Head Trauma

Robby Hermawan
 HEAD TRAUMA

• Trauma is one of the most frequent

indications for emergent neuroimaging
• Imaging play a key role in patient triage
and management
• Traumatic brain injury (TBI) 
worldwide public health problem
• Enormous personal and societal impact
• Direct and indirect medical cost are high
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Epidemiology
• Of all head injuries  10% fatal
• 5-10%  serious permanent neurologic
deficits
• 20-40%  moderate disability
 HEAD TRAUMA

Clinical Classification
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How to Image?
• Skull Radiography
– Calvarial fracture
– Can not depict the far more important presence of
extraaxial hemorrhages and parenchymal injuries
– 25%-33% of autopsied patients with fatal brain
injuries  no skull fracture
– No role in current management of head injured
patient
– It’s the brain that matters – not the skull
 HEAD TRAUMA

How to Image?
• CT scan
– World wide screening tool
– Depicts both bone and soft tissue injuries
– Widely accessible, fast, effective, and
relatively inexpensive
– From just below the foramen magnum to the
vertex (cervical spine can also be included if
there is an indication).
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How to Image?
• CT scan
– 2 reconstruction algorithms
• Brain
• Bone
– Windowing
• Brain window (W:80, C:35)
• Bone window (W:4000, C:400)
• Blood window ((W:200, C:60)
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HEAD TRAUMA
Look at the scout view
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How to Image?
• CT Angiography
– Skull base fracture traverses the carotid
canal or dural venous sinus
– Penetrating neck injury
– Fractured foramen transversarium
– Facet subluxation
– Finding: arterial laceration/dissection, dural
venous injury, traumatic pseudoaneurysm,
carotid cavernous fistula.
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 HEAD TRAUMA

How to Image?
• MR
– For subtle abnormalities
• Minimal contusion  GRE/SWI
• Diffuse axonal injuries  GRE/SWI
• Chronic (child abuse)
• MR Spectroscopy  ↓NAA
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Who and When to Image?

• Moderate & severe head injury  examined!
• The debate is in mild head injury (GCS 13-15).
• America College Radiology (ACR) criteria:
– Mild HI with
• Focal neurologic deficit
• All children under 2 years of age

• New Orleans Criteria

• Canadian Head CT Rule
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Who and When to Image?

 HEAD TRAUMA

Who and When to Image?

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Primary effect
• Scalp and skull injuries
• Extraaxial hemorrhage
• Parenchymal Injuries
• Miscellaneous injuries

Secondary effects and sequele

• Herniation syndrome
• Edema, ischemia, and vascular injury
• Chronic effects of CNS trauma
 Anatomy
Layer of the scalp and meninges
 Anatomy
Layer of the scalp and meninges
 Anatomy
Brain Covering (Meninges)
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Scalp and Skull Injuries

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Scalp Injury
• Cephalohematoma
• Usually in infants
• Subperiosteal, limited by sutures
• Typically small, unilateral; resolves spontaneously
• Subgaleal hematoma
• Between galea (aponeurosis) & periosteum of calvaria
• Not limited by sutures
• Bilateral, can be extensive

The differentiation is important because subgaleal

hematoma can cause hypovolemia and hypotension
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 HEAD TRAUMA
Skull Fractures
Linear • Rare, usually in young children
• Sharp lucent line • Fracture lacerates dura-
Depressed arachnoid
• Internally displaced fragments • Brain tissue/arachnoid herniates
• Often lacerates dura-arachnoid through torn dura
Elevated • Trapped tissue prevents bone
healing
• Rare; fragment rotated outward
• CT shows rounded edges,
Diastatic
scalloped margins
• Widens suture or synchondrosis
• MR shows CSF ± brain
• > 3mm in < 2year old
• > 2mm in ≥ 3 year old

Growing
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Skull Fractures
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Extraaxial hematoma/hemorrhage
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Extraaxial hematoma/hemorrhage

1. Traumatic subarachnoid hemorrhage (most common)

2. Subdural hematoma (10-20% of head trauma)
3. Epidural/extradural hematoma (1-4% of head trauma)
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Epidural Hemorrhage (EDH)
• Extra-axial
• Between inner table of the skull &
outer (periosteal) layer of the dura
• Unilateral, supratentorial (>90%)
• Etiology:
• Associated skull fracture in 90-
95%
• 90% arterial injury (middle
meningeal a.)
• 10% venous (dural venous
sinus)
 HEAD TRAUMA
Epidural Hemorrhage (EDH)
Epidemiology
• Relatively rare (1-4% of head
trauma)
• Older children and young adult
• M:F = 4:1
Clinical Issues
• Classic “lucid interval” in 50 % of
cases
• Delayed deterioration
• Prompt recognition and
treatment  low mortality
 HEAD TRAUMA
Epidural Hemorrhage (EDH)

• Ellipsoid (biconvex)
• Dura stripped away from the
skull
• Hyperdense lens-shaped
• Hypodensity “swirl” sign  rapid
bleeding
• Well-defined margin
• Usually doesn’t cross the suture
• Vertex EDH usually venous can
cross midline
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Epidural Hemorrhage (EDH)
Hypodensity inside the EDH can be caused by:
• Rapid bleeding  “swirl” sign of serum/fresh blood
• Leakage of CSF
• Anemic patients
• Subacute but if there is fluid-fluid level  rebleeding
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Subdural Hemorrhage (SDH)

• Extra-axial
• Plano-conveks
• Usually cross the suture
• Well-defined margin
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Subdural Hemorrhage (SDH)
• Extra-axial suture
• Plano-conveks • Well-defined
margin

• Usually cross the

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The difference between EDH and SDH

Characteristic EDH SDH

Shape Biconvex Crescent
Associated skull Almost always Frequently in the
fracture absence of skull
fracture

Suture crossing Rare Usually

Falx or tentorium Can Rare
crossing
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The difference between EDH and SDH
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Subarachnoid Hemorrhage
• Most common
traumatic extraaxial
hemorrhage
• tSAH > aneurysmal
SAH
• Adjacent to cortical
contusions
• Superficial sulci >
basilar cisterns
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Subarachnoid Hemorrhage
• Extra-axial
• Cortical sulci • Sylvian fissure
• Basal cistern • Superior cerebellar
cystern
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Parenchymal Injuries
 HEAD TRAUMA
Parenchymal Injuries
• Cerebral contusions and
laceration
• Diffuse Axonal Injury
• Diffuse Vascular Injury
• Subcortical Injury
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Cerebral Contusion
• Most common intraaxial injury
• Brain impacts skull and/or dura
• Causes brain bruises in gyral crests
• Usually multiple, often bilateral
• Anteroinferior frontal, temporal lobes most
common sites
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Cerebral Contusion
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Cerebral Contusion
Imaging:
• Superficial petechial, focal hemorrhage along gyral
crest
• Edema, hemorrhage more apparent with time
• Vary in size from tiny lesions to large confluent
hematoma.
• Contusion that occur at the site of impact  coup
lesions
• Contusion that occur at 1800 opposite the site of
impact  contre-coup lesions
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Cerebral Contusion
Imaging:
• CT :
• Hyperdens lesion with perifocal hypodense area
• MRI:
• T1WI: mild inhomogenous isointensity and mass
effect
• T2WI : patchy hyperintense area (edema)
surrounding hypointense foci of hemorrhage
• T2* (GRE, SWI) most sensitive imaging  blooming
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Kronik (>4minggu) Hemosiderin Hipointens Hipointens
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Cerebral Contusion
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Cerebral Contusion
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Cerebral Contusion
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Cerebral Contusion
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Cerebral Contusion
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Cerebral Laceration
• Brain laceration occurs when severe
trauma disrupt the pia and literally tears
the underlying brain
• A burst lobe is the most severe form of
brain laceration
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Cerebral Laceration
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Diffuse Axonal Injury
• Second most common intraaxial injury
• Most are axonal strecth injury.
• Spares cortex, involves subcortical/deep WM
• Imaging:
• GCS low; initial imaging minimally abnormal.
• Subcortical, deep petechial hemorrhages (tip
of iceberg)
• T2* (GRE, SWI) most sensitive
• DWI : restricted area
• DTI : depicting white matter disruption
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Diffuse Axonal Injury
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Diffuse Axonal Injury
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Diffuse Axonal Injury
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Diffuse Vascular Injury
• Extreme end of diffuse axonal injury
• Disrupted microvascular injury
• Fatal, mostly do not survive long enough for
imaging.
• Imaging:
• CT shows diffuse brain swelling +/- a few
small foci of hemorrhage
• T2 and FLAIR  few scattered
hyperintensities
• SWI  innumerable linear hypointensity
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Diffuse Vascular Injury
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Diffuse Vascular Injury
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Subcortical (Deep Brain) Injury
• Traumatic deep brain structures :
• Brain stem (midbrain, pons)
• Basal ganglia
• Thalami
• Ventricles
• “The deeper the injuries, the worse it is”
• Hemorrhages, axonal injuries, brain tears
• Gross intraventricular hemorrhage
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Subcortical (Deep Brain) Injury
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Pneumocephalus
• Presence of gas or air within the skull
(intracranial)
• Tension pneumocephalus  mass efect
on the brain.
• Pneumatocele or aerocele  less
commonly term to a focal gas collection
within the brain parenchyma
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Pneumocephalus
• Never normal (except after surgery)
• Breach in integrity:
• Calvaria
• Mastoid
• Paranasal sinus
• Infection  rare cause
• Intravenous  i.v catheter (usually
cavenous sinus)
• Intraarterial  air embolism or brain death
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Pneumocephalus
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Pneumocephalus
Rotterdam CT Score
Marshall CT Classification
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Secondary Effects and
Sequele of CNS Trauma
• Herniation syndrome
• Edema, Ischemia, and Vascular Injury
• Chronic effects of CNS Trauma
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Herniation Syndrome
• Subfalcine Herniation
• Descending Transtentorial Herniation
• Ascending Transtentorial Herniation
• Tonsillar Herniation
• Ascending Transalar Herniation
• Descending Transalar Herniation
• Transcranial/Transdural Herniation
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Subfalcine Herniation
• Most common cerebral herniation
• Cingulate gyrus, ACA, ICV displaced
across the midline
• Foramen of Monro kinked  obstructed
• Ipsilateral ventricle small, contralateral
enlarged
• Complication:
• Obstructive hydrocephalus
• Secondary ACA infarction
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Subfalcine Herniation
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Descending Transtentorial Herniation
• Second most common cerebral herniation
• Unilateral / Bilateral
• Unilateral
• Temporal lobe (uncus  suprasellar cistern,
hippocampus  ambient cistern) pushed
over tentorial incisura
• Bilateral
• Hypothalamus, chiasm flattened againts sella
• Basal cistern completely effaced
• Midbrain push down
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Descending Transtentorial Herniation
• Complication:
• CN III compression (pupil palsy)
• Secondary occipital (PCA) +/-
hypothalamus infarct
• Compresion of contralateral cerebral
peduncle (Kernohan notch)
• Midbrain (Duret) hemorrhage
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Descending Transtentorial Herniation
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Descending Transtentorial Herniation
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Descending Transtentorial Herniation
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Descending Transtentorial Herniation
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