HEAD TRAUMA

IMAGING
Ma. Socorro I. Martinez, MD, FPCR, FUSP, FCT-MRISP

Role of Skull X-rays debatable

CT
Imaging procedure of choice for acute injury or neurologic deficit Quick, easy, reliable & available Valuable in making a dx, excluding alternative diagnoses or sequelae of other pathology Px monitoring is simple & safe compatible w/ px stabilization devices Identification & localization of calvarial fxs & bony/metallic fragments Optimal assessment for acute hemorrhage & mass effect Contrast infusion rarely indicated

CT may reveal:
No abnormality (30%) Areas of edema (10%) Hemorrhagic contusion (20%) Extradural or subdural hematoma (20%) Combination of the above (20%)

Epidural hematoma
may present as primary depressed consciousness or ff a lucid interval assoc w/ skull fx (calvarium), not always usu temporoparietal Laceration of dural a. or a venous sinus (middle meningeal a. or one of its branches) bld collects b/n inner table of skull & dura (periosteal layer)

 uniformly hyperdense (acute) well-defined biconvex mass; may contain hypodense foci due to active bleeding often w/ significant mass effect (compression of ipslateral lat ventricle & dilatation of opp lat ventricle due to obstrxn of foramen of Monro) basal cisterns may be effaced

Subdural hematoma
b/n dura and arachnoid from ruptured veins crossing this potential space more common in elderly - space enlarges as brain atrophies

Acute subdural hematoma

can have equally severe consequences due to mass effect, requiring urgent surgery Deceleration and acceleration or rotational forces that tear bridging veins

 CT
Crescent-shaped Hyperdense, may contain hypodense foci due to serum, CSF or active bleeding Does not cross dural reflections

Subacute Subdural Hematoma

may be difficult to visualize by CT - becomes isodense to normal gray matter as hemorrhage is reabsorbed shift of midline structures w/o an obvious mass (subtle) contrast may help- enhancement of dura & adj vascular structures, distinct interface b/n hematoma & adj brain - Compressed lat ventricle - Effaced sulci - White matter "buckling" - Thick cortical "mantle"

Chronic subdural
etiol not always clear; prob due to trauma, often minor vague symptoms & often dev slowly w/ gradual depression or fluctuation of consciousness bilateral in 10% becomes low density as hemorrhage is further reabsorbed crescentic, often w/ mass effect may be loculated if w/ rebleeding- mixed density and fluid/sedimentation levels

Intracerebral Hemorrhage Hemorrhagic contusion

stretching & shearing injury most common primary intraaxial injury brain impacts on bony ridge or dural fold contre coup - directly opp impact site, subcutaneous hematoma, fx, or EDH common locations: - Temporal lobe - ant tip, inf surface, sylvian region - Frontal lobe - ant pole, inf surface - Dorsolateral midbrain - Inf cerebellum

 CT -ill-defined hypodense area mixed with foci of hemorrhage Adj SAH common After 24-48 hrs
hmgic transformation or coalescence of petechial hemorrhages into a rounded hematoma is common

Multiple petechial hemorrhages

may be throughout cerebral hemispheres often very small & at grey/white matter interface due to shearing injury w/ rupture of small IC vessels in a comatose px w/ no other obvious cause - implies severe diffuse brain injury w/ poor prognosis Larger hemorrhages in severe trauma; may not be apparent on immediate scan, becomes prominent after a day or two MRI more sensitive, part. in the absence of hemorrhage

Diffuse Axonal Injury

"shear injury most common cause of significant morbidity in CNS trauma 50% of all primary intra-axial injuries Acceleration, deceleration and rotational forces Immediate loss of consciousness is typical CT may be normal CT - ill-defined areas of high density or hemorrhage occurs in a sequential pattern of locations based on the severity of the trauma
Subcortical white matter Posterior limb internal capsule Corpus callosum Dorsolateral midbrain

Subarachnoid hemorrhage
alone or in assoc w/ other IC or EC hematomas injury of small arteries or veins on surface of brain b/n pia & arachnoid matter most common cause of non-traumatic SAHcerebral aneurysm rupture may also be due to ruptured aneurysm or AVM; may have led to subsequent trauma (imptce of history). Cerebral angio

 TRAUMA -most common cause of SAH most commonly over cerebral convexities or adj to injured brain (i.e.cerebral contusion) CT- focal high density in sulci and fissures, Sylvian fissure, basal cisterns or ventricular system may be complicated by hydrocephalus

Intraventricular Hemorrhage assoc w/ DAI, deep gray matter injury, and brainstem contusion isolated intraventricular hemorrhage may be due to rupture of subependymal veins

Edema
Focal edema - localized poorly defined areas of low density
MRI more sensitive

Diffuse edema - esp in children

may be difficult to detect on CT

Infarction

Infarction in a typical vascular territory may suggest dissection of a vessel, such as the carotid artery after a direct blow to the neck.

Skull Fractures
linear (more common) or depressed Imptce of bone windows May involve PNS or skull base Vs. sutures in anatomical locations (sagittal, coronal, lambdoidal) and venous channels (undulating margins & sclerotic margins) Depressed fractures - inward displacement of fx fragments

Depressed skull fractures

Skull base fractures

not always visible blood in sinuses is suggestive prone to dev meningitis & require antibiotic prophylaxis If w/ clinical evidence of skull base fx (eg CSF rhinorrhoea or bleeding from EAM), a normal CT does not exclude such a fx

Pneumocephalus
indicates an open head injury, such as due to a basal fracture communicating with sinuses or a penetrating injury to vault (eg a bullet wound) indicates the need for antibiotics

Petrous temporal bone fractures

Transverse ; longitudinal may be associated with post traumatic deafness transverse fracture is more severe in this respect

Orbital blowout fracture

Thank you