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Imaging of Head Trauma

Part 1: Introduction

Rathachai Kaewlai, MD

Created: December 2006


  When to do brain imaging in trauma setting?

  What imaging is appropriate?

  Advantage and disadvantage of each imaging modality

  Review of important cranial CT anatomy


  Significance of craniocerebral injuries

  Common cause of hospital admission following trauma
  High morbidity and mortality particularly in adolescent and
young adults
  Concepts
  Brain is contained within the skull which is a rigid and inelastic
container, so only small increases in volume can be tolerated
(Intracranial volume = Brain + CSF + Blood volume)
  Cerebral perfusion pressure (CPP) in injured areas is pressure-
passive flow (no autoregulation, cerebral blood flow dependent
on blood pressure)


  Traumatic brain injury: 2 categories

1.  Primary injury
–  Initial injury to the brain as a result of direct trauma
–  Example: hematoma, diffuse axonal injury, contusion
2.  Secondary injury
–  Subsequent injury to the brain after the initial insult
–  Result from systemic hypotension, hypoxia, elevated
intracranial pressure (ICP) or biochemical insults

When to Do Imaging
and What to Do?

  Minor or mild acute closed head injury (GCS > 13)

  Without risk factors or neurologic deficit head CT without
contrast can be performed but known to be low yield (see next page)
  With risk factors or neurologic deficit head CT without
contrast most appropriate and should be performed, brain MRI
reserved for problem solving
  Children < 2 years old head CT without
contrast most appropriate and should be performed

According to American College of Radiology (ACR) Appropriateness Criteria

When to Do Imaging
and What to Do?

  Indications for CT in patients with minor head injury

  Haydel MJ et al. Indications for CT in patients with minor
head injury. New Engl J Med 2000;343:100-5.
  520 patients with minor head injury who had a normal Glasgow
Coma Scale and normal findings on a brief neurologic
examination underwent CT scans: 36 patients (6.9%) had positive
  All patients with positive scans had one of the clinical findings: short-
term memory deficit, drug or alcohol intoxication, physical
evidence of trauma above clavicles, age > 60 yr, seizure, headache,
vomiting, or coagulopathy

When to Do Imaging
and What to Do?

  Indications for CT in patients with minor head injury

  Haydel MJ et al. Indications for CT in patients with minor
head injury. N Engl J Med 2000;343:100-5.
  Results were tested in another 909 patients; using at least one of
the clinical findings above, the sensitivity of seven clinical findings
was 100%.
  CT abnormalities in 93 patients with positive CT scans: cerebral
contusion (none had surgery), subdural hematoma (6% had
surgery), subarachnoid hemorrhage (none had surgery), epidural
hematoma (22% had surgery), depressed skull fracture (20% had

When to Do Imaging
and What to Do?

  Moderate or severe acute closed head injury

  Head CT without contrast most appropriate and should be
  X-ray and/or CT of cervical spine also appropriate and
  MRI reserved for problem solving

  Rule out carotid or vertebral artery dissection

  MRI with MRA, or CT with CTA of the head and neck most
  Cerebral angiography reserved for problem solving

According to American College of Radiology (ACR) Appropriateness Criteria

When to Do Imaging
and What to Do?

  Penetrating injury, stable, neurologically intact

  Head CT without contrast most appropriate and should be performed
  Skull x-ray also appropriate if calvarium is the site of injury
  C spine x-ray or CT appropriate if neck or C-spine is the site of injury
  CTA of head and neck if vascular injury suspected

  Skull fracture
  Head CT without contrast most appropriate and should be performed
  CTA of head and neck if vascular injury suspected

According to American College of Radiology (ACR) Appropriateness Criteria

Skull Radiography

  1/3 of patients with severe brain injury don’t have fracture

  Role of skull radiography in acute head injury

  Calvarial fractures
  Linear fracture that is ‘in plane’ with axial CT scan can be missed. Scout image
of head CT, or CT reformation is useful
  Penetrating injuries
  Provide rapid assessment of degree of foreign body penetration, e.g. stab
  Radiopaque foreign bodies
  Example: patients with gunshot wounds to the head (to screen for retained
intracranial bullet fragments)

Computed Tomography (CT)

  Advantages
  High sensitivity for demonstrating mass effect, ventricular size and
configuration, bone injury, acute hemorrhage regardless of
  Widespread availability, rapid scanning, compatibility with other
medical and life support devices
  Limitations
  Insensitivity to detect small and nonhemorrhagic lesions such as
contusion, particularly when adjacent to bony surfaces, diffuse
axonal injury
  Relatively insensitive to detect early brain edema, hypoxic-
ischemic encephalopathy (HIE)

Computed Tomography (CT)

  Role of CT in acute head injury

  Patients with moderate-risk or high-risk for intracranial injury should
undergo early non-contrast CT to look for…
  Intracerebral hematoma
  Midline shift
  Increased intracranial pressure
  Patients with low-risk for intracranial injury: clinical selection for CT is
still problematic
  CT may be able to triage this patient group to admission, surgery or discharge
  CT may lower the cost of hospital admission for observation
  Trade-off with greater use of CT in emergency setting

Computed Tomography (CT)

  Repeat head CT
  Required for clinical or neurologic deterioration, especially within
72 hours after trauma
  Detection of delayed hematoma, hypoxic-ischemic lesions and
cerebral edema

  Pediatric patients
  Lower threshold for doing a CT scan
  Clinical criteria for scanning is less reliable, particularly in children
less than 2 years
  CT order needs to be balanced with risk of radiation exposure

Magnetic Resonance Imaging

  Advantages
  Sensitive for detection of diffuse axonal injury or contusion with
susceptibility sequence (T2 gradient echo), distinguish different ages of
  Useful for screening of vascular lesions such as thromboses,
pseudoaneurysms, or dissection

  Limitations
  Insensitive for subarachnoid hemorrhage, air and fracture
  Certain absolute contraindications, e.g. pacemaker
  Limited availability in acute setting, longer imaging time (than CT),
incompatibility with some medical devices

Magnetic Resonance Imaging

  Role of MRI in acute head injury

  Problem solving tool when CT is inconclusive or high clinical
  Diffuse axonal injury: CT is less sensitive than MRI. For example,
patients with severe head injury but normal CT
  Brain contusion
  Vascular examinations of the brain and neck
  Suspicion of dissection, aneurysm or thrombosis
  CT angiography also has a competitive role as MR angiography

Brain CT: Normal Anatomy

  Make sure to look at all 3 different window displays on

one head CT exam.

Brain window Subdural window Bone window

3 1 3

Make sure the first image

include the foramen magnum
(red circle), otherwise you will miss
1 (impending) tonsillar herniation
1 = cervicomedullary junction
2 = CSF space (should be dark)
3 = Cerebellar tonsils (tonsils are
not midline structures)

5 = Pons (usually not clearly seen due to
‘beam hardening artifact’ from bony skull
6 = Middle cerebellar peduncle
(structure that connects pons and cerebellar
7 = Cerebellar hemisphere
8 = Forth ventricle (CSF cavity behind
the brainstem, slit-like appearance when


7 = Cerebellum
9 = Midbrain (heart-shaped structure
normally surrounded by CSF. Effacement of CSF
may suggest early brain herniation)
10 = Temporal lobe
11 = Temporal horn of lateral ventricle
13 (Look for earliest hydrocephalus here. Normally
slit-like, or curvilinear)

10 12 = Uncus (Most medial portion of temporal

12 lobes; uncal herniation is called when uncus
displaces medially and obliterates the CSF space
11 9 on the side of midbrain)
13 = CSF cistern (Not seeing CSF around
midbrain may be abnormal; that’s what
radiologists call ‘effacement of the cistern’ as a
7 sign of cerebral herniation. Also a place to look
for subarachnoid hemorrhage)

14 = Anterior falx (Know where it is, so
14 you can draw a ‘midline’ to see if there is
‘midline shift’ or not)
15 = Posterior falx
16 = Basal ganglia (Lateral to the frontal
horn of lateral ventricle)
17 = Thalamus (lateral to the third
ventricle which is very narrow here)
16 18 = Sylvian fissure (CSF space dividing
frontal from temporal lobes. Look for
subarachnoid hemorrhage here)
17 Red line = Cerebral convexity (Look
for extra-axial hemorrhage here, better seen in
‘subdural window’)

• Intra-axial = any pathology ‘in’ the brain

• Extra-axial = any pathology ‘not in the
parenchyma’ e.g. subarachnoid, subdural and
epidural pathology

19 = Lateral ventricle
20 = Septum pellucidum (midline
structure dividing right and left lateral
ventricles; helps in measuring degree of
midline shift)


2 = CSF space (Look for subarachnoid
hemorrhage here)

Red lines = Temporomandibular
joint (socket)
21 = Condyle of mandible (ball;
should sit in the socket. Missing fracture or
dislocation in this region will cause patients’
long term disability)
21 22 = Mastoid air cells (should be filled
with air density, otherwise fracture of the
skull base should be suspected)


23 = Sphenoid sinus (Look for fluid or
blood density, air-fluid level which may represent
skull base fracture)


Checklist for Trauma Head CT

  Have 3 different windows to look for different pathology (brain,

subdural and bone windows)

  First image includes foramen magnum

  Look first for the pathology that needs emergent Rx

  Hydrocephalus

  Look for primary pathology (hemorrhage in different compartments,

depressed skull fracture)

Checklist for Trauma Head CT

  Look for secondary pathology (brain herniation, midline shift)

  Look at the mastoid and sphenoid sinuses for hemorrhage

which implies skull base fractures
  Always look at scout CT image for fracture ‘in plane’
with axial scans

  Look at temporo-mandibular joints for fracture and/or


Traumatic brain pathology will be continued on ‘Part 2’

  The information provided in this presentation…
  Is intended to be used as educational purposes only.
  Is designed to assist emergency practitioners in providing
appropriate radiologic care for patients.
  Is flexible and not intended, nor should they be used to
establish a legal standard of care.