Basic Knowledge and Film
Practices: Head Trauma
Nuttha Sanghan, M.D.
Radiology Department
Prince of Songkla University
Head Trauma
• Imaging modalities
• Primary traumatic lesions
• Secondary effects
Imaging Modalities
Skull radiography
• Calvarial fractures
• Penetrating injuries
• Radiopaque foreign bodies
• Shift away from skull radiography
toward CT scan
AJNR 2007: 28; 1619-21.
Imaging Modalities
CT Scan
MRI
•
•
•
•
•
•
•
•
Faster
Wide availablility
Lack contraindication
High accuracy
Treatable lesions
Longer time
Lesser availability
Difficult monitoring
More sensitive
Parenchyma
Extraparenchyma
• Lower accuracy
Skull fracture
AJNR 2007: 28; 1619-21.
Primary Traumatic Lesions
• Skull and scalp lesions
• Extraaxial hemorrhage
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Subarachnoid hemorrhage (SAH)
• Intraaxial lesions
Diffuse axonal injury (DAI)
Cortical contusion
Deep gray matter/brainstem injury
Skull and Scalp Lesions
• Skull fractures
Linear fracture
Comminuted fracture
Depressed fracture
Compound fracture
Diastatic fracture
http://radiopaedia.org
Skull and Scalp Lesions
“SCALP”
• S : skin
• C : connective tissue
• A : [galea] aponeurosis
• L : loose connective tissue
• P : periosteum
http://radiopaedia.org
Skull and Scalp Lesions
Bilateral subgaleal hematoma
http://radiopaedia.org
Skull and Scalp Lesions
Acute and chronic cephalohematoma; a crescent-shaped soft-tissue mass in the
periosteum of the left parietal and a partially calcified mass in the periosteum of
the left parietal bone. The mass originated from a cephalohematoma.
Radiographics 2004; 24:1655–1674
Primary Traumatic Lesions
• Skull and scalp lesions
• Extraaxial hemorrhage
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Subarachnoid hemorrhage (SAH)
• Intraaxial lesions
Diffuse axonal injury (DAI)
Cortical contusion
Deep gray matter/brainstem injury
Primary Traumatic Lesions
• Extraaxial hemorrhage
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Subarachnoid hemorrhage (SAH)
Epidural Hematoma (EDH)
• 1-4% craniocerebral trauma
• Lucid interval 50%
• Delay 10-30%
24-48 hours
Epidural Hematoma (EDH)
Imaging
• Displaced dura matter
Certain diagnosis
• Focal biconvex/lentiform configuration
• Not cross suture
• Cross dural attachments
Falx cerebri
Tentorium cerebelli
Epidural Hematoma (EDH)
http://emedicine.medscape.com
Epidural Hematoma (EDH)
• Arterial origin
Laceration: fracture 85-90%
Stretching
Temporal/temporoparietal region: MMA
• Venous origin
Lacerated dural sinus
Posterior cranial fossa
Epidural Hematoma (EDH)
Classic arterial epidural hematoma; a lentiform, high attenuation
collection adjacent to the right temporal lobe, caused by skull fracture
with middle meningeal artery injury.
Neurotherapeutics 2011; 8: 39-53.
Epidural Hematoma (EDH)
Venous epidural hematoma; scalp soft tissue swelling with lentiform EDH and
pneumocephalus indicated an associated skull fracture. CT venogram was obtained
as the fracture line extended over the expected location of the right transverse sinus.
The opacified transverse sinuses are patent with compression and displacement from
the inner table by the EDH caused by injury to the transverse sinus.
Neurotherapeutics 2011; 8: 39-53.
Epidural Hematoma (EDH)
•
•
•
•
Size variable
2/3 hyperdense
1/3 mixed hyper/hypodense
Swirl sign
Low density: active bleeding
Osborn
Epidural Hematoma (EDH)
• Coronal reconstructions
Vertex EDH
http://radiopaedia.org
Epidural Hematoma (EDH)
• Small EDH
Not always differentiation SDH
Classic shape
Fracture
Epidural Hematoma (EDH)
• Mortality 5%
• Poor outcome
Delayed diagnosis
Posterior cranial fossa
Primary Traumatic Lesions
• Extraaxial hemorrhage
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Subarachnoid hemorrhage (SAH)
Subdural Hematoma (SDH)
•
•
•
•
•
10-20% craniocerebral trauma
30% fatal injuries
Lack trauma
Stretching & tearing of bridging veins
Asymptomatic-unconsciousness
Subdural Hematoma (SDH)
Imaging
• Crescent shape
• Cross suture
• Not cross dural attachment
Subdural Hematoma (SDH)
• Supratentorial convexity
• Posterior cranial fossa
• Falx-tentorium
Nonaccidental trauma
http://www.taem.or.th
Subdural Hematoma (SDH)
Acute (a few days)
• Hyperdense 60%
• Mixed 40%
• Nearly isodense
Coagulopathy
Severe anemia
http://www.neurosurgery.com.sg
Subdural Hematoma (SDH)
Subacute (a few weeks)
• Isodense
Displaced GW interface
Sulci-inner table
• Contrast administration
Cortical vessels
Neomembrane
http://radiopaedia.org
Subdural Hematoma (SDH)
http://rad.usuhs.edu
Subdural Hematoma (SDH)
Chronic (months)
• Hypodense
• Neomembrane
Capillary-rich
• Rebleeding 10-40%
Mixed density
Fluid-fluid levels
Septate-loculation
• Calcification 1-2%
Subdural Hematoma (SDH)
AJR 2011: 196; 166-73.
Subdural Hematoma (SDH)
http://www.surgicalneurologyint.com
Differentiation
Epidural hematoma
• Fracture 85-95%
• Arterial/venous
• Biconvex
• Not cross suture
• Cross dura
Subdural hematoma
• Stretching/tearing
• Bridging cortical veins
• Crescent
• Cross suture
• Not cross dura
Primary Traumatic Lesions
• Extraaxial hemorrhage
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Subarachnoid hemorrhage (SAH)
Subarachnoid Hemorrhage (SAH)
• Moderate to severe head trauma
• Superficial sulci
• CSF cisterns
http://www.radswiki.net
Subarachnoid Hemorrhage (SAH)
Common causes
• Head trauma
• Intracranial aneurysm
• Perimesencephalic hemorrhage
Less frequent etiologies
• Arteriovenous malformation
• Arterial dissection
• Extension from intracerebral hemorrhage
Subarachnoid Hemorrhage (SAH)
• Pseudo-subarachnoid hemorrhage
Severe diffuse brain edema
Relatively hyperdense vasculatures
A 34-year-old man with cardiac arrest. A, On the first day, no abnormal finding is seen. B, On the 8th day, the brain shows diffuse
low attenuation with obliteration of cisterns-sulci and narrowed ventricles. High-attenuation areas along sylvian fissures and
tentorium cerebelli. C, On the 129th day, brain edema becomes more severe with more prominent high attenuation areas.
Subarachnoid Hemorrhage (SAH)
• Pseudo-empty delta sign: SSS thrombosis
Posterior parafalcine/interhemispheric SDH
SAH around sinus
AJR 2007; 189: 64-75.
Primary Traumatic Lesions
• Skull and scalp lesions
• Extraaxial hemorrhage
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Subarachnoid hemorrhage (SAH)
• Intraaxial lesions
Diffuse axonal injury (DAI)
Cortical contusion
Deep gray matter/brainstem injury
Primary Traumatic Lesions
• Intraaxial lesions
Diffuse axonal injury (DAI)
Cortical contusion
Deep gray matter/brainstem injury
Diffuse Axonal Injury (DAI)
•
•
•
•
Shear-strain deformation
Acceleration/deceleration
Rotational force
Diffuse, bilateral
http://www.givengain.com
Diffuse Axonal Injury (DAI)
Locations
• GW interface
• Corpus callosum
Posterior body
Splenium
• Dorsolateral upper brainstem
• Sequentially deeper with increasing severity
http://www.nursing-lectures.com
Diffuse Axonal Injury (DAI)
Imaging
• Initial normal/subtle
• Nonhemorrhagic 80%
Hypodense foci
Site of shearing
• Petechial hemorrhages 20-50%
• Tip of the iceberg
• Delayed scans with new lesions
http://radiopaedia.org
Diffuse Axonal Injury (DAI)
Diffuse axonal injury in a patient who was on
anticoagulants: CT scan on day1 and day 2
http://radiopaedia.org
Diffuse Axonal Injury (DAI)
Diffuse axonal injury: small hemorrhagic foci in the right parasagittal
posterior frontal lobe and in the splenium of the corpus callosum
Neurotherapeutics 2011; 8: 39-53.
Primary Traumatic Lesions
• Intraaxial lesions
Diffuse axonal injury (DAI)
Cortical contusion
Deep gray matter/brainstem injury
Cortical Contusions
• Second primary intraaxial lesions
• Less initial loss of consciousness
• Gray matter
More vascularity
Likely hemorrhage
Variable size
http://www.givengain.com
Cortical Contusions
Locations
• Temporal lobe
Petrous part
Greater sphenoid wing
• Frontal lobe
Cribiform plate-orbit
Planum sphenoidale
Lesser sphenoid wing
http://www.nebraskabraininjurylawyer.com
Cortical Contusions
Locations
• Cerebellum 10%
Superior vermis
Tonsils
Inferior hemisphere
• Gliding contusion
Parasagittal region
emedicine.medscape.com
Cortical Contusions
http://www.braininjury.com
A typical coup-contrecoup pattern of injury with an extracranial/skull
injury at the point of direct impact and a more pronounced area of
intracranial contusions at the directly opposite side of the head.
http://images.radiopaedia.org
Cortical Contusions
• Evolve with time
• Early
Ill-defined low density
Small petechial hemorrhage
• 24-48 hours
More lesions
20% delayed hemorrhage
Cortical Contusions
Blossoming of hemorrhagic contusions.
(a)Multiple intracranial hemorrhages including a subtle left temporal hemorrhagic contusion, SDH
along the right tentorium and SAH in the basilar cisterns and Sylvian fissure.
(b) CT scan 6 hours later demonstrates expansion of the left temporal contusion.
Neurotherapeutics 2011; 8: 39-53.
Intraventricular Hemorrhage (IVH)
• 1-5% close head injury
• Other primary intraaxial lesions
• Etiology
Disrupted subependymal veins
Ruptured intracranial hemorrhage
Focal choroid plexus hematoma
• Isolated IVH better outcome
http://anatpat.unicamp.br
Primary Traumatic Lesions
• Intraaxial lesions
Diffuse axonal injury (DAI)
Cortical contusion
Deep gray matter/brainstem injury
Deep Gray Matter/Brainstem Injury
• 5-10% primary brain injury
• Direct trauma
• Shearing force
Disrupted perforating blood vessels
Petechial hemorrhage
• Locations
Dorsolateral brainstem
Diffuse axonal injury
Duret hemorrhage
Periaqueductal region
Deep gray matter
9-year-old boy with motor
vehicle accident.
Initial CT showed
subcortical hemorrhagic
foci in left fronal lobe. Due
to persistent reduced
vigilance, MRI was ordered
Diffuse axonal injuries in
classic locations: Gray/white
matter interface
(predominantly in frontal
and temporal lobes), the
corpus callosum (especially
the splenium) and the
dorsolateral midbrain
http://images.radiopaedia.org
Secondary Effects
•
•
•
•
Diffuse brain swelling
Cerebral herniations
Secondary hemorrhage
Traumatic ischemia/infarct
Diffuse Brain Swelling
• Cerebral hyperemia
Increased blood volume
• Cerebral edema
Vasogenic: disrupted BBB
Cytotoxic: failured cell membrane pumps
Diffuse Brain Swelling
Diffuse cerebral swelling in this 32-year-old patient who sustained head trauma: diffuse
sulcal effacement but relative preservation of gray-white differentiation.
Neurotherapeutics 2011; 8: 39-53.
Diffuse Brain Swelling
• Twofold higher in children
More prone to dysautoregulation
Vasodilatation and hyperemia
Cerebral swelling
Secondary Effects
•
•
•
•
Diffuse brain swelling
Cerebral herniations
Secondary hemorrhage
Traumatic ischemia/infarct
Cerebral Herniations
• Increased intracranial pressure
• Herniaed brain to another compartment
Bony ridges
Dural folds
http://www.sonoworld.com
Cerebral Herniations
• Subfalcine
• Uncal
• Transtentorial
Descending
Ascending
• Tonsillar
• Central
• Transcalvarial
http://missinglink.ucsf.edu
Large left holohemispheric and parafalcine subdural hematoma
results in midline shift and subfalcine herniation.
Neurotherapeutics 2011; 8: 39-53.
http://www.hawaii.edu
Uncus protrudes into suprasellar cistern.
http://www.hawaii.edu
Subacute subdural hematoma producing
extensive midline shift with subfalcine and
right uncal herniation. There is trapping of the
ventricles with acute ependymal cerebrospinal
fluid seepage, predominantly in the left
periatrial and occipital regions.
http://brighamrad.harvard.edu
Cerebral Herniations
Descending transtentorial herniation due to massive subdural hematoma
radiologyimages.blogspot.com
Descending transtentorial herniation
https://www.thieme-connect.de
Cerebral Herniations
http://www.aao.org
Cerebral Herniations
Tonsillar herniation
• Rare
• Foramen magnum
Compressing medulla
Upper cervical spinal cord
• Early
Difficult on axial view
Best on sagittal MRI
http://rad.usuhs.mil
Secondary Effects
•
•
•
•
Diffuse brain swelling
Cerebral herniations
Secondary hemorrhage
Traumatic ischemia/infarct
Secondary Hemorrhage
http://medinfo.ufl.edu
Secondary Hemorrhage
Large left holohemispheric and parafalcine subdural hematoma results in midline shift and
uncal herniation. Downward brainstem herniation has led to classic Duret hemorrhage.
Neurotherapeutics 2011; 8: 39-53.
Secondary Hemorrhage
Extensive cerebral edema with descending transtentorial herniation and a relatively large
hemorrhage in brainstem. Because there is brain herniation, this hemorrhage is most
likely Duret hemorrhage.
http://rad.usuhs.edu
Secondary Hemorrhage
Thin chronic subdural hematoma with abnormal signal in the
contralateral crus cerebri; Kernohan’s notch phenomenon.
http://ars.sciencedirect.com
Secondary Effects
•
•
•
•
Diffuse brain swelling
Cerebral herniations
Secondary hemorrhage
Traumatic ischemia/infarct
Traumatic Ischemia/Infarction
• 2% traumatic brain injuries
• Mechanical compression
PCA-transtentorial herniation
ACA-subfalcine herniation
Perforating branches
Traumatic Ischemia/Infarction
Right-sided holohemispheric
subdural hematoma results in
subfalcine and uncal herniation
with subsequently developed
infarcts in ACA and PCA
distributions with infarction of
the posterior limb of the right
internal capsule due to
compression of the
anterior choroidal artery with
uncal herniation.
Neurotherapeutics 2011; 8: 39-53.
Traumatic Ischemia/Infarction
• Primary vascular injuries
Vasospasm
Dissection
Laceration
Occlusion
Pseudoaneurysm
Traumatic Ischemia/Infarction
• CT screening-basal skull fracture
Carotid canal
Sphenoid bone
Petrous temporal bone
Occipital bone
• Implement CT angiography
• Conventional angiography
Referrence
• AJNR 2007: 28; 1619-21.
• Gentry LR, Knopp EA. Head Trauma. In:
Atlas SW, editor. Magnetic resonance
imaging of the brain and spine. 4th ed.
Philadelphia: Lippincott Williams & Wilkins;
2009. 894-926.
Referrence
• Neurotherapeutics 2011; 8: 39-53.
• Yousem DM, Grossman RI. Head Trauma.
In: Neuroradiology. 3rd ed. Philadelphia:
Mosby; 2010. p.170-91.
• กนกพร โอฬารรัตนชัย. ภาพรังสี กะโหลกศีรษะ. ใน: จันทิมา เอื้อตรงจิตต์, สนาน สิ มารักษ์, บรรณาธิ การ. รังสี วิทยาพื้นฐาน. พิมพ์ครั้งที่ 1.
เชียงใหม่: ธนุชพริ้ นติ้ง; 2553. หน้า 28-54.