Download - Emergency Cranial Radiological Assessment
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Emergency Cranial Radiological Assessment
The Society of Neurological SurgeonsBootcamp
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Objectives
• Identify basic intracranial structures
• Identify brain shift, intracranial hemorrhage, and skull fractures
• Be able to communicate accurately to the chief resident or attending the important findings that may impact clinical decision making and emergent patient management.
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CT Scan
Bone Window Soft Tissue Window
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Foramen spinosum
Foramen ovale
Carotid canal
Mastoid air cells
Jugular fossa
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Carotid canal
Sphenoid sinus
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Suprasellar
Interpeduncular
Ambient
Cisterns
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Thalamus
Internal capsule
Caudate
Choroid Plexus
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CT Scan
• Computerized Axial Tomography or CT scan is the most often used emergency imaging study in neurosurgery. A CT scan is an excellent study for identifying intracranial hemorrhage and skull fractures.
• Calcified structures such as bone or the pineal gland appear white or hyperdense.
• Acute blood clot appears white or hyperdense. Chronic hematomas appear dark or hypodense.
• Ischemic strokes are hard to identify on CT until they are about 6 – 12 hours old.
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Hematomas
• Epidural Hematoma (EDH)• Subdural Hematomas (SDH)• Subarachnoid Hemorrhage (SAH)• Intracerebral Hemorrhage (ICH)• Intraventricular Hemorrhage (IVH)
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Epidural Hematoma– Between the skull and the dura. – Biconvex or lens shaped.– More common in children and young adults.
Uncommon in the elderly since the dura is very adherent to the skull.
– Over 90% are associated with a skull fracture. Classically due to laceration of the middle meningeal artery.
– Initial concussion - “lucid interval” - deterioration– Treatment is usually emergent surgery.
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Case Example: 6 year old girl, MVA, GCS 7T, LOC at scene, lucid interval, now with lethargy and left side weakness
Taken to OR for emergent evacuation of EDH
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Acute SDH• More likely to be “crescent shaped” than
“lens shaped”.
• Often holohemispheric.
• Can extend along falx or tentorium.
• Does not cross the midline.
• Higher morbidity and mortality than EDH due to additional underlying brain injury.– 50-90% mortality.
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Subdural Hematoma: Clot age and CT Imaging Characteristics
Acute ChronicSubacute
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Chronic SDH• 50% without significant history of trauma
• Hypodense/isodense crescent shaped collection
• Evacuate if symptomatic
• Looks like motor oil
• Often occurs in the elderly on aspirin, plavix, or coumadin
• Can be treated by twist drill craniostomy, burr hole or craniotomy
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Subarachnoid Hemorrhage
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Subarachnoid Hemorrhage: Pattern Recognition
ACoA Aneurysm Perimesenchephalic syndrome
Diffuse SAH
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55 year old male, fell off ladder, no LOC, mild headache
Repeat head CT stable, discharged next day with routine follow up
Traumatic SAH
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Intracerebral Hemorrhage: Chronic Hypertension
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Intracerebral Hemorrhage
• Hypertensive IPH – 50% in basal ganglia – 15% thalamus
– 10-15% pons
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IPH, IVH, Acute Hydrocephalus
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Lobar Intracerebral Hemorrhage:
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Intraventricular HemorrhageFrontal Horn Temporal Horn Lateral Ventricle
FrontalThirdFourth
Occipital Horns
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Intraventricular HemorrhageAneurysmal SAH w/ IVH HTN w/ IVH
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Traumatic Contusions
• Coup or contra-coup contusion
• Hemorrhagic contusions can enlarge or “blossom” as well as develop extreme edema, so must follow examination closely and consider repeat CT scans
• Surgical evacuation if there is excessive mass effect
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47 year old gentleman, was inebriated, fall, LOC, GCS 7T (E2, M4, V1T), PERRL, In cervical collar
EVD placed, Medical management of ICP, gradually improved over several days, neck cleared after extubation and improvement in neuro status
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18 year old male, shot in head while sitting in car, GCS 15 with no focal deficits, open scalp wound over skull fracture
Scalp debrided, bullet fragment extracted, wound closed
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7 year old boy with posterior fossa tumor, drowsy, less responsive through the day
EVD placed, immediately better
Acute Hydrocephalus
EVD
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Ischemic Stroke
• Typically follow a vascular distribution such as the territory of the MCA, PCA or ACA.
• A stroke may take several hours before it is apparent on a CT scan.
• Typically is seen earlier on an MRI
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MCA Infarcts
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Infarct with a Midline Shift
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Cerebral Edema
• Loss of Grey/White Differentiation
• Cisternal Effacement
• Midline Shift
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Cerebral Edema
• Vasogenic: from brain tumor– BBB disrupted– Responds to
steroids• Cytotoxic: from
trauma– BBB closed– NO steroids
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Basal Cistern Effacement
Normal Tight Swollen Brain
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49 y/o male, MVA GCS 3T with fixed/dilated pupils
No improvement, pronounced brain dead 24 hours later
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Fractures
• Linear
• Depressed
• Open Depressed
• Basal Skull Fracture
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Depressed Skull Fracture
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Open Depressed
Skull Fracture
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Open Depressed
Skull Fracture s/p
MVA
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Reconstruction
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Basilar Skull
Fracture
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Basilar Skull Fracture of the Temporal Bone Seen on Bone Windows
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Basic Principles of MR Imaging• Images are created based on signals returning from spinning
protons
• Not based on density
• Objects are described in terms of intensity (hypointense, isointense, hyperintense)
• T1 and T2 Weighted Imaging
• T1 Post Contrast Enhancement
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T1 Weighted Image of the Normal Brain
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T2 Weighted Image of the Normal Brain
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MRI: Views in different planes
Axial Sagittal Coronal
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T1 Post Gadolinium Image of a Brain Tumor
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Diffuse Axonal Injury (DAI)
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Magnetic Resonance Imaging: Stroke • Diffusion Weighted Imaging:
– Ischemia
– Cytotoxic edema
– Increase in signal as soon as 5-10 minutes after stroke onset
Left: DWIRight: ADC map