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Emergency Cranial Radiological Assessment

Emergency Cranial Radiological Assessment. The Society of Neurological Surgeons Bootcamp. Objectives. Identify basic intracranial structures Identify brain shift, intracranial hemorrhage, and skull fractures

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Emergency Cranial Radiological Assessment

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  1. Emergency Cranial Radiological Assessment The Society of Neurological Surgeons Bootcamp

  2. 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.

  3. CT Scan Bone Window Soft Tissue Window

  4. Foramen ovale Foramen spinosum Carotid canal Jugular fossa Mastoid air cells

  5. Sphenoid sinus Carotid canal

  6. Cisterns Suprasellar Interpeduncular Ambient

  7. Caudate Internal capsule Thalamus Choroid Plexus

  8. 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.

  9. Hematomas • Epidural Hematoma (EDH) • Subdural Hematomas (SDH) • Subarachnoid Hemorrhage (SAH) • Intracerebral Hemorrhage (ICH) • Intraventricular Hemorrhage (IVH)

  10. 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.

  11. 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

  12. 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.

  13. Subdural Hematoma: Clot age and CT Imaging Characteristics Acute Subacute Chronic

  14. 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

  15. Subarachnoid Hemorrhage

  16. Subarachnoid Hemorrhage: Pattern Recognition ACoA Aneurysm Perimesenchephalic syndrome Diffuse SAH

  17. 55 year old male, fell off ladder, no LOC, mild headache Traumatic SAH Repeat head CT stable, discharged next day with routine follow up

  18. Intracerebral Hemorrhage: Chronic Hypertension

  19. Intracerebral Hemorrhage • Hypertensive IPH • 50% in basal ganglia • 15% thalamus • 10-15% pons

  20. IPH, IVH, Acute Hydrocephalus

  21. Lobar Intracerebral Hemorrhage:

  22. Intraventricular Hemorrhage Frontal Horn Temporal Horn Lateral Ventricle FrontalThird Fourth Occipital Horns

  23. Intraventricular Hemorrhage Aneurysmal SAH w/ IVH HTN w/ IVH

  24. 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

  25. 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

  26. 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

  27. Acute Hydrocephalus 7 year old boy with posterior fossa tumor, drowsy, less responsive through the day EVD EVD placed, immediately better

  28. 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

  29. MCA Infarcts

  30. Infarct with a Midline Shift

  31. Cerebral Edema • Loss of Grey/White Differentiation • Cisternal Effacement • Midline Shift

  32. Cerebral Edema • Vasogenic: from brain tumor • BBB disrupted • Responds to steroids • Cytotoxic: from trauma • BBB closed • NO steroids

  33. Basal Cistern Effacement Normal Tight Swollen Brain

  34. 49 y/o male, MVA • GCS 3T with fixed/dilated pupils No improvement, pronounced brain dead 24 hours later

  35. Fractures • Linear • Depressed • Open Depressed • Basal Skull Fracture

  36. Depressed Skull Fracture

  37. Open Depressed Skull Fracture

  38. Open Depressed Skull Fracture s/p MVA

  39. Reconstruction

  40. Basilar Skull Fracture

  41. Basilar Skull Fracture of the Temporal Bone Seen on Bone Windows

  42. 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

  43. T1 Weighted Image of the Normal Brain

  44. T2 Weighted Image of the Normal Brain

  45. MRI: Views in different planes Axial Sagittal Coronal

  46. T1 Post Gadolinium Image of a Brain Tumor

  47. Diffuse Axonal Injury (DAI)

  48. Magnetic Resonance Imaging: Stroke • Diffusion Weighted Imaging: • Ischemia • Cytotoxic edema • Increase in signal as soon as 5-10 minutes after stroke onset Left: DWI Right: ADC map

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