RADIOLOGICAL

SUPPORT:
ACUTE HEAD INJURY
Nurul Najwa Zulkifli
 Always describe CT
findings as densities

• Isodense / hypodense / hyperdense

• Hyperdense: higher density - white
appearance
• Hypodense: lower density - darker
appearance
• Brain is the reference density
• Anything of the density as brain -
isodense
• Higher density (white) than brain -
hyperdense (skull)
• Lower density (darker) than brain -
hypodense (CSF and air)
 Common indications
for CT scan

• Strokes
• Head trauma
• Tumors
• Hydrocephalus
• Cerebral atrophy
• Internal bleeding
• Skull fractures
CT brain in emergency settings

BLOOD CAN BE VERY BAD

Blood Cistern Brain Ventricles Bones

parenchyma
 Extra- axial
• Extradural haemorrhage
BLOOD • Subdural haemorrhage
• Subarachnoid hemorrhage
Type of
haemorrhage
Intra- axial
• Intraparenchymal haemorrhage
• Intraventricular haemorrhage
 Extradural
hemorrhage (EDH) 1. Biconvex,
lenticular shape
• also known as epidural 2. Does not cross
hematoma, is a collection suture lines
of blood that forms 3. Hyperdense,
between the inner surface sharply demarcated
of the skull and outer layer
of the dura, which is called
the endosteal layer.
 • EDHs are usually limited in their extent by the
Extradural hemorrhage (EDH) cranial sutures, as the periosteum crosses
through the suture continuous with the outer
periosteal layer.
 1. Crescentic (concave)
shape along brain
surface
2. Crosses suture lines
3. Hyperdense extra-
axial collection that
spreads diffusely over
the affected
hemisphere.

• a collection of blood accumulating in the subdural space, the

potential space between the dura and arachnoid mater of the
Subdural meninges around the brain.
hemorrhage (SDH) • common sites for subdural hematomas are frontoparietal
convexities and the middle cranial fossa.
 - can result either from
trauma or from ruptures of
aneurysms or arteriovenous
malformations.
- classic presentation- sudden
1. Hyperdense in the onset of a severe headache
fissure (a thunderclap headache).

2. Filling cisterns

• Occur between the arachnoid and pia meningeal layers, tears of

small subarachnoid vessels
Subarachnoid
• Blood is seen layering into the brain along sulci and fissures, or
Haemorrhage (SAH) filling cisterns (most often the suprasellar cistern because of the
presence of the vessels of the circle of Willis and their branch
points within that space).
 • Classify appearance of SAH on CT scan
Fisher Grade
Intraparenchymal
haemorrhage

• Bleeding within the brain tissue

• Characteristics:
• Hyperdense lesion (uniform white)
Intraventricular
Hemorrhage
• bleeding within the brain's ventricles
Volume of Blood

Formula = A x B x C
2

A : Longest axis of the lesion

B : Largest diameter perpendicular to A
C : Slice thickness x no of slices
 • Is any opening in the
subarachnoid space of the
brain created by separation of
the arachnoid and pia mater
• Filled with CSF
• Major subarachnoid cistern
• 1. Cerebellomedullary cistern
(Cistern magna) – largest
• 2. Pontine cistern
• 3. Interpeduncular cistern
• 4. Superior cistern (quadrigeminal
cistern / cistern of great cerebral
CISTERN vein)
• 5. Ambient cistern
There are 3 basal cistern to look for:

• 2 ambient cisterns and 1 quadrigeminal

cistern
• When trauma occurs to the brain, the
basal cistern might occlude because the
brain swells.
• Loss of symmetry of one or more of the
cisterns may be a sign of midline shift.
Degree of midline shift

• Midline shift is a shift of the brain past its

center line
• Line across the Foramen Monro
• the opposite side that being pushed to
Marshall Grading
• The Marshall classification of
traumatic brain injury is a CT
scan derived metric using
only a few features and has
been shown to predict
outcome in patients with
traumatic brain injury.
• Higher grade have worse
prognosis and survival.
General Introduction to some Abnormality
• Abnormal tissue density
• Mass effect- midline shift, ventricular compression, Obliteration of basal cistern
& sulci
Tissue Density
High Density (brighter) Low Density (darker)
• Blood*** • Infarction
• Tumor • Tumor
• Abscess
• Edema
• Resolving Hematoma***
 BRAIN PARENCHYMA
Identify :
- Lobes (frontal, parietal, temporal,
occipital)
- Brainstem (midbrain, pons,
medulla)
- Cerebellum
- Deep structures (thalamus, corpus
Occipital
callosum, caudate nucleus, int lobe
and ext capsule, lentiform
nucleus)

Comment :
- Any prominent hypodense or
hyperdense region
- Indicate: tumor, edema, abcess,
haemorrhage, hematoma,
infarction
Stroke
Ischemic Stroke Hemorrhagic Stroke
Brain Tumor
 VENTRICLES
Identify:
- Lateral ventricles
- Third ventricle
- Forth ventricle *connected to 3rd ventricle
by cerebral aqueduct

Comment:
- Any ventricle dilatation (hydrocephalus)
- Any intraventricular haemorrhage (appear
hyperdensity within ventricular system)
- Ventricular effacement (cerebral edema)
 MIDLINE SHIFT
Midline structures
- Falx cerebri *red arrow
- Pineal gland (calcified) *yellow arrow

Midline shift:
- Locate slice with prominent 2 lateral
ventricles *blue arrow
- The location of both ventricles should be
symmetry
- Technical: draw a line joining the falx
cerebri anteriorly and posteriorly. Septum
of lateral ventricles should not deviate
more than 5mm from midline
 BONES
• Skull fracture is a break in the skull bone and generally occurs as a result of direct
impact.

• Four main types of skull fracture:

- Linear skull fracture

- Depressed skull fracture

- Diastatic skull fracture

- Basilar skull fracture

 1. Linear Skull Fracture
Linear Skull Fracture Sutures Vascular Markings
-Straight, translucent lines with - tortuous lines, saw-tooth -less lucent than #
sharp margins appearance
-ill-defined margins
-Width >3mm, widest at the -symmetrical sclerotic
center and narrow at the ends margins -Indent the inner table
of the skull only
-Course through both the outer -Less than 2mm in
and the inner lamina of bone width,same width -vascular indentations
throughout branch and taper
-Cross the suture
-Standard anatomic -symmetrical branching
- Does not branch & taper location pattern
2) Depressed skull fracture
• Displaced or depressed skull
fractures may result in overlapping
bone which causes white lines of
increased density
 3. Diastatic Skull Fractures
• # occurs along the suture lines (most common location - lambdoid and sagittal sutures ).
Extend into and separate suture

• Usually affects newborns& infants in whom suture fusion has not yet happened
4. Basilar Skull Fractures
• # involving the thick base of the skull, often associated with dural tears.
• Anterior cranial fossa skull #:
- CSF rhinorrhea
- Subconjunctival haemorrhage
- Periorbital haematoma (Racoon eye)
• Mastoid process of temporal bone #:
- CSF otorrhoea
- Bleeding from ext. auditory meatus
- Battle’s sign
 Pneumocephalus
• Gas within cranial cavity

• In acute trauma setting, this is commonly due to fractures of PNS and temporal bones (open
skull fracture is another cause)

• Most do not cause immediate danger but rapid expansion can lead to brain compression (tension
pneumocephalus) – Mount Fuji sign

• Usually decreases by 10-15 days and almost never present by 3 weeks

References
• Graham.R, Gllagher.F, Oxford Handbook of Emergency in Radiology, 1 st ed, 2009
• E. Tintinalli. J, et.al, Tintinalli’s Emergency Medicine 7th ed, 2011
• Handbook of Neurosurgery 7th Ed, Ch 27 Head Trauma