jurding radiologi
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IMAGING of the POST-
OPERATIVE CRANIUM
Supervisor: dr. Yanto Budiman,
Sp.Rad, M.Kes
Audrey G. Sinclair, MBBCh, MRCP, FRCR Daniel J. Scoffings, MBBS,MRCP, FRCR
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Introduction
Imagingroutine post op neurosurgery fol-up
CT1st line imaging to evaluate complications
Fast, cost effective, easily accessible.
MRI
Higher sensitivity for detecting post-op infection &
ischemia
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Discuss:
The surgical techniques
N post-op imaging appearances of burr holes,
craniotomy, craniectomy, cranioplasty
Describe the appearances of post-op
complications
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Normal anatomy
Scalp AP-ly from the supraorbital ridge to
the sup nuchal line, lat-ly to the
zygomatic arch & EAM.
5 layers (skin, SC, galea
aponeurotica, loose areolar connective
tissue, pericranium)
3 primary muscle groups (frontalis,
occipitalis, temporalis)
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Galea aponeurotica
A layer of thick fibrous tissue
Cont w/ the occipitofrontalis & auricularis
muscles.
Temporalis muscle arises from the temporal fossa
pericranium & lies deep to the temporalis fascia,continuous w/ the galea superiorly.
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Subgaleal spaceeasily dissected, allows
fluid to accumulate & spread across thecranium.
Pericranium : Adheres to the margins of the underlying skull
bones at the suture lines.
Isntusually visible as a separate structure unless
an underlying hematoma is present.
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Duramater :
Tough 2-layered membrane.
Outer layerby the periost of the inner table of
the calvaria
Inner layerthe duramater proper
Lacks a BBBenhances after IV contrast inj(most prominent in the segments over the
convexities)
Arachnoid & piamater arent normally visible at
imaging.
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Burr Holes
Small hole
Created in the calvaria with a surgical drill
To insert a device (eg, a ventricular drain/shunt
catheter, endoscope, ICP monitoring devic/deepbrain stimulator electrode)
Provide access for stereotactic brain biopsy
To drain a chronic subdural hematoma
A prelude to the formation of a craniotomy flap
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Complications
Infection, skull #, hemorrhage.
Plunge the drill into the cranium, breach theduramater & cause ICH.
T2W MRI, a defect caused by plungingarea of
high-signal-intensity edema underlying the burrhole (mushroom sign).
Growing burr hole.
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CRANIOTOMY
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Indications and Techniques
Surgical removal
portion of skull
Bone flap replaced
end of procedure
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Normal Appearance
Artifactmetal
clips
Scalp swelling
Tram-track
discontinuity
Small extra-axial
fluid collection
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Normal PostOperative Enhancement
Neovascular
Granulation Tissue
1st year after surgery
Duramater40
year
Brain resection< 1
month
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Normal Pneumoenchepalus
Inevitable
Most often subdural,
frontal lobe
< 3 weeks
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Complication
Tension Pneumoenchepali
Most Often: posterior fosa
craniotomy
Peaking sign
Mount Fuji sign
Treatment : Conservativeatau surgical
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Complication
Soft Tissue Infection
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Complication
Bone Flap Infection
Manifestation : 1- 2
weeks after infection
Causes : Bakteri Gram +
(S.aureus)
CT : abnormal texture and
lytic area
MRI : > in T2
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POSTOPERATIVE HEMORRHAGE
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Postoperative Hemorrhage
1.1% of postcraniotomy intracranialhematomassurgical
In this studyhematomas intraparenchymal
43% , extradural 33%, subdural 5%, and mixed8%.
The frequency variestype of surgery
meningioma resection 6.2%7.1% Symptoms: focal neurologic deficit,
consciousness, seizure
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Extradural Hematomas
Occur between the outer periosteal layer ofthe dura mater and the inner skull.
Regional (62,5%) : occur just under the bone
flap Adjacent (31.3%): occur at the craniotomy
margins, most often posteriorly
Remote (6.3%) :occur distant from thecraniotomy site. Multiple remote hematomasmay be present
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Regional Adjacent
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Intraparenchymal Hemorrhage.
Post-op intracranial10,8%
Majority were small (5cm)poorer outcome
Causes :incomplete hemostasis in the surgical
bed, incomplete tumor resection, postoperative
hypertension, and bleeding diatheses.
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Remote Cerebellar Hemorrhage
Rare, usually benign, self-limiting complication
Most often occurs after supratentorial
craniotomy
Symptoms :consciousness, gait ataxia,
weakness
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Remote Cerebellar Hemorrhage
Streaky curvilinear areas of increased attenuation in
the cerebellar sulci and foliazebra sign
May be unilateral or bilateral
Most often involves the superior aspect of thecerebellum
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Craniectomy
Is a removal of a portion of the skull without
subsequent replacement of the bone
Remove an infected bone flap, tumor that has
infiltrated the calvaria, primary procedure to
decompress intracranial contents.
The bone flap from craniectomy is not
discardedmay be stored in an abdominal
subcutaneous pocket or frozen in a bone bank
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Craniectomy (normal appearance)
Normal postcraniectomy imaging appearancesdepend partly on what is done with the duramater.
Duramater open, the subarachnoid spaceherniate outward through the defectpseudomeningocele
In most patients, craniectomy obliterates the
subgaleal spacemeningogaleal complex(galea,subgaleal connective tissue, fibrosis, andduramater)
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CT scan: meningogaleal complexsingle
layer of smooth, curvilinear, slightly
hyperattenuating tissue that demonstrates
mild enhancement
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Complication
Extracranial Herniation
Defect too small the swollen brain may herniate
through the defect (27.8%)
Subdural and Subgaleal Hygromas
Disturbance of CSF circulation after craniectomy
subdural or subgaleal hygroma (21.3% -50%)
ipsilateral
Appear within days of surgeryresorb over a
period of weeks - months.
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CT scanlow-attenuation fluid collections
deep to the galea or in the subdural space
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External Brain Tamponade
Rarepotentially life-threatening
complicationpressurized subgaleal fluid
collection
Diagnostic criteriatense craniectomy flap,
neurologic, subgaleal fluid collection with
an associated mass effect on the underlying
brain, and neurologic after drainage of thefluid collection.
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CT scan : bulging skin flap seen with a
subgaleal fluid collection that compresses the
brain at the craniectomy site
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Trephine Syndrome
Manifests :headaches, seizures, dizziness, undue
fatiguability, mood changes, and, often, a sunken
appearance of the skin flap
CT and MR imaging show a depressed skin flap at thecraniectomy site and concave deformity of the
adjacent brain
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Paradoxical Herniation.
Large craniectomy defectCSF drainage CSF
pressureintracranial pressure cause subfalcine
and transtentorial herniation away from the craniectomy
defect and results in mesodiencephalic dysfunction
Paradoxical herniation is a neurosurgical emergency.
Urgent treatment : intracranial pressure, stop any CSF
leakage, and restore the continuity of the calvaria.
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Paradoxical Herniation.
CT scan : a sunken skin flap + herniation of the brain
away from the craniectomy defectmidline shift,
compression of the midbrain, and effacement of the
basal cisterns
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CRANIOPLASTY
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Indications
Surgical Repair of skull defect
Cosmesis, relieve discomfort, normal ICP,
Ideal : good contour, protector, osteogenic,
biocompatible, good imaging
Types : autologous, acrylic, titanium
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Autologous
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Autologous
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Autologous
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Acrylic
Resin methylmethacrylate (MMA) with(out)
prefabricated acrylic plate
Acrylic cranioplasties are radiolucent
MMA contain gas bubbles
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Signal Void
(arrowhead)
+ Less in weight
+ Easy to shape.
+ Less reaction..
+ Most used material!
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Titanium
Resists corrosion, nontoxic, no inflammatory reaction!
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Titanium
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Complications
Infection! Autologous 5,5-26%, Acrylic 5-20%,Titanium 2,6-16,6%
Th/ Remove the cranioplasty!
Fluid collections (sterile/empyema) may be insubgaleal, extradural, or subdural
Bone resorbtion (autologous)
Acrylic fracture
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Conclusions
1. Learn the normal brain CT & MR
2. Aware of the complications to prevent delay
of diagnosis & treatment
3. CT is fast, accessible and cost effective
4. MR is more sensitive and reliable
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