CT in Head Trauma

To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all. Structures from above downwards: falx cerebri, frontal horns of lateral ventricles, third ventricle, basal cistern, skull, scalp & again the falx cerebri

Sir William Osler, 1849-1919, Professor of Medicine, Oxford

Preface N O R M A L C T

CT is a vital tool in the assessment of patients with serious head injury & revolutionized management when it was introduced. It is the investigation of choice even following the advent of MRI, due both to the ease of monitoring of injured patients & the better demonstration of fresh bleeding and bony injury. This scan is a slice through the human brain and you should imagine that you are viewing it as if looking up from the patient's feet. Thus, the patient's left is to your right & vise versa. The shape of the ventricles is quite distinctive. Each lateral ventricle has 2 frontal & 2 occipital horns. The presence of the third ventricle (slit-like) in the midline is one of the first things to look for. If the third ventricle is either not visible, or shifted away from the midline, this suggests that there is an abnormality. The basal cistern is the CSF-filled space around the back of the midbrain. Blood clots or swelling of the brain may cause this to become narrowed or not visible at all.

Extradural (Epidural) hematoma

They arise between the inner table of the skull & the dura. They usually develop from injury to the middle meningeal artery or one of its branches, and therefore are usually temporoparietal in location. A temporal bone fracture is often the cause but is not essential. The expanding hematoma dissects the dura from the skull; this attachment is quite strong such that the hematoma is confined, giving rise to its characteristic biconvex (lenticular) shape, with a well-defined margin. It is usually of uniform (homogenous) high density but may contain hypodense foci due to active bleeding. There is often significant mass effect (midline shift) with compression of the ipsilateral lateral ventricle and dilatation of the opposite lateral ventricle due to shift of the CSF & obstruction of the foramen of Munro. It can cross the dural reflections unlike a subdural hematoma but not suture lines where the dura tightly adheres to the adjacent skull.

Subdural hematoma
They arise between the dura & arachnoid matter, usually from ruptured veins crossing this potential space. This space enlarges as the brain atrophies (due to aging) and so subdural hematomas are more common in the elderly due to senile brain atrophy. Acute subdural hematomas have high attenuation (hyperdense); this

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decreases with time, becoming isodense after a week (subacute subdural hematoma) and hypodense after 2 weeks (chronic subdural hematoma).

A.

Acute subdural Hematoma

C.

Chronic subdural hematoma

On CT, the hematoma is hyperdense Crescent-shaped (concave) & may contain hypodense foci due to active bleeding. It has more irregular inner margin & does not cross dural reflections. Blood may spread more widely in the subdural space (e.g. interhemispheric in the falx cerebri as in the third figure).

They are hypodense crescentic collections (hemolyzed blood) & may be loculated.

D.

Acute on top of chronic subdural hematoma

B.

Subacute subdural hematoma

Rebleeding may occur in chronic subdural hematomas with accumulation of the layering of the chronic hematoma anteriorly & the hyperdense fresh blood posteriorly (fluid-fluid level).

As the hemorrhage is reabsorbed, it becomes isodense to the normal gray matter. A subacute SDH should be suspected when you identify shift of the midline structures without an obvious mass.

A.

Intracerebral Hemorrhage Hemorrhagic contusions

They are the most common primary lesions. They occur due to impaction of the brain against the skull or dural fold. The inferior frontal lobes and anterior temporal lobes are common sites after a blow to the back of the head.

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B.

Multiple Petechial hemorrhages

Brain edema
Focal edema may be seen as localized poorly defined areas of low density. Diffuse edema may develop, especially in children. This may be difficult to detect on CT.

Multiple contusions may be present throughout the cerebral hemispheres. They are often small and visible at the gray/white matter interface. They are due to a shearing injury with rupture of small intracerebral vessels, and in a comatose patient with no other obvious cause they imply a severe diffuse brain injury with a poor prognosis (diffuse axonal injury). Adjacent foci of petechial hemorrhage may coalesce later into a big hematoma.

Subarachnoid & intraventricular hemorrhage

A subarachnoid hemorrhage occurs with injury of small arteries or veins on the surface of the brain. The ruptured vessel bleeds into the space between the pia and arachnoid matter. Hyperdense blood is seen in the CSF spaces, over the cerebral hemispheres (look at the Sylvian fissure), in the basal cisterns or in the ventricular system. Trauma is the most common cause of SAH. SAH also occurs due to rupture of cerebral aneurysm (old age) & arteriovenous malformation (young age).

A.

Skull Fractures (bone window) Fissure (linear) fractures

These are indicative of the severity of the injury, and uncomplicated fractures are not of great significance otherwise, except that temporal bone fractures may predispose to extradural hematoma due to injury of the middle meningeal artery. They have to be differentiated from suture lines & vascular markings

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B.

Depressed skull fractures

Intracranial air (pneumocephalus) C. Skull base fractures

These are not always visible, but blood in the sinus cavities (sphenoid sinus) suggests their presence. This is important as such patients are prone to developing meningitis and require antibiotic prophylaxis. If the patient has clinical sign of skull base fracture (e.g. rhinorrhoea or otorrhea) a normal CT does not exclude such a fracture. This indicates an open head injury; such as due to a basal fracture communicating with sinuses or a penetrating injury to the vault (e.g. a bullet wound). On CT, air is the most hypodense structure (jet-black). Again it indicates the need for antibiotics.

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