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Neuroimaging in Trauma

Dr Satyen Shukla SpR Radiology Royal Hospital Neuroradiology Department Belfast

Trauma
Annual incidence 0.2-0.3% pa 5-6% pa in the 15 - 24 age group due to RTA and assaults Second peak in the elderly due to falls

10% fatal, 10-20% moderate severity males x4 > female

Mechanism of injury
Primary
Direct mechanical

Secondary
Delayed sequelae resulting in pathophysiological changes

Imaging modalities
Plain film
Computed Tomography (CT)

MRI catheter angiography

Skull x-ray

CT Brain Anatomy

CT Brain Anatomy

CT Brain Anatomy

Primary Injury
Neuronal Haemorrhagic Vascular

Secondary Injuries
Oedema Brain herniation Vascular occlusion Diffuse hypoxic injury

Late Sequelae
Encephalomalacia / Porencephaly Atrophy Delayed Subdurals Hydrocephalus

Primary Injuries
Neuronal Haemorrhagic Vascular

Primary Neuronal
Diffuse Axonal Injury (DAI) Cerebral Contusion (CC) Subcortical Grey Matter Injury (SGMI) Primary Brain Stem Injury (PBSI)

CT
DAI CC SGMI PBSI
20% 50% 5% <5%

Pathology
>50% >50% 5-10% 5-10%

Primary Neuronal; DAI


Acceleration/deceleration and rotational injury = shear stress at corticomedullary interfaces

Severe impaired conscious level common Survivors severely disabled Small lesions (mm)

DAI
Common Sites
Gray/white matter interface- frontotemporal lobe Corpus callosum /deep gray matter Brainstem- Dorsolateral midbrain

Imaging

CT poor MRI for prognostic assessment

DAI

CT Brain

Right INO Post Closed Head Injury

Primary Neuronal; Cerebral Contusion


Commonly normal / minimal impaired conscious level Maximum at Day 5 Larger than DAI (cm)

Cerebral Contusion
Common Sites
Frontal and temporal Usually inferolateral

Imaging
CT : poor for skull base and cerebellum MRI : rarely used in practice

Cerebral Contusions

Primary Injuries
Neuronal Haemorrhagic Vascular

Primary Haemorrhagic
Extradural (EDH) Subdural (SDH) Intracerebral (ICH) Intraventricular (IVH) Subarachnoid (SAH)

IMAGING of PRIMARY HAEMORRAGE CT almost exclusively in UK However MRI more accurate, especially
Venous EDH Small convexity and inferior SDH

Primary Haemorrhage Extradural Haematoma


Inner skull table/ outer dura (periosteum) Arterial Venous

Extra Dural Haematoma:

Primary Haemorrhage Subdural Haematoma


Dura/ subarachnoid membrane Venous Acute/ Subacute/ Chronic Acute Traumatic vs Minor Injury

SDH

Primary Injuries
Neuronal Haemorrhagic Vascular

Primary Vascular
Vessel Dissection Vessel Occlusion Vessel Laceration

Primary Vascular Vessel Dissection


Severe trauma with skull base fracture has highest incidence But can occur with trivial trauma

36yo drooping right eye neck pain after recent roller coaster ride

Primary Vascular Vessel Laceration

Secondary Injuries
Oedema Brain herniation Vascular occlusion Diffuse hypoxic injury

Secondary Injury Oedema

10% florid 5% isolated

Oedema

Isolated oedema

Secondary Injuries
Oedema Brain herniation Vascular occlusion Diffuse hypoxic injury

Secondary Injury Brain Herniation


Subfalcine Midline Shift Transtentorial Tonsillar

Herniation

Herniation

Secondary Injuries
Oedema Brain herniation Vascular occlusion Diffuse hypoxic injury

Secondary Injury Vessel Occlusion


Secondary to Dissection Secondary to Venous Thrombosis

Appearance of haemorrhage on MRI


Acute

Appearance of haemorrhage on MRI


Hyperacute

Spinal Injury

Cervical Spinal Injury

Cervical Spinal Injury

Cervical Spinal Injury

Thoracic spine

Thoracic Spine

Lumbar Spinal Injury

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Thank you