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THE REQUISITES
Emergency
Radiology
SERIES EDITOR OTHER VOLUMES IN THE REQUISITES
RADIOLOGY SERIES
James H. Thrall, MD
Radiologist-in-Chief Emeritus Breast Imaging
Department of Radiology Cardiac Imaging
Massachusetts General Hospital Gastrointestinal Imaging
Distinguished Juan M.Taveras Professor of Radiology Genitourinary Imaging
Harvard Medical School Musculoskeletal Imaging
Boston, Massachusetts Neuroradiology
Nuclear Medicine
Pediatric Radiology
Thoracic Radiology
Ultrasound
Vascular and Interventional Radiology
THE REQUISITES
Emergency
Radiology
SECOND EDITION
Jorge A. Soto, MD
Professor of Radiology
Department of Radiology
Boston University School of Medicine;
Vice Chairman
Boston Medical Center
Boston, Massachusetts
Brian C. Lucey, MD
Associate Professor
Boston University School of Medicine
Boston, Massachusetts;
Clinical Director
The Galway Clinic
Doughiska, County Galway, Ireland
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
EMERGENCY RADIOLOGY:THE REQUISITES, SECOND EDITION ISBN: 978-0-323-37640-2
Copyright © 2017 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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(other than as may be noted herein).
Notices
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broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
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With respect to any drug or pharmaceutical products identified, readers are advised to check the
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Previous edition copyright © 2009 by Mosby, Inc., an affiliate of Elsevier, Inc.
Library of Congress Cataloging-in-Publication Data
Soto, Jorge A., editor.

Lucey, Brian C., editor.
Emergency radiology / [edited by] Jorge A. Soto, Brian C. Lucey.
Emergency radiology (Soto) | Requisites in radiology. | Requisites series.
Second edition. | Philadelphia, PA : Elsevier, [2017] | Requisites |Requisites radiology series
Includes bibliographical references and index.
LCCN 2015037285
ISBN 9780323376402 (hardcover : alk. paper)
MESH: Diagnostic Imaging. | Emergency Medical Services.
LCC RC78 | NLM WN 180 | DDC 616.07/572--dc23 LC record available at http://lccn.loc.gov/2015037285
Executive Content Strategist: Robin Carter

Content Development Specialist: Amy Meros
Publishing Services Manager: Patricia Tannian
Project Manager: Stephanie Turza
Senior Book Designer: Amy Buxton
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my parents, Jorge Sr. and Socorro, for their example and guidance, and to my
wife, Ana, and children, Andrea and Alejandro, for their sustained support and
patience as I devote my time to academic radiology.
J.A.S.
To my parents, James and Anne; sister, Suzanne; wife, Ciara; and son, James.
Thanks for the unconditional support.
B.C.L.
This page intentionally left blank

Contributors
Carlos A. Anaya, MD Ana Maria Gomez, MD
Medical Director Department of Radiology
Cardiovascular Interventional Institute Manati Medical Center
Department of Radiology Manati, Puerto Rico
Manati Medical Center
Manati, Puerto Rico Rathachai Kaewlai, MD
Instructor
Stephan W. Anderson, MD Division of Emergency Radiology
Associate Professor of Radiology Department of Diagnostic and Therapeutic Radiology
Boston University Medical Center Ramathibodi Hospital
Boston, Massachusetts Faculty of Medicine
Mahidol University
Laura L. Avery, MD Bangkok,Thailand
Assistant Professor
Massachusetts General Hospital Russ Kuker, MD
Harvard Medical School Department of Radiology
Boston, Massachusetts University of Miami Hospital
Miami, Florida
Glenn D. Barest, MD
Assistant Professor of Radiology Christina A. LeBedis, MD
Boston Medical Center Assistant Professor
Boston, Massachusetts Boston University Medical Center
Sarah D. Bixby, MD
Assistant Professor of Radiology Brian C. Lucey, MD
Harvard Medical School; Associate Professor
Pediatric Radiologist Department of Radiology
Department of Radiology Boston University School of Medicine
Boston Children’s Hospital Boston, Massachusetts;
Boston, Massachusetts Clinical Director
Anna K. Chacko, MD The Galway Clinic
Adjunct Professor of Radiology Doughiska, County Galway, Ireland
Boston University
Boston, Massachusetts; Asim Z. Mian, MD
Professor of Telemedicine Assistant Professor of Radiology
John A. Burns School of Medicine Boston Medical Center
University of Hawaii Boston University
Honolulu, Hawaii Boston, Massachusetts
Margaret N. Chapman, MD Sarah S. Milla, MD

Chief of Neuroradiology Associate Professor
Boston VA Healthcare System; Department of Radiology and Imaging Sciences
Assistant Professor of Radiology Emory University;
Boston Medical Center Attending Pediatric Radiologist and Neuroradiologist
Boston University School of Medicine Children’s Healthcare of Atlanta
Boston, Massachusetts Egleston Hospital
Atlanta, Georgia
Luis E. Diaz, MD
Associate Chief of Radiology Felipe Munera, MD
VA Boston Health Care System; Department of Radiology
Associate Professor of Radiology University of Miami Hospital
Boston University Miami, Florida
Rohini N. Nadgir, MD
Alejandra Duran-Mendicuti, MD Assistant Professor of Radiology and Radiological Science
Department of Radiology Johns Hopkins Medical Institutions
Brigham and Women’s Hospital Baltimore, Maryland
vii
viii Contributors
Osamu Sakai, MD, PhD Joshua W. Stuhlfaut, MD

Chief of Neuroradiology Beth Israel Deaconess Hospital
Professor of Radiology, Otolaryngology–Head and Neck Plymouth, Massachusetts
Surgery and Radiation Oncology
Boston Medical Center Jennifer C. Talmadge, MD
Boston University School of Medicine Department of Radiology
Boston, Massachusetts Children’s Hospital Boston
Rashmikant B. Shah, MD
Diagnostic Radiology Salvatore G. Viscomi, MD
St. James Healthcare Clinical Instructor
Butte, Montana Harvard Medical School;
Attending Radiologist
Ajay Singh, MD Department of Radiology
Department of Radiology Brigham and Women’s Hospital
Massachusetts General Hospital Boston, Massachusetts;
Boston, Massachusetts Chairman
Aaron D. Sodickson, MD, PhD Cape Cod Hospital
Department of Radiology Hyannis, Massachusetts
Brigham and Women’s Hospital
Boston, Massachusetts Scott White, MD
Jorge A. Soto, MD Brigham and Women’s Hospital
Professor of Radiology Boston, Massachusetts
Boston University School of Medicine; Ryan T. Whitesell, MD
Vice Chairman St. Paul Radiology
Department of Radiology Regions Hospital
Boston Medical Center St. Paul, Minnesota
Michael Stella, MD
Brigham and Women’s Hospital
Foreword
Time passes quickly, and it is now time to introduce the THE REQUISITES books have become old friends to
second edition of Emergency Radiology: THE REQUI- imagers for over 25 years. We have tried to remain true
SITES. Drs. Soto and Lucey, along with their coauthors, to the original philosophy of the series, which was to pro-
have once again created an excellent text that captures vide residents, fellows, and practicing radiologists with
the fundamental building blocks of emergency radiology a text that might be read within several days. From feed-
practice. back I have received, many residents do exactly that at
Drs. Soto and Lucey have maintained the logical division the beginning of each rotation. During first rotations this
of their book by both body part and indication—trauma allows them to acquire enough knowledge to really ben-
versus nontrauma with separate chapters for special con- efit from their day-to-day exposure to clinical material and
siderations in children and for nuclear medicine applica- the conditions about which they have just read. During
tions.This allows the reader of Emergency Radiology: THE subsequent rotations, a rereading imprints the knowledge
REQUISITES to go immediately to the material of interest. they will need subsequently for upcoming certification
As a side note, only two or so decades ago, nontrauma emer- exams. For the practicing radiologist, it serves as a useful
gency patients were not imaged nearly as often as they are refresher, like a booster shot.At the workstation, the books
today.Today, emergency applications for the nontrauma pain THE REQUISITES series are useful as a first reference
tient are just as important as the historic role of imaging source and guide to differential diagnosis.
in trauma. Imaging is truly the “guiding hand” of medical THE REQUISITES books are not intended to be exhaus-
practice, making possible rapid diagnosis, triage, and dispo- tive. There are other large reference books to catalog rare
sition, which are vitally important given the time and re- and unusual cases and to present different sides of con-
source constraints faced by busy emergency departments. troversies. Rather, THE REQUISITES books are intended
In the years between the preparation of the first edition to provide information on the vast majority of conditions
and the current work, much has happened to enhance that radiologists see every day, the ones that are at the core
the role of radiology in the emergency department and of radiology practice. In fact, one of the requests to authors
to reshape our thinking. These changes affect every area is to not look up anything they do not know but to put
of application and include, among many others, optimiza- in the book what they teach their own residents at the
tion of computed tomographic (CT ) protocols in every workstation. Since the authors are experienced experts in
organ system for lower radiation exposure, taking advan- their respective areas, this is predictably the most impor-
tage of fast CT scanning capabilities to reduce contrast us- tant material.
age and an increasing appreciation for the potential roles Drs. Soto and Lucey and their coauthors have again
of MRI for both traumatic and nontraumatic indications. done an outstanding job in sustaining the philosophy
Conventional radiography continues to play an important and excellence of THE REQUISITES series and deserve
role, especially for extremity trauma and some thoracic congratulations. Their book reflects the contemporary
imaging applications such as pneumonia and congestive practice of emergency imaging and should serve radiolo-
heart failure. However, for most applications, radiography gists, emergency medicine specialists, and other physi-
is being inexorably replaced by cross-sectional imaging. cians who deal with emergencies as a concise and useful
Drs. Soto and Lucey have again assembled an outstand- foundation for understanding the indications for imaging
ing team of coauthors to help ensure that Emergency and the significance of imaging findings in the emergency
Radiology: THE REQUISITES is as up to date as possible. setting.
Thanks to all the authors for their contributions.
Each chapter presents a different challenge in present- James H. Thrall, MD
ing material. All share a rich opportunity for illustrations, Chairman Emeritus
and Emergency Radiology: THE REQUISITES is extremely Department of Radiology
well illustrated. Otherwise the use of outline lists, boxes, Massachusetts General Hospital
and tables has been dictated by the material requiring Distinguished Taveras Professor of Radiology
presentation. Harvard Medical School
ix

Preface
Emergency Radiology is a unique title in THE REQUI- including CT angiography in the emergency department
SITES series. Although both the organ system–based and for coronary, aorta, brain/neck, visceral, and extremity ar-
modality-based divisions of radiology have existed for
teries, updated CT protocols in trauma and nontraumatic
some time, this REQUISITES title is the first to embrace a emergencies, and new and better quality images obtained
multimodality, multisystem approach to radiology. There with the latest imaging technology. Stepping away from
is an ongoing paradigm shift in medical management over the organ- and modality-based divisions, we acknowledge
the past 25 years or so, away from inpatient-oriented health that there is potential for overlap among this text and
care toward an increasingly outpatient-based system. No- others in THE REQUISITES series. However, to avoid this,
where is this more apparent than in emergency depart- we have endeavored to confine the text to medical and
ments across the United States and around the world. The surgical conditions that commonly present through the
reliance on imaging for diagnosis and guiding management emergency department rather than including every imag-
decisions throughout medicine has been increasing, and ing possibility that may present. We apologize in advance
this is exemplified in the emergency setting. All imaging if any overlap is identified—it was included for complete-
modalities are available to the emergency physician. More ness—or for any deficiencies; some rare entities may have
than in any other modality, the massive increase in the use been omitted for the sake of brevity.The fundamental divi-
of computed tomograpy (CT ) has led to the development sion of the book is in two parts, one dealing with acute
and growth of the specialty of emergency radiology. The trauma and the other with nontraumatic acute processes,
value of CT in the setting of trauma, investigation of severe and the division of the chapters reflects this. This makes it
headache, abdominal pain, and the evaluation of patients possible to easily select those chapters relevant to an in-
with suspected pulmonary embolus forms the bedrock of dividual radiology practice. Some departments, especially
emergency imaging, although there is an increasing role large academic departments with residency programs, will
for MR and ultrasound imaging in the emergency setting, have trauma units, whereas some community practices
particularly for the rapid evaluation of musculoskeletal in- may run an emergency department without dealing with
jury and emergent neurologic evaluation. The book is an acute trauma.
attempt to collate all the radiology information required We are pleased with how this revision has developed
in today’s emergency department setting into one suc- from an abstract concept into reality and built upon the
cinct, practical, and current text that can be used by both first edition. It has taken substantial effort, and we fully ap-
residents in training and general radiologists in practice, preciate the contributions from the authors, all of whom
as well as emergency department physicians and trauma have considerable experience in emergency imaging. We
surgeons. hope that the revision will be as well received as the first
The goal of this revision is to provide updates to address edition and will act as an integral resource for all radiology
the rapid changes in emergency imaging requirements, departments and training programs.
xi

Acknowledgments
We would like to thank many people who helped trans- are experienced radiologists with extensive knowledge
form the concept of this book into a reality. First, we owe in the various aspects of emergency radiology. Each au-
thanks to innumerable individuals (staff, residents, fel- thor has added his or her own subspecialty expertise
lows, technologists, and nurses) at the Boston University to the chapters, which has resulted in the final product,
Medical Center who helped us and our colleagues build a textbook that we believe they should all be proud of.
multidisciplinary groups for the care of the acutely ill Finally, thanks to all the staff at Elsevier, especially Amy
patient. This was the principal driving force behind our Meros and Robin Carter, who waited patiently for us to
growing interest in the field of emergency radiology. We deliver the various parts of the book, sometimes at a
would also like to thank Dr. James Thrall for insisting on slower-than-hoped-for pace.
the timeliness and necessity of this text to add to THE J.A.S.
REQUISITES series. We would also like to extend a sin- B.C.L.
cere thank you to the contributing authors, all of whom
xiii

Contents
Chapter 1 Chapter 8
Traumatic and Nontraumatic Emergencies of the Nontraumatic Emergency Radiology of the
Brain, Head, and Neck 1 Thorax 243
Glenn D. Barest, Asim Z. Mian, Rohini N. Nadgir, and Osamu Sakai Alejandra Duran-Mendicuti, Scott White, Salvatore G. Viscomi,
Michael Stella, and Aaron D. Sodickson
Chapter 2
Chest Trauma 61 Chapter 9
Ryan T. Whitesell and Laura L. Avery Nontrauma Abdomen 281
Stephan W. Anderson, Brian C. Lucey, and Jorge A. Soto
Chapter 3
Abdomen Trauma 81 Chapter 10
Joshua W. Stuhlfaut, Christina A. LeBedis, and Jorge A. Soto Pelvic Emergencies 316
Brian C. Lucey
Chapter 4
Extremity Trauma 115 Chapter 11
Rathachai Kaewlai and Ajay Singh Vascular Emergencies 327
Russ Kuker, Carlos A. Anaya, Ana Maria Gomez, and Felipe Munera
Chapter 5
Extremities: Nontrauma 165 Chapter 12
Luis E. Diaz Emergency Nuclear Radiology 369
Anna K. Chacko and Rashmikant B. Shah
Chapter 6
Imaging Evaluation of Common Pediatric Index 395
Emergencies 186
Jennifer C. Talmadge, Sarah S. Milla, and Sarah D. Bixby
Chapter 7
Traumatic and Nontraumatic Spine
Emergencies 221
Glenn D. Barest and Margaret N. Chapman
xv

THE REQUISITES
Emergency
Radiology

Chapter 1
Traumatic and Nontraumatic
Emergencies of the Brain,
Head, and Neck
Glenn D. Barest, Asim Z. Mian, Rohini N. Nadgir, and Osamu Sakai
Imagine you are asked to create a list of the disorders of to study the other volumes in the Requisites series (es-
the brain, head, and neck that one might commonly expect pecially Neuroradiology, Musculoskeletal Imaging, and
to encounter at an emergency department (ED) and de- Pediatric Radiology), which cover this material in great
scribe the typical imaging features. At first, this challenge detail. In this attempt at condensing so much material
seems straightforward enough. However, upon beginning into one useful volume, important topics inevitably have
the task, it soon becomes clear that almost every disorder been neglected. We hope that this volume can serve as
within the realm of neuroradiology/head and neck radi- a starting point for further study and become a valuable
ology might at one time or another present as an acute reference to on-call radiologists, emergency department
emergency. Inclusion of certain diagnoses such as stroke, physicians, and residents of both specialties.
fractures, and epiglottitis is a must. Other diagnoses, such
as oligodendroglioma or perhaps a slowly growing le- INTRACRANIAL HEMORRHAGE AND
sion, might seem less clear-cut. Ultimately, it is important TRAUMATIC BRAIN INJURY
to realize that a wide variety of processes will result in
an alteration in mental status leading to an ED visit, with Whether in the setting of head trauma, spontaneous de-
imaging playing a key role in diagnosis and appropriate velopment of headache, or alteration of mental status, the
management. ability to diagnose intracranial hemorrhage (ICH) is of
Upon admission, inpatient workups now occur on a primary importance for all practitioners. These presenta-
24/7 basis, with many complex examinations completed tions are some of the most common indications for brain
during the night shift. On-call radiologists (often residents imaging in the emergency setting. Almost invariably, the
or fellows) are expected to provide “wet readings” or requisition will read, “Rule out bleed.” An understanding
complete interpretations for complex cases covering the of traumatic and nontraumatic causes of ICH, the usual
full spectrum of medicine, pediatrics, surgery, and related workup, and recognition of ICH is therefore important
subspecialties. It was not that many years ago that the ra- and seems like a natural starting point. A discussion of the
diologist was faced with a seemingly never-ending stack important types of mass effect resulting from ICH and
of plain films from the ED, inpatient wards, and intensive traumatic brain injury is also included in this section. An
care units requiring rapid interpretations. This work was understanding of hemorrhage and herniation syndromes
interrupted by an occasional computed tomography (CT) is central to the discussion of other topics that follow, such
scan. In this new millennium, during a typical shift the radi- as stroke and neoplasms.
ologist must maintain a rapid pace to review thousands of The word hemorrhage has Greek origins: the prefix
cross-sectional CT and magnetic resonance images (MRI) haima-, meaning “blood,” and the suffix -rrhage, meaning
with two-dimensional (2D) and three-dimensional (3D) re- “to gush or burst forth.” Incidence of ICH is approximate-
formats. For this reason, the majority of the discussion and ly 25 to 30 per 100,000 adults in the United States, with a
most of the examples in this chapter are based on these higher incidence in elderly hypertensive patients. ICH is
modalities and the latest techniques. typically more common in the African American and Asian
The most daunting part of preparing this chapter was populations. Bleeding may take place within the substance
to boil down all of the disorders and details to a set of req- of the brain (intraaxial) or along the surface of the brain
uisites. Division of this chapter into sections is not quite (extraaxial). Intraaxial hemorrhage implies parenchymal
as neat as one might think. For example, it is not possible hemorrhage located in the cerebrum, cerebellum, or brain-
to separate the vascular system from discussion of the stem. Extraaxial hemorrhages include epidural, subdural,
brain, head and neck, or spine, and the imaging methods and subarachnoid hemorrhages, and intraventricular hem-
applied to the extracranial vessels in the setting of stroke orrhage can be considered in this group as well. Hem-
are similar to those used for blunt or penetrating trauma orrhages can lead to different types of brain herniation,
to the neck. One may therefore notice mention of similar from direct mass effect and associated edema or develop-
techniques and findings in several places with examples ment of hydrocephalus, causing significant morbidity and
appropriate to the context. All readers would do well mortality.
1
2 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck
TABLE 1-1 Usual Magnetic Resonance Signal Characteristics of Hemorrhage

Stage Time Component T1 T2
Hyperacute (0-12 h) Oxyhemoglobin Isointense Hyperintense

Acute (12 h-3 days) Deoxyhemoglobin Isointense Hypointense
Early subacute (3-7 days) Methemoglobin Hyperintense Hypointense
(intracellular)
Late subacute (1 wk-1 mo) Methemoglobin Hyperintense Hyperintense
(extracellular)
Chronic (>1 mo) Hemosiderin Hypointense Hypointense
General Imaging Characteristics of the injury. Although it is beyond the scope of this
of Hemorrhage chapter, a description of the physics of the signal char-
acteristics of blood products on MRI is generally based
The appearance of ICH on a CT scan can vary depending on the paramagnetic effects of iron and the diamagnetic
on the age of the hemorrhage and the hemoglobin level. effects of protein in the hemoglobin molecule. The usual
The attenuation of blood is typically based on the protein signal characteristics of hemorrhage and the general time
content, of which hemoglobin contributes a major por- course over which hemorrhages evolve are summarized
tion. Therefore the appearance of hyperacute/acute blood in Table 1-1.
is easily detected on a CT scan in patients with normal
hemoglobin levels (approximately 15 g/dL) and typically EXTRAAXIAL HEMORRHAGE
appears as a hyperattenuating mass. This appearance is
typical because, immediately after extravasation, clot for- Extraaxial hemorrhage occurs within the cranial vault but
mation occurs with a progressive increase in attenuation outside of brain tissue. Hemorrhage can collect in the epi-
over 72 hours as a result of increased hemoglobin concen- dural, subdural, or subarachnoid spaces and may be trau-
tration and separation of low-density serum. On the other matic or spontaneous. It is important to recognize these
hand, in anemic patients with a hemoglobin level less than entities because of their potential for significant morbidity
10 g/dL, acute hemorrhage can appear isoattenuating to and mortality. Poor clinical outcomes are usually the result
the brain and can make detection difficult. Subsequently, of mass effect from the hemorrhage, which can lead to
after breakdown and hemolysis, the attenuation of the clot herniation, increased intracranial pressure, and ischemia.
decreases until it becomes nearly isoattenuating to cere- Intraventricular hemorrhage will be considered with these
brospinal fluid (CSF) by approximately 2 months. In the other types of extracerebral hemorrhage.
emergency setting, one should be aware of the “swirl” sign
with an unretracted clot that appears to be hypoattenuat-
Epidural Hemorrhage
ing and resembles a whirlpool; this sign may indicate ac-
tive bleeding and typically occurs in a posttraumatic set- Epidural hematoma is the term generally applied to a
ting. It is important to recognize this sign, because prompt hemorrhage that forms between the inner table of the cal-
surgical evacuation may be required. The amount of mass varium and the outer layer of the dura because of its mass-
effect on nearby tissues will depend on the size and loca- like behavior. More than 90% of epidural hematomas are
tion of the hemorrhage, as well as the amount of second- associated with fractures in the temporoparietal, frontal,
ary vasogenic edema that develops. and parieto-occipital regions. CT is usually the most effi-
Use of an intravenous contrast agent usually is not nec- cient method for evaluation of this type of hemorrhage.An
essary for CT detection of ICH. If a contrast agent is used, epidural hematoma typically has a hyperdense, biconvex
an intraaxial hemorrhage can demonstrate an enhancing appearance. It may cross the midline but generally does
ring that is usually due to reactive changes and formation not cross sutures (because the dura has its attachment at
of a vascularized capsule, which typically occurs 5 to 7 the sutures), although this might not hold true if a fracture
days after the event and can last up to 6 months. Subacute disrupts the suture. Epidural hematomas usually have an
and chronic extraaxial hematomas also can demonstrate arterial source, commonly a tear of the middle meningeal
peripheral enhancement, usually because of reactive artery, and much less commonly (in less than 10% of cases)
changes and formation of granulation tissue. Unexpected a tear of the middle meningeal vein, diploic vein, or ve-
areas of enhancement should raise concern, because ac- nous sinus (Figs. 1-1 and 1-2). The classic clinical presenta-
tive bleeding can appear as contrast pooling. Refer to the tion describes a patient with a “lucid” interval, although
section on aneurysms and vascular malformations in this the incidence of this finding varies from 5% to 50% in the
chapter for a discussion of CT angiography in the setting literature. Prompt identification of an epidural hematoma
of acute ICH. is critical, because evacuation or early reevaluation may
MRI has greatly revolutionized the evaluation of ICH. be required. Management is based on clinical status, and
The evolution of hemorrhage from the hyperacute to therefore alert and oriented patients with small hemato-
the chronic stage will have corresponding signal chang- mas may be safely observed. The timing of follow-up CT
es on T1-weighted images (T1WIs), T2-weighted images depends on the patient’s condition, but generally the first
(T2WIs), fluid-attenuated inversion recovery (FLAIR) im- follow-up CT scan may be obtained after 6 to 8 hours and,
ages, and gradient-echo sequences. These properties can if the patient is stable, follow-up may be extended to 24
assist in detection and understanding of the time course hours or more afterward.
Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck 3
A B
C
FIGURE 1-1 An epidural hematoma. A, Computed tomography (CT) shows a usual biconvex, hyperdense acute
epidural hematoma causing effacement of sulci and lateral ventricles and shift of midline structures. B, A CT
volume-rendered image shows a nondisplaced fracture at the vertex involving the coronal suture. C, Coronal
multiplanar reconstruction shows a biconvex epidural hematoma crossing midline over the superior sagittal sinus
(arrows).
Subdural Collections
hyperattenuating, crescentic appearance overlying the ce-
Subdural hematoma (SDH) is the term generally applied rebral hemisphere (Fig. 1-3).These hemorrhages can cross
to a hemorrhage that collects in the potential space sutures and may track along the falx and tentorium but do
between the inner layer of the dura and the arachnoid not cross the midline. Inward displacement of the cortical
membrane. It is typically the result of trauma (e.g., mo- vessels may be noted on a contrast-enhanced scan. SDHs
tor vehicle collisions [MVCs], assaults, and falls, with the have a high association with subarachnoid hemorrhage.
latter especially occurring in the elderly population). Acute SDHs thicker than 2 cm that occur with other pa-
An SDH causes a tear of the bridging vein(s) and has a renchymal injuries are associated with greater than 50%
mortality. As the SDH evolves to the subacute stage (with- isoattenuating SDHs can be especially challenging be-
in 5 days to 3 weeks) and then to the chronic stage (after cause findings are symmetric. One should beware of bilat-
more than 3 weeks), it decreases in attenuation, becoming eral isoattenuating SDHs, particularly in elderly patients
isodense to the brain and finally to CSF. A subacute SDH who do not have generous sulci and ventricles. At this
can have a layered appearance as a result of separation stage, the SDH should be conspicuous on MRI, especially
of formed elements from serum. Subacute hemorrhages on FLAIR sequences. A subacute SDH also may be very
may be relatively inconspicuous when they are isodense, conspicuous on T1WIs because of the hyperintensity of
and therefore it is especially important to recognize signs methemoglobin.
of mass effect, such as sulcal effacement, asymmetry of Chronic subdural hematomas are collections that have
lateral ventricles, and shift of midline structures, as well been present for more than 3 weeks. Even a chronic he-
as sulci that do not extend to the skull (Fig. 1-4). Bilateral matoma may present in the emergency setting, such as
A B
C D
FIGURE 1-2 An epidural hematoma and complications demonstrate on noncontrast CT. A, The “swirl” sign in
this large epidural hematoma suggests continued bleeding. B, A pontine (Duret) hemorrhage (arrow) and efface-
ment of the basal cisterns as a result of downward herniation. C, Uncal herniation (the arrow shows the margin
of the left temporal lobe) and a resultant left posterior cerebral artery territory infarct. The brainstem is distorted
and also abnormally hypodense. D, Infarcts in bilateral anterior cerebral, left middle cerebral, and left posterior
cerebral artery territories as a result of herniations.
in a patient prone to repeated falls who is brought in a contrast agent. Calcification of chronic SDH can occur
because of a change in mental status. On both CT and and may be quite extensive (Fig. 1-5). Areas of hyperden-
MRI, these collections typically have a crescentic shape sity within a larger hypodense SDH may indicate an acute
and may demonstrate enhancing septations and mem- component due to recurrent bleeding, termed an “acute
branes surrounding the collection after administration of on chronic subdural hematoma.” Mixed density collec-
tions also may be acute as a result of active bleeding or
CSF accumulation as a result of tearing of the arachnoid
membrane. A chronic SDH is usually isointense to CSF on
both T1WIs and T2WIs, but the appearance can be vari-
able depending on any recurrent bleeding within the col-
lection.The FLAIR sequence is typically very sensitive for
detection of chronic SDH as a result of hyperintensity
based on protein content. Hemosiderin within the hema-
toma will cause a signal void because of the susceptibility
effect, and “blooming” (i.e., the hematoma appears to be
larger than its true size) will be noted on a gradient-echo
sequence.
A subdural hygroma is another type of collection that
is commonly thought to be synonymous with a chronic
subdural hematoma. The actual definition of a hygroma
is an accumulation of fluid due to a tear in the arachnoid
membrane, usually by some type of trauma or from rapid
ventricular decompression with associated accumulation
of CSF within the subdural space. Many persons still use
this term interchangeably with chronic subdural hema-
toma. CT demonstrates a fluid collection isodense to CSF
in the subdural space. MRI can be useful in differentiat-
ing CSF from a chronic hematoma based on the imaging
characteristics of the fluid on all sequences. Occasionally
hygromas are difficult to differentiate from the promi-
nence of the extraaxial CSF space associated with cere-
bral atrophy. The position of the cortical veins can be a
FIGURE 1-3 A subdural hematoma with a mixed density layered helpful clue. In the presence of atrophy, the cortical veins
pattern due to recurrent hemorrhages. The image (arrow) shows are visible traversing the subarachnoid space, whereas
one method of measuring midline shift.
A B
FIGURE 1-4 An isodense subdural hematoma. A, Sulcal effacement and a midline shift to the right are clues to
the presence of a left-sided subdural hematoma. B, Reexpansion of the left Sylvian fissure and a reduction in
midline shift after evacuation.
A B
FIGURE 1-5 Calcified subdural hematomas. A, Colpocephaly configuration of the lateral ventricles. B, Bone
window/level settings more clearly show the calcified subdurals in this adult patient who, as a child, had a shunt
implanted because of congenital hydrocephalus.
with a hygroma, they are displaced inward along with the be confounded by artifacts from CSF pulsations, an el-
arachnoid membrane by the fluid in the subdural space. evated level of protein (meningitis), or oxygen concen-
tration (i.e., a high fraction of inspired oxygen) in CSF
Subarachnoid Hemorrhage on FLAIR images and the presence of blood products
from previous microhemorrhages on gradient-echo
Subarachnoid hemorrhage (SAH) fills the space between images.
the pia and the arachnoid membrane, outlining the sulci
and basilar cisterns. SAH can be due to a variety of causes, Intraventricular Hemorrhage
including trauma, a ruptured aneurysm, hypertension, ar-
teriovenous malformation, occult spinal vascular malfor- In the adult population, intraventricular hemorrhage
mation, and hemorrhagic transformation of an ischemic (IVH) is typically caused by trauma. It can result from ex-
infarction. SAH is often associated with overlying traumat- tension of a parenchymal hemorrhage into the ventricles
ic SDH. SAHs generally do not cause mass effect or focal or from redistribution of SAH. Primary IVH is uncommon
regions of edema. However, in patients presenting with and is usually caused by a ruptured aneurysm, an intra-
ominous signs on clinical grading scales, such as stupor or ventricular tumor, vascular malformation, or coagulopa-
coma, diffuse cerebral edema may be evident. On CT, hy- thy (Fig. 1-8). Large IVHs are quite conspicuous on CT or
perdensity is seen within the sulci and/or basilar cisterns MRI. They may occupy a majority of the ventricle(s) and
(Figs. 1-6 and 1-7). may result in hydrocephalus and increased intracranial
Although MRI may be as sensitive as CT for the de- pressure. Small amounts of IVH may be difficult to de-
tection of acute parenchymal hemorrhage and SAH, CT tect; one must check carefully for dependent densities
generally remains the modality of choice (and the im- within the atria and occipital horns of the lateral ventri-
aging gold standard). The sensitivity of CT for the de- cles. Normal choroid plexus calcifications in the atria of
tection of SAH compared with CSF analysis can vary lateral ventricles, in the fourth ventricle, and extending
from up to 98% to 100% within 12 hours to approxi- through the foramina of Luschka should not be mistaken
mately 85% to 90% after 24 hours of symptom onset. for acute IVH.
Other factors affecting sensitivity are the hemoglobin Another less common type of extracerebral ICH that
concentration and the size and location of the hemor- may present acutely is a pituitary hemorrhage, which is
rhage. CT is widely available, can be performed rapidly, usually associated with pituitary apoplexy due to pituitary
and is relatively inexpensive. In several small studies, necrosis that may become hemorrhagic. Presenting symp-
MRI has demonstrated sensitivity equivalent to CT for toms may include headache, visual loss, ophthalmoplegia,
detection of acute parenchymal hemorrhage and SAH. nausea, and vomiting. Other causes of pituitary hemor-
In some cases of “CT-negative” (subacute) hemorrhage, rhage include tumors (e.g., macroadenoma and germino-
MRI has shown greater sensitivity. However, results may ma) and, less commonly, trauma.
A B
C
FIGURE 1-6 Subarachnoid hemorrhage from a ruptured aneurysm. A, Noncontrast computed tomography (CT)
shows ill-defined hyperdense subarachnoid hemorrhage in the left Sylvian cistern (black arrow) and rim calcifica-
tion in the wall of the aneurysm (white arrow). B, A volume-rendered image from CT angiography shows a large
aneurysm (arrow) projecting above the lesser sphenoid wing. C, Reconstruction from a three-dimensional rota-
tional digital subtraction angiogram shows the carotid-ophthalmic aneurysm to the best advantage.
INTRAAXIAL HEMORRHAGE Contusion

The cause of intraaxial (parenchymal) hemorrhages can Parenchymal contusions result from blunt trauma and can
generally be categorized as spontaneous or traumatic.Trau- occur in the cortex or white matter. Their locations are
matic causes include blunt injury from MVCs, assault, and typically at the site of greatest impact of brain on bone,
penetrating injuries such as gunshot wounds. Intraaxial including the anterior/inferior frontal lobes and the tem-
hemorrhages have many spontaneous causes, which are poral lobes. They can be considered coup (occurring at
discussed in the section on hemorrhagic stroke. the site of impact) or contrecoup (opposite the site of
B
FIGURE 1-7 Subarachnoid hemorrhage and complications. A, Three computed tomography (CT) images show
diffuse hyperdense subarachnoid hemorrhage filling basal cisterns and cerebral sulci bilaterally. Diffuse loss of
gray–white differentiation and effacement of the sulci and cisterns probably preclude the need for further work-
up. B, A volume-rendered image from CT angiography demonstrates lack of enhancement of intracranial vessels
suggesting poor intracranial flow consistent with the expected elevation of intracranial pressure.
impact) types. On CT, a contusion typically appears as an Diffuse Axonal Injury

area of hyperdensity with a surrounding rim of hypodense
edema. A parenchymal contusion can initially appear as a Diffuse axonal injury (DAI) is another type of traumatic
focal area of subtle hypodensity and may blossom on fol- brain injury that may present with parenchymal hemor-
low-up examination at 12 to 24 hours with development rhages and is distinct from a parenchymal contusion. DAI
of an obvious central area of hyperdensity and a larger sur- is an injury to the axons caused by acceleration/decelera-
rounding zone of hypodense edema (Fig. 1-9). On MRI, sig- tion injury with a rotational component (usually from an
nal characteristics reflect the hemorrhagic and edematous MVC or other blunt trauma to the head). Complete tran-
components. Over time, the density and signal character- section of axons may occur with injury to the associated
istics of the hemorrhage will evolve in a fashion similar capillaries, or partial disruption of the axons may occur.
to a spontaneous hemorrhage. Parenchymal hemorrhage DAI lesions typically occur at the interfaces of gray and
due to penetrating trauma, such as from a gunshot wound white matter in the cerebral hemispheres, the body and
or impalement, will follow the same general pattern of splenium of the corpus callosum, the midbrain, and the
evolution. upper pons. Lesions also may be seen in the basal ganglia.
A B
FIGURE 1-8 Intraventricular hemorrhage. A, A fluid-attenuated inversion recovery magnetic resonance image
shows a hyperintense hemorrhage isolated to the frontal horn of the right lateral ventricle. B, An image from a
right internal carotid artery digital subtraction angiogram in the late arterial phase shows a nidus (arrow) and an
early draining vein (arrowhead) diagnostic of an arteriovenous malformation.
A B
FIGURE 1-9 Blossoming of a contusion. A, Computed tomography (CT) shows a thin left frontoparietal subdural
hematoma tracking along the anterior falx and mild sulcal effacement. B, A follow-up CT scan after 24 hours
shows a hyperdense parenchymal hemorrhage and surrounding edema in left frontal lobe and a stable subdural
hematoma. Notice the mass effect on the left lateral ventricle.
Patients sustaining DAI typically lose consciousness who recover usually demonstrate lingering effects such
at the moment of impact. DAI may be suspected when as headaches and cognitive deficits. Initial CT scans in
the clinical examination is worse than expected based more than half of patients with DAI may be negative. CT
on the findings of an initial CT scan. Usually, the greater findings include hypodense foci due to edema in areas of
the number of lesions, the worse the prognosis. Persons incomplete axonal disruption and hyperdense foci due
Another random document with
no related content on Scribd:
“Lament” the other day among some old papers, and as it is quite a
curiosity, I will let you see it:—
“Full twenty suns have risen and set

And eke as many moons,
Since I found thee dead, without a head,
In the bloody pantaloons!
“As thy foe did rob thee of a leg

In his hunger and despite,
An L. E. G. I give to thee,
In song, dear Sam, to-night.
“Thy tail was full of feathers gay;

Thy comb was red and fine;
I hear no crow, where’er I go,
One half so loud as thine.
“O, I mourn thee still, as on the morn

When cold and stiff I found thee,
And laid thee dead, without a head,
The cabbage-leaf around thee!”
TOBY, the HAWK.
TOBY, THE HAWK.
About the queerest pet that I ever had was a young hawk. My
brother Rufus, who was a great sportsman, brought him home to me
one night in spring. He had shot the mother-hawk, and found this
young half-fledged one in the nest. I received the poor orphan with
joy, for he was too small for me to feel any horror of him, though his
family had long borne rather a bad name. I resolved that I would
bring him up in the way he should go, so that when he was old he
should not destroy chickens. At first, I kept him in a bird-cage, but
after a while he grew too large for his quarters, and had to have a
house built for him expressly. I let him learn to roost, but I tried to
bring him up on vegetable diet. I found, however, that this would not
do. He eat the bread and grain to be sure, but he did not thrive; he
looked very lean, and smaller than hawks of his age should look. At
last I was obliged to give up my fine idea of making an innocent
dove, or a Grahamite, out of the poor fellow, and one morning
treated him to a slice of raw mutton. I remember how he flapped his
wings and cawed with delight, and what a hearty meal he made of it.
He grew very fat and glossy after this important change in his diet,
and I became as proud of him as of any pet I ever had. But my
mother, after a while, found fault with the great quantity of meat
which he devoured. She said that he eat more beef-steak than any
other member of the family. Once, when I was thinking about this,
and feeling a good deal troubled lest some day, when I was gone to
school, they at home might take a fancy to cut off the head of my pet
to save his board-bill, a bright thought came into my mind. There
was running through our farm, at a short distance from our house, a
large mill-stream, along the banks of which lived and croaked a vast
multitude of frogs. These animals are thought by hawks, as well as
Frenchmen, very excellent eating. So, every morning, noon, and
night, I took Toby on my shoulder, ran down to the mill-stream, and
let him satisfy his appetite on all such frogs as were so silly as to
stay out of the water and be caught. He was very quick and active,—
would pounce upon a great, green croaker, and have him halved and
quartered and hid away in a twinkling. I generally looked in another
direction while he was at his meals,—it is not polite to keep your eye
on people when they are eating, and then I couldn’t help pitying the
poor frogs. But I knew that hawks must live, and say what they
might, my Toby never prowled about hen-coops to devour young
chickens. I taught him better morals than that, and kept him so well
fed that he was never tempted to such wickedness. I have since
thought that, if we want people to do right, we must treat them as I
treated my hawk; for when we think a man steals because his heart
is full of sin, it may be only because his stomach is empty of food.
When Toby had finished his meal, he would wipe his beak with his
wing, mount on my shoulder, and ride home again; sometimes, when
it was a very warm day and he had dined more heartily than usual,
he would fall asleep during the ride, still holding on to his place with
his long, sharp claws. Sometimes I would come home with my
pinafore torn and bloody on the shoulder, and then my mother would
scold me a little and laugh at me a great deal. I would blush and
hang my head and cry, but still cling to my strange pet; and when he
got full-grown and had wide, strong wings, and a great, crooked
beak that every body else was afraid of, I was still his warm friend
and his humble servant, still carried him to his meals three times a
day, shut him into his house every night, and let him out every
morning. Such a life as that bird led me!
Toby was perfectly tame, and never attempted to fly beyond the
yard. I thought this was because he loved me too well to leave me;
but my brothers, to whom he was rather cross, said it was because
he was a stupid fowl. Of course they only wanted to tease me. I said
that Toby was rough, but honest; that it was true he did not make a
display of his talents like some folks, but that I had faith to believe
that, some time before he died, he would prove himself to them all to
be a bird of good feelings and great intelligence.
Finally the time came for Toby to be respected as he deserved. One
autumn night I had him with me in the sitting-room, where I played
with him and let him perch on my arm till it was quite late. Some of
the neighbours were in, and the whole circle told ghost-stories, and
talked about dreams, and warnings, and awful murders, till I was half
frightened out of my wits; so that, when I went to put my sleepy hawk
into his little house, I really dared not go into the dark, but stopped in
the entry, and left him to roost for one night on the hat-rack, saying
nothing to any one. Now it happened that my brother William, who
was then about fourteen years of age, was a somnambulist,—that is,
a person who walks in sleep. He would often rise in the middle of the
night, and ramble off for miles, always returning unwaked.
Sometimes he would take the horse from the stable, saddle and
bridle him, and have a wild gallop in the moonlight. Sometimes he
would drive the cows home from pasture, or let the sheep out of the
pen. Sometimes he would wrap himself in a sheet, glide about the
house, and appear at our bedside like a ghost. But in the morning he
had no recollection of these things. Of course, we were very anxious
about him, and tried to keep a constant watch over him, but he would
sometimes manage to escape from all our care. Well, that night
there was suddenly a violent outcry set up in the entry. It was Toby,
who shrieked and flapped his wings till he woke my father, who
dressed and went down stairs to see what was the matter. He found
the door wide open, and the hawk sitting uneasily on his perch,
looking frightened and indignant, with all his feathers raised. My
father, at once suspecting what had happened, ran up to William’s
chamber and found his bed empty; he then roused my elder
brothers, and, having lit a lantern, they all started off in pursuit of the
poor boy. They searched through the yard, garden, and orchard, but
all in vain. Suddenly they heard the saw-mill, which stood near,
going. They knew that the owner never worked there at night, and
supposed that it must be my brother, who had set the machinery in
motion. So down they ran as fast as possible, and, sure enough,
they found him there, all by himself. A large log had the night before
been laid in its place ready for the morning, and on that log sat my
brother, his large black eyes staring wide open, yet seeming to be
fixed on nothing, and his face as pale as death. He seemed to have
quite lost himself, for the end of the log on which he sat was fast
approaching the saw. My father, with great presence of mind,
stopped the machinery, while one of my brothers caught William and
pulled him from his perilous place. Another moment, and he would
have been killed or horribly mangled by the cruel saw. With a terrible
scream, that was heard to a great distance, poor William awoke. He
cried bitterly when he found where he was and how he came there.
He was much distressed by it for some time; but it was a very good
thing for all that, for he never walked in his sleep again.
As you would suppose, Toby, received much honor for so promptly
giving the warning on that night. Every body now acknowledged that
he was a hawk of great talents, as well as talons. But alas! he did not
live long to enjoy the respect of his fellow-citizens. One afternoon
that very autumn, I was sitting at play with my doll, under the thick
shade of a maple-tree, in front of the house. On the fence near by
sat Toby, lazily pluming his wing, and enjoying the pleasant, golden
sunshine,—now and then glancing round at me with a most knowing
and patronizing look. Suddenly, there was the sharp crack of a gun
fired near, and Toby fell fluttering to the ground. A stupid sportsman
had taken him for a wild hawk, and shot him in the midst of his
peaceful and innocent enjoyment. He was wounded in a number of
places, and was dying fast when I reached him. Yet he seemed to
know me, and looked up into my face so piteously, that I sat down by
him, as I had sat down by poor Keturah, and cried aloud. Soon the
sportsman, who was a stranger, came leaping over the fence to bag
his game. When he found what he had done, he said he was very
sorry, and stooped down to examine the wounds made by his shot.
Then Toby roused himself, and caught one of his fingers in his beak,
biting it almost to the bone. The man cried out with the pain, and
tried to shake him off, but Toby still held on fiercely and stoutly, and
held on till he was dead. Then his ruffled wing grew smooth, his
head fell back, his beak parted and let go the bleeding finger of his
enemy.
I did not want the man hurt, for he had shot my pet under a mistake,
but I was not sorry to see Toby die like a hero. We laid him with the
pets who had gone before. Some were lovelier in their lives, but
none more lamented when dead. I will venture to say that he was the
first of his race who ever departed with a clean conscience as
regarded poultry. No careful mother-hen cackled with delight on the
day he died,—no pert young rooster flapped his wings and crowed
over his grave. But I must say, I don’t think that the frogs mourned
for him. I thought that they were holding a jubilee that night; the old
ones croaked so loud, and the young ones sung so merrily, that I
wished the noisy green creatures all quietly going brown, on some
Frenchman’s gridiron.
MILLY, THE PONY, AND CARLO, THE
DOG.
When I was ten or eleven years of age, I had two pets, of which I
was equally fond, a gentle bay pony and a small pointer dog. I have
always had a great affection for horses, and never knew what it was
to be afraid of them, for they are to me exceedingly obliging and
obedient. Some people think that I control them with a sort of animal
magnetism. I only know that I treat them with kindness, which is, I
believe, after all, the only magnetism necessary for one to use in this
world. When I ride, I give my horse to understand that I expect him to
behave very handsomely, like the gentleman I take him to be, and he
never disappoints me.
MILLY the pony & CARLO the dog.
Our Milly was a great favorite with all the family, but with the children
especially. She was not very handsome or remarkably fleet, but was
easily managed, and even in her gait. I loved her dearly, and we
were on the best terms with each other. I was in the habit of going
into the pasture where she fed, mounting her from the fence or a
stump, and riding about the field, often without saddle or bridle. You
will see by this that I was a sad romp. Milly seemed to enjoy the
sport fully as much as I, and would arch her neck, and toss her
mane, and gallop up and down the little hills in the pasture, now and
then glancing round at me playfully, as much as to say, “Aint we
having times!”
Finally, I began to practise riding standing upright, as I had seen the
circus performers do, for I thought it was time I should do something
to distinguish myself. After a few tumbles on to the soft clover, which
did me no sort of harm, I became quite accomplished that way. I was
at that age as quick and active as a cat, and could save myself from
a fall after I had lost my balance, and seemed half way to the
ground. I remember that my brother William was very ambitious to
rival me in my exploits; but as he was unfortunately rather fat and
heavy, he did a greater business in turning somersets from the back
of the pony than in any other way. But these were quite as amusing
as any other part of the performances. We sometimes had quite a
good audience of the neighbours’ children, and our schoolmates, but
we never invited our parents to attend the exhibition. We thought that
on some accounts it was best they should know nothing about it.
In addition to the “ring performances,” I gave riding lessons to my
youngest brother, Albert, who was then quite a little boy. He used to
mount Milly behind me, and behind him always sat one of our chief
pets, and our constant playmate, Carlo, a small black and white
pointer. One afternoon, I remember, we were all riding down the
long, shady lane which led from the pasture to the house, when a
mischievous boy sprang suddenly out from a corner of the fence,
and shouted at Milly. I never knew her frightened before, but this
time she gave a loud snort, and reared up almost straight in the air.
As there was neither saddle nor bridle for us to hold on by, we all
three slid off backward into the dust, or rather the mud, for it had
been raining that afternoon. Poor Carlo was most hurt, as my brother
and I fell on him. He set up a terrible yelping, and my little brother
cried somewhat from fright. Milly turned and looked at us a moment
to see how much harm was done, and then started off at full speed
after the boy, chasing him down the lane. He ran like a fox when he
heard Milly galloping fast behind him, and when he looked round and
saw her close upon him, with her ears laid back, her mouth open,
and her long mane flying in the wind, he screamed with terror, and
dropped as though he were dead. She did not stop, but leaped clear
over him as he lay on the ground. Then she turned, went up to him,
quietly lifted the old straw hat from his head, and came trotting back
to us, swinging it in her teeth. We thought that was a very cunning
trick of Milly’s.
Now it happened that I had on that day a nice new dress, which I
had sadly soiled by my fall from the pony; so that when I reached
home, my mother was greatly displeased. I suppose I made a very
odd appearance. I was swinging my bonnet in my hand, for I had a
natural dislike to any sort of covering for the head. My thick, dark hair
had become unbraided and was blowing over my eyes. I was never
very fair in complexion, and my face, neck, and arms had become
completely browned by that summer’s exposure. My mother took me
by the shoulder, set me down in a chair, not very gently, and looked
at me with a real frown on her sweet face. She told me in plain terms
that I was an idle, careless child! I put my finger in one corner of my
mouth, and swung my foot back and forth. She said I was a great
romp! I pouted my lip, and drew down my black eyebrows. She said I
was more like a wild, young squaw, than a white girl! Now this was
too much; it was what I called “twitting upon facts”; and ’twas not the
first time that the delicate question of my complexion had been
touched upon without due regard far my feelings. I was not to blame
for being dark,—I did not make myself,—I had seen fairer women
than my mother. I felt that what she said was neither more nor less
than an insult, and when she went out to see about supper, and left
me alone, I brooded over her words, growing more and more out of
humor, till my naughty heart became so hot and big with anger, that it
almost choked me. At last, I bit my lip and looked very stern, for I
had made up my mind to something great. Before I let you know
what this was, I must tell you that the Onondaga tribe of Indians had
their village not many miles from us. Every few months, parties of
them came about with baskets and mats to sell. A company of five or
six had been to our house that very morning, and I knew that they
had their encampment in our woods, about half a mile distant. These
I knew very well, and had quite a liking for them, never thinking of
being afraid of them, as they always seemed kind and peaceable.
To them I resolved to go in my trouble. They would teach me to
weave baskets, to fish, and to shoot with the bow and arrow. They
would not make me study, nor wear bonnets, and they would never
find fault with my dark complexion.
I remember to this day how softly and slyly I slid out of the house
that evening. I never stopped once, nor looked round, but ran swiftly
till I reached the woods. I did not know which way to go to find the
encampment, but wandered about in the gathering darkness, till I
saw a light glimmering through the trees at some distance. I made
my way through the bushes and brambles, and after a while came
upon my copper-colored friends. In a very pretty place, down in a
hollow, they had built them some wigwams with maple saplings,
covered with hemlock-boughs. There were in the group two Indians,
two squaws, and a boy about fourteen years old. But I must not
forget the baby, or rather pappoose, who was lying in a sort of
cradle, made of a large, hollow piece of bark, which was hung from
the branch of a tree, by pieces of the wild grape-vine. The young
squaw, its mother, was swinging it back and forth, now far into the
dark shadows of the pine and hemlock, now out into the warm fire-
light, and chanting to the child some Indian lullaby. The men sat on a
log, smoking gravely and silently; while the boy lay on the ground,
playing lazily with a great yellow hound, which looked mean and
starved, like all Indian dogs. The old squaw was cooking the supper
in a large iron pot, over a fire built among a pile of stones.
For some time, I did not dare to go forward, but at last I went up to
the old squaw, and looking up into her good-humored face, said, “I
am come to live with you, and learn to make baskets, for I don’t like
my home.” She did not say any thing to me, but made some
exclamation in her own language, and the others came crowding
round. The boy laughed, shook me by the hand, and said I was a
brave girl; but the old Indian grinned horribly and laid his hand on my
forehead, saying, “What a pretty head to scalp!” I screamed and hid
my face in the young squaw’s blue cloth skirt. She spoke soothingly,
and told me not to be afraid, for nobody would hurt me. She then
took me to her wigwam, where I sat down and tried to make myself
at home. But somehow I did’nt feel quite comfortable. After a while,
the old squaw took off the pot, and called us to supper. This was
succotash, that is, a dish of corn and beans, cooked with salt pork.
We all sat down on the ground near the fire, and eat out of great
wooden bowls, with wooden spoons, which I must say tasted rather
too strong of the pine. But I did not say so then,—by no means,—but
eat a great deal more than I wanted, and pretended to relish it, for
fear they would think me ill bred. I would not have had them know
but what I thought their supper served in the very best style, and by
perfectly polite and genteel people. I was a little shocked, however,
by one incident during the meal. While the young squaw was helping
her husband for the third or fourth time, she accidentally dropped a
little of the hot succotash on his hand. He growled out like a dog, and
struck her across the face with his spoon. I thought that she showed
a most Christian spirit, for she hung her head and did not say any
thing. I had heard of white wives behaving worse.
When supper was over, the boy came and laid down at my feet, and
talked with me about living in the woods. He said he pitied the poor
white people for being shut up in houses all their days. For his part,
he should die of such a dull life, he knew he should. He promised to
teach me how to shoot with the bow and arrows, to snare partridges
and rabbits, and many other things. He said he was afraid I was
almost spoiled by living in the house and going to school, but he
hoped that, if they took me away and gave me a new name, and
dressed me properly, they might make something of me yet. Then I
asked him what he was called, hoping that he had some grand
Indian name, like Uncas, or Miantonimo, or Tushmalahah; but he
said it was Peter. He was a pleasant fellow, and while he was talking
with me I did not care about my home, but felt very brave and
squaw-like, and began to think about the fine belt of wampum, and
the head-dress of gay feathers, and the red leggins, and the yellow
moccasons I was going to buy for myself, with the baskets I was
going to learn to weave. But when he left me, and I went back to the
wigwam and sat down on the hemlock-boughs by myself, somehow I
couldn’t keep home out of my mind. I thought first of my mother, how
she would miss the little brown face at the supper-table, and on the
pillow, by the fair face of my blue-eyed sister. I thought of my young
brother, Albert, crying himself to sleep, because I was lost. I thought
of my father and brothers searching through the orchard and barn,
and going with lights to look in the mill-stream. Again, I thought of my
mother, how, when she feared I was drowned, she would cry bitterly,
and be very sorry for what she had said about my dark complexion.
Then I thought of myself, how I must sleep on the hard ground, with
nothing but hemlock-boughs for covering, and nobody to tuck me up.
What if it should storm before morning, and the high tree above me
should be struck by lightning! What if the old Indian should not be a
tame savage after all, but should take a fancy to set up the war-
whoop, and come and scalp me in the middle of the night!
The bell in the village church rang for nine. This was the hour for
evening devotions at home. I looked round to see if my new friends
were preparing for worship. But the old Indian was already fast
asleep, and as for the younger one, I feared that a man who
indulged himself in beating his wife with a wooden spoon would
hardly be likely to lead in family prayers. Upon the whole, I
concluded I was among rather a heathenish set. Then I thought
again of home, and doubted whether they would have any family
worship that night, with one lamb of the flock gone astray. I thought
of all their grief and fears, till I felt that my heart would burst with
sorrow and repentance, for I dared not cry aloud.
Suddenly, I heard a familiar sound at a little distance,—it was Carlo’s
bark! Nearer and nearer it came; then I heard steps coming fast
through the crackling brushwood, then little Carlo sprang out of the
dark into the fire-light, and leaped upon me, licking my hands with
joy. He was followed by one of my elder brothers, and by my mother!
To her I ran. I dared not look in her eyes, but hid my face in her
bosom, sobbing out, “O mother, forgive me! forgive me!” She
pressed me to her heart, and bent down and kissed me very
tenderly, and when she did so, I felt the tears on her dear cheek.
I need hardly say that I never again undertook to make an Onondaga
squaw of myself, though my mother always held that I was dark
enough to be one, and I suppose the world would still bear her out in
her opinion.
I am sorry to tell the fate of the faithful dog who tracked me out on
that night, though his story is not quite so sad as that of some of my
pets. A short time after this event, my brother Charles was going to
the city of S——, some twenty miles away, and wished to take Carlo
for company. I let him go very reluctantly, charging my brother to take
good and constant care of him. The last time I ever saw Carlo’s
honest, good-natured face, it was looking out at me through the
window of the carriage. The last time, for he never came back to us,
but was lost in the crowded streets of S——.
He was a simple, country-bred pointer, and, like many another poor
dog, was bewildered by the new scenes and pleasures of the city,
forgot his guide, missed his way, wandered off, and was never
found.
CORA, THE SPANIEL.
The pet which took little Carlo’s place in our home and hearts was a
pretty, chestnut-colored water-spaniel, named Cora. She was a
good, affectionate creature, and deserved all our love. The summer
that we had her for our playmate, my brother Albert, my sister Carrie,
and I, spent a good deal of time down about the pond, in watching
her swimming, and all her merry gambols in the water. There grew,
out beyond the reeds and flags of that pond, a few beautiful, white
water-lilies, which we taught her to bite off and bring to us on shore.
Cora seemed to love us very much, but there was one whom she
loved even more. This was little Charlie Allen, a pretty boy of about
four or five years old, the only son of a widow, who was a tenant of
my father, and lived in a small house on our place. There grew up a
great and tender friendship between this child and our Cora, who
was always with him while we were at school. The two would play
and run about for hours, and when they were tired, lie down and
sleep together in the shade. It was a pretty sight, I assure you, for
both were beautiful.
It happened that my father, one morning, took Cora with him to the
village, and was gone nearly all day; so little Charlie was without his
playmate and protector. But after school, my sister, brother, and I
called Cora, and ran down to the pond. We were to have a little
company that night, and wanted some of those fragrant, white lilies
for our flower-vase. Cora barked and leaped upon us, and ran round
and round us all the way. Soon as she reached the pond, she sprang
in and swam out to where the lilies grew, and where she was hid
from our sight by the flags and other water-plants. Presently, we
heard her barking and whining, as though in great distress. We
called to her again and again, but she did not come out for some
minutes. At last, she came through the flags, swimming slowly along,
dragging something by her teeth. As she swam near, we saw that it
was a child,—little Charlie Allen! We then waded out as far as we
dared, met Cora, took her burden from her, and drew it to the shore.
As soon as we took little Charlie in our arms, we knew that he was
dead. He was cold as ice, his eyes were fixed in his head, and had
no light in them. His hand was stiff and blue, and still held tightly
three water-lilies, which he had plucked. We suppose the poor child
slipped from a log, on which he had gone out for the flowers, and
which was half under water.
Of course we children were dreadfully frightened. My brother was
half beside himself, and ran screaming up home, while my sister
almost flew for Mrs. Allen.
O, I never shall forget the grief of that poor woman, when she came
to the spot where her little dead boy lay!—how she threw herself on
the ground beside him, and folded him close in her arms, and tried to
warm him with her tears and her kisses, and tried to breathe her own
breath into his still, cold lips, and tried to make him hear by calling,
“Charlie, Charlie, speak to mamma! speak to your poor mamma!”
But Charlie did not see her, nor feel her, nor hear her any more; and
when she found that he was indeed gone from her for ever, she gave
the most fearful shriek I ever heard, and fell back as though she
were dead.
By this time, my parents and a number of the neighbours had
reached the spot, and they carried Mrs. Allen and her drowned boy
home together, through the twilight. Poor Cora followed close to the
body of Charlie, whining piteously all the way. That night, we could
not get her out of the room where it was placed, but she watched
there until morning.
Ah, how sweetly little Charlie looked when he was laid out the next
day! His beautiful face had lost the dark look that it wore when he
was first taken from the water; his pretty brown hair lay in close
ringlets all around his white forehead. One hand was stretched at his
side, the other was laid across his breast, still holding the water-lilies.
He was not dressed in a shroud, but in white trousers, and a pretty
little spencer of pink gingham. He did not look dead, but sleeping,
and he seemed to smile softly, as though he had a pleasant dream in
his heart.
Widow Allen had one other child, a year younger than Charlie,
whose name was Mary, but who always called herself “Little May.” O,
it would have made you cry to have seen her when she was brought
to look on her dead brother. She laughed at first, and put her small
fingers on his shut eyes, trying to open them, and said, “Wake up
Charlie! wake up, and come play out doors, with little May!” But
when she found that those eyes would not unclose, and when she
felt how cold that face was, she was grieved and frightened, and ran
to hide her face in her mother’s lap, where she cried and trembled;
for though she could not know what death was, she felt that
something awful had happened in the house.
But Cora’s sorrow was also sad to see. When the body of Charlie
was carried to the grave, she followed close to the coffin, and when it
was let down into the grave, she leaped in and laid down upon it,
and growled and struggled when the men took her out. Every day
after that, she would go to that grave, never missing the spot, though
there were many other little mounds in the old church-yard. She
would lie beside it for hours, patiently waiting, it seemed, for her
young friend to awake and come out into the sunshine, and run
about and play with her as he was used to do. Sometimes she would
dig a little way into the mound, and bark, or whine, and then listen for
the voice of Charlie to answer. But that voice never came, though the
faithful Cora listened and waited and pined for it, through many days.
She ate scarcely any thing; she would not play with us now, nor
could we persuade her to go into the pond. Alas! that fair, sweet
child, pale and dripping from the water, was the last lily she ever
brought ashore. She grew so thin, and weak, and sick, at last, that
she could hardly drag herself to the grave. But still she went there
every day. One evening, she did not come home, and my brother
and I went down for her. When we reached the church-yard, we
passed along very carefully, for fear of treading on some grave, and
spoke soft and low, as children should always do in such places.
Sometimes we stopped to read the long inscriptions on handsome
tombstones, and to wonder why so many great and good people
were taken away. Sometimes we pitied the poor dead people who
had no tombstones at all, because their friends could not afford to
raise them, or because they had been too wicked themselves to
have their praises printed in great letters, cut in white marble, and
put up in the solemn burying-ground, where nobody would ever dare
to write or say any thing but the truth. When we came in sight of
Charlie’s grave, we talked about him. We wondered if he thought of
his mother, and cried out any when he was drowning. We thought
that he must have grown very weary with struggling in the water, and
we wondered if he was resting now, sleeping down there with his
lilies. We said that perhaps his soul was awake all the time, and that,
when he was drowned, it did not fly right away to heaven, with the
angels, to sing hymns, while his poor mother was weeping, but
stayed about the place, and somehow comforted her, and made her
think of God and heaven, even when she lay awake in the night, to
mourn for her lost boy.
So talking, we came up to the grave. Cora was lying on the mound,
where the grass had now grown green and long. She seemed to be
asleep, and not to hear our steps or our voices. My brother spoke to
her pleasantly, and patted her on the head. But she did not move. I
bent down and looked into her face. She was quite dead!
JACK, THE DRAKE.
I have hesitated a great deal about writing the history of this pet, for
his little life was only a chapter of accidents, and you may think it
very silly. Still, I hope you may have a little interest in it after all, and
that your kind hearts may feel for poor Jack, for he was good and
was unfortunate.
It happened that once, during a walk in the fields, I found a duck’s
egg right in my path. We had then no ducks in our farm-yard, and I
thought it would be a fine idea to have one for a pet. So I wrapped
the egg in wool, and put it into a basket, which I hung in a warm
corner by the kitchen-fire. My brothers laughed at me, saying that the
egg would never be any thing more than an egg, if left there; but I
had faith to believe that I should some time see a fine duckling
peeping out of the shell, very much to the astonishment of all
unbelieving boys. I used to go to the basket, lift up the wool and look
at that little blue-hued treasure three or four times a day, or take it
out and hold it against my bosom, and breathe upon it in anxious
expectation; until I began to think that a watched egg never would
hatch. But my tiresome suspense finally came to a happy end. At
about the time when, if he had had a mother, she would have been
looking for him, Jack, the drake, presented his bill to the world that
owed him a living. He came out as plump and hearty a little fowl as
could reasonably have been expected. But what to do with him was
the question. After a while, I concluded to take him to a hen who had
just hatched a brood of chickens, thinking that, as he was a
friendless orphan, she might adopt him for charity’s sake. But Biddy
was already like the celebrated
“Old woman that lived in a shoe,
Who had so many children she didn’t know what to do.”

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EMERGENCY RADIOLOGY:THE REQUISITES, SECOND EDITION ISBN: 978-0-323-37640-2

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Margaret N. Chapman, MD Sarah S. Milla, MD

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TABLE 1-1 Usual Magnetic Resonance Signal Characteristics of Hemorrhage

Hyperacute (0-12 h) Oxyhemoglobin Isointense Hyperintense

INTRAAXIAL HEMORRHAGE Contusion

impact) types. On CT, a contusion typically appears as an Diffuse Axonal Injury

“Full twenty suns have risen and set

“As thy foe did rob thee of a leg

“Thy tail was full of feathers gay;

“O, I mourn thee still, as on the morn

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EMERGENCY RADIOLOGY:THE REQUISITES, SECOND EDITION ISBN: 978-0-323-37640-2