IMAGING OF HEAD TRAUMA

Dr. Thanh Binh Nguyen

University of Ottawa, Canada

July 2009

OUTLINE
Clinical indications for imaging
Imaging technique
Extraaxial hemorrhage
Intraaxial injury
Brain herniations
Skull fractures

INTRODUCTION
Head trauma is the leading cause of

death in people under the age of 30.

Males have 2-3 x frequency of brain
injury than females
Due mainly to motor vehicle accidents
and assaults

Classification of TBI
Primary
Injury to scalp, skull fracture
Surface contusion/laceration
Intracranial hematoma
Diffuse axonal injury, diffuse vascular injury
Secondary

Hypoxia-ischemia, swelling/edema, raised

intracranial pressure
Meningitis/abscess

IMAGING TECHNIQUE
The presence of a skull fracture increases the

risk of having a posttraumatic intracranial

lesion.
However, the absence of a skull fracture does
not exclude a brain injury, which is particularly
true in pediatric patients due to the capacity of
the skull to bend.
NO ROLE FOR PLAIN FILMS IN ACUTE
HEAD TRAUMA

IMAGING TECHNIQUE
CT without contrast is the modality of

choice in acute trauma (fast, available,

sensitive to acute subarachnoid
hemorrhage and skull fractures)
MRI is useful in non-acute head trauma
(higher sensitivity than CT for cortical
contusions, diffuse axonal injury,
posterior fossa abnormalities)

OUR CT PROTOCOLS
ROUTINE: posterior fossa and

supratentorial region (slice thickness = 5mm)

TRAUMA: posterior fossa (2.5mm),
supratentorial region (5mm)
TEMPORAL BONE: <1mm in axial or
coronal plane
ORBITS/FACIAL BONES: 1.25 mm
axial/coronal orbits

APPROACH TO CT BRAIN
Look at the scout film: ? Fracture of upper

cervical spine or skull

Look for brain asymmetry
Look at sulci, Sylvian fissure and cisterns to
exclude subarachnoid hemorrhage
Change windows to look for subdural collection
Look at bone windows to see fractures
Determine if mass is intraaxial (in the brain) or
extraaxial (outside)

SCALP INJURY

SCALP INJURY
Cephalohematoma: blood between the bone

and periosteum. Cannot cross the suture

lines.
Subgaleal hematoma: blood between the
periosteum and aponeurosis. Can cross the
suture lines.
Caput Succ: swelling across the midline with
scalp moulding. Resolves spontaneously.

Extraaxial fluid collections

Subarachnoid hemorrhage(SAH)
Subdural hematoma(SDH)
Epidural hematoma
Subdural hygroma
Intraventricular hemorrhage

Subarachnoid hemorrage
Can originate from direct vessel injury,

contused cortex or intraventricular

hemorrhage.
Look in the interpeduncular cistern and
Sylvian fissure
Usually focal (but diffuse from
aneurysm)
Can lead to communicating
hydrocephalus

SUBDURAL HEMATOMA
Occurs between the dura and arachnoid
Can cross the sutures but not the dural

reflections
Due to disruption of the bridging cortical
veins
Hypodense(hyperacute, chronic),
isodense(subacute), hyperdense(acute)

W=33 L=41

MANAGEMENT OF aSDH
Acute SDH with thickness > 10 mm or

midline shift > 5mm should be

evacuated
Patient in coma with a decrease in GCS
by >2 points with a SDH should
undergo surgical evacuation.

EPIDURAL HEMATOMA
Located between the skull and

periosteum
Due to laceration of the middle
meningeal artery or dural veins
Can cross dural reflections but is limited
by suture lines
Lentiform shape (but concave shape in
SDH)

MANAGEMENT OF aEDH
EDH > 30 cm3 should be evacuated.
EDH < 30 cm3 and <15 mm thickness

and < 5 mm midline shift and GCS >8

may be managed nonoperatively with
serial CT

Intraventricular hemorrhage
Most commonly due to rupture of

subependymal vessels
Can occur from reflux of SAH or
contiguous extension of an intracerebral
hemorrhage
Look for blood-cerebrospinal fluid level
in occipital horns

INTRA-AXIAL INJURY
Surface contusion/laceration
Intraparenchymal hematoma
White matter shearing injury/diffuse

axonal injury
Post-traumatic infarction
Brainstem injury

CONTUSION/LACERATIONS
Most common source of traumatic SAH
Contusion: must involve the superficial gray

matter
Laceration: contusion + tear of pia-arachnoid
Affects the crests of gyri
Hemorrhage present cases and occur at
right angles to the cortical surface
Located near the irregular bony contours:
poles of frontal lobes, temporal lobes, inferior
cerebellar hemispheres

From http://
neuropathology.neouc
om.edu
/
Dr.Agamanolis

Intraparenchymal hematoma
Focal collections of blood that most

commonly arise from shear-strain injury

to intraparenchymal vessels.
Usually located in the frontotemporal
white matter or basal ganglia
Hematoma within normal brain
DDx: DAI, hemorrhagic contusion

DIFFUSE AXONAL INJURY

Rarely detected on CT ( 20% of DAI

lesions are hemorrhagic)

MRI: T1, T2, T2 GRE, SWI

DAI
Due to acceleration/deceleration to

whtie matter + hypoxia

Patients have severe LOC at impact
Grade 1: axonal damage in WM only
-67%
Grade 2: WM + corpus callosum
(posterior > anterior) 21%
Grade 3: WM + CC + brainstem

DAI
Hours:
hemorrhages

and tissue tears

Axonal swellings
Axonal bulbs
Days/weeks: clusters of microglia and

macrophages, astrocytosis
Months/years: Wallerian degeneration

From
http://neuropathology.neo
ucom.edu/
Dr.Agamanolis

Sagittal T1-W images

Axial FLAIR images

AXIAL FLAIR

AXIAL T2 GRADIENT-ECHO

BRAINSTEM INJURY
By direct or indirect forces
Most commonly associated with DAI
Involves the dorsolateral midbrain and upper

pons and is usually hemorrhagic

Duret hemorrhage is an example of indirect
damage: tearing of the pontine perforators
leading to hemorrhage in the setting
transtentorial herniation
<20% of brainstem lesions are seen on CT

18 biker hit by a car

BRAIN HERNIATIONS

SUBFALCIAL HERNIATION
Subfalcial: displacement of the

cingulate gyrus under the free edge of

the falx along with the pericallosal
arteries.
Can lead to anterior cerebral artery
infarction

UNCAL HERNIATION
Displacement of the medial temporal lobe

through the tentorial notch

Displacement of the midbrain
Effacement of the suprasellar cistern
Displacement of the contralateral cerebral
peduncle against the tentorium
Widening of the ipsilateral cerebello pontine
angle
Compression of the posterior cerebral artery

DOWNWARD HERNIATION
Caudal displacement of the thalamus

and midbrain
Effacement of the perimensencephalic
cistern and 4th ventricle.
Can cause a 3rd nerve palsy and disrupt
pontine vessels leading to brainstem
hemorrhage

UPWARD HERNIATION
Due to posterior fossa mass causing

superior displacement of the vermis

through the tentorial incisura
Compression of the 4th ventricle and
effacement of the quadrigeminal plate
cistern.
Compression of the superior cerebellar
artery

TONSILLAR HERNIATION
Inferior displacement of the cerebellar

tonsils through the foramen magnum

Can lead to posterior cerebellar artery
infarction

EXTERNAL HERNIATION
Due to a defect in the skull in

combination with elevated ICP

Venous obstruction can occur at
the margins of the defect.

SIGNIFICANT SKULL
FRACTURES
Depressed: inner table is depressed

by the thickness of the skull.

Overlie major venous sinus, motor
cortex, middle meningeal artery
Pass through sinuses
Look for sutural diastasis (lambdoid)

TEMPORAL BONE
FRACTURES
Look for opacification of the mastoid
Longitudinal: 70%, parallel to long axis

of petrous bone, conductive hearing

loss (from ossicular dislocation), facial
nerve paralysis (20%)
Transverse: 20%, sensorineural hearing
loss, facial nerve paralysis (50%)
Complex
Complications: meningitis, abscess

POST TRAUMATIC
SEQUELAE
Carotid-cavernous fistula(CCF)
Dissection/pseudoaneurysm
Infarction
Atrophy/encephalomalacia
Infection
Leptomeningeal cyst