aneurysm,
CT angiography should be
done
  DIFFUSE  AXONAL  INJURY:  
•  Widespread  disrup<on  of  axons  at  the  <me  of  
an  accelera<on/decelera<on  injury  (high  
speed  motor  vehicle  crashes)  
•  Usually  not  seen  on  imaging  but  beVer  seen  
by  MRI  than  CT  
  DIFFUSE  AXONAL  INJURY:  
•  CT:  
–  Subtle  or  absent  findings  
–  Most  common  –  small  petechial  hemorrhages  at  
the  gray-­‐white  maVer  junc<on  or  corpus  callosum  
–  Ill-­‐defined  areas  of  decreased  aVenua<on  may  
occasionally  be  seen  
  DIFFUSE  AXONAL  INJURY:  
•  punctate,  high-­‐
aVenua<on  foci  with  
surrounding  edema  in  
the  leg  frontal  and  
parietal  white  maVer  
à  hemorrhagic  DAI  
  DIFFUSE  AXONAL  INJURY:  
•  MR:  
–  Small  foci  of  increased  signal  within  the  white  
maVer,  mul<ple  as  many  as  15-­‐20  lesions  in  
severe  head  injury  
  DIFFUSE  AXONAL  INJURY:  

•  T2-­‐weighted  MR:  
–  several  adjacent  foci  
of  high  signal,  
represen<ng  DAI  in  
the  right  frontal  
parasagiVal  white  
maVer.  
 CORTICAL  CONTUSION:  
•  Areas  of  focal  brain  injury  primarily  involving  
the  superficial  gray  maVer  
•  Less  likely  to  have  loss  of  consciousness  and  
with  beVer  prognosis  than  in  pa<ents  with  
diffuse  axonal  injury  
 CORTICAL  CONTUSION:  
•  Well  seen  on  CT  
–  Tend  to  be  mul<ple  and  bilateral  
–  Occurs  near  bony  protuberance  
–  Common  sites:    
•  temporal  lobes  above  the  petrous  bone  or  posterior  to  the  greater  
sphenoid  wing  
•  frontal  lobes  above  the  cribriform  plate,  planum  sphenoidale  and  
lesser  sphenoid  wing  
–  can  also  occur  at  the  margins  of  depressed  skull  fractures  
•  hemorrhagic  lesions  
–  foci  of  higher  aVenua<on  within  superficial  gray  maVer  
which  may  be  surrounded  by  larger  area  of  low  
aVenua<on  secondary  to  edema  
 CORTICAL  CONTUSION  
•  CT  scan  
–  small  right  frontal  
hematoma  
–  leg  parietal  sog  
<ssue  swelling    
 CORTICAL  CONTUSION:  
•  MR:  
–  Poorly  marginated  areas  of  increased  signal  on  
T2W  in  the  characteris<c  loca<ons  
•  Hemorrhage  –  heterogeneous  signal  intensity  
that  varies  depending  on  age  of  lesion  
CORTICAL  CONTUSION:  
•  SagiVal  T1WI  
–  mul<ple  
peripheral  areas  
of  increased  
signal  intensity  
in  the  inferior  
frontal,  anterior  
temporal,  and  
superior  frontal  
lobes  
CT  scan:  Findings????  
•  hemorrhagic  cor<cal  
contusions  
–  bilateral  inferior  
frontal  and  anterior  
temporal  gray  maVer  
•  intraventricular  
hemorrhage:    
•  within  the  lateral  
ventricles  
•  subarachnoid  
hemorrhages  
•  Bilateral  temporal  
lobe    
 FACIAL
FRACTURES
 FACIAL  TRAUMA  
•   Indirect  signs  of  facial  injury  on  plain  films  can  
help  provide  objec<ve  evidence  of  trauma,  
localize  the  site  of  impact  and  direct  aVen<on  to  
areas  of  poten<al  bony  injury.  
•  SOFT  TISSUE  SWELLING  is  most  commonly  seen  
plain  film  finding  in  facial  trauma.  
•  PARANASAL  SINUS  OPACIFICATION  –  suggests  
presence  of  an  associated  fracture,  par<cularly  
when  air  fluid  levels  are  seen.  
•  AIR  IN  THE  SOFT  TISSUES  (eg.  Orbital  
emphysema)  
 NASAL  FRACTURES  
•  Nasal  bone  fractures  –  most  common  
fractures  of  the  facial  skeleton  
•  Fractures  may  be  transverse  or  longitudinal.  
NASAL  FRACTURES  
NASAL  FRACTURES  
•  The  orbit  is  involved  in  a  number  of  facial  
fractures  including  the  tripod,  Le  fort,  and  
nasoehtmoidal  complex  fractures.  
•  Orbital  floor  fractures  –  usually  linear  when  
seen  in  associa<on  with  other  facial  fractures.  
•  Comminuted  orbital  floor  fractures  or  blow-­‐
out  fractures  –  seen  as  an  isolated  injury  and  
result  from  a  direct  blow  to  the  eye.  
 
•  PLAIN  FILM  FINDINGS:  
–   orbital  emphysema  
–   fluid  level  in  the  
ipsilateral  maxillary  
sinus  
–   indis<nct  orbital  floor  
on  Water’s  view  
–   sog  <ssue  
represen<ng  prolapsed  
orbital  contents  in  the  
superior  aspect  of  the  
maxillary  sinus  
NORMAL OR ABNORMAL?
FINDINGS?
 Orbital floor
fracture

Air Fluid Tear drop sign

level
FRACTURE
DEPRESSED ORBITAL
FLOOR

AIR FLUID
LEVEL
 FRACTURE  OF  THE  ZYGOMA  
•  ZYGOMA  or  “cheek  bone”  –  pne  of  the  
common  sites  of  injury  in  fractures  that  
involve  mu<ple  facial  bones.  
•  Zygoma<c  arch  fractures  may  occur  as  an  
isolated  finding,  or  as  part  of  a  
zygoma<comaxillary  complex  (“tripod”,  
“quadripod”  or  “trimalar”)  fracture.  
 FRACTURE  OF  THE  ZYGOMA  
•  Comminu<on  and  depression  are  frequently  
seen  with  zygoma<c  arch  fractures.  
•  On  plain  films:  zygoma<c  arch  is  best  
evaluated  on  submento-­‐vertex  view  
SUBMENTO-
VERTEX
VIEW
 OM30 view

OCCIPITO-MENTAL
VIEW
FRACTURES OF THE MIDFACE :
LE FORT FRACTURES
•  LE  FORT  1    
–  Guerin  fracture    
–  Transverse  fracture  that  transects  the  inferior  aspect  maxilla,  
nasal  septum  and  most  inferior  por<ons  of  the  pterygoid  plate    
–  “Floa<ng  palate”    
•  LE  FORT  2    
–  Fracture  that  it  produces  is  pyramidal  in  shape    
–  Nasal  bone,  frontal  process  of  maxilla,  medial  orbital  wall,  
inferior  orbital  wall,  maxillary  sinus,  pterygoid  plate    
–  “Floa<ng  maxilla”    
•  LE  FORT  3    
–  Produces  craniofacial  separa<on    
–  Horizontal  fracture  that  transects  the  nasofrontal  suture,  
medial,  inferior  and  lateral  orbital  walls,  zygoma<c  arches  and  
pterygoid  plate  base    
–  “Floa<ng  face”    
Pterygoid plate
Le Fort I
LE  FORT  1  
Le Fort
II
Le Fort II
TRIPOD FRACTURE
 ZYGOMATICOMAXILLARY
FRACTURE (TRIPOD)
•  Zygoma  –  2nd  most  commonly  fractured  bone  of  the  
midface  (nasal  bones  –  most  commonly  fractured  
bone  of  the  midface)    
•  Zygoma<c  sutures  separa<on    
–  Zygoma<cosphenoidal    
–  Zygoma<cofrontal    
–  zygoma<coma<cotemporal    
 Tripod fracture, left

hVp://crashingpa<ent.com/  

hVp://ectsia.org/  
NORMAL ZYGOMATICO-
FRONTAL SUTURE
Widened
suture
Orbital floor fracture

Zygomatic
arch fracture
SOFT TISSUE SWELLING

ZYGOMA

ARCH  
END  OF  PART  1.