Neuroimaging

dr. Mashuri, Sp.Rad(K).,M.Kes

Department of Radiology
Faculty of Medicine
University of Lambung Mangkurat/
Ulin Hospital
Banjarmasin
 Classification of Brain Trauma
 Primary
• Injury to scalp, skull fracture
• Surface contusion/laceration
• Intracranial hematoma
• Diffuse axonal injury, diffuse vascular injury
 Secondary
• Hypoxia-ischemia, swelling/edema, raised intracranial
pressure
• Meningitis/abscess
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Primary Brain Injury – Cellular Level
Primary Cellular Injury
Oxygen Free Radical Lipid Peroxidation
Massive Depolarization of
Pathway Activation Cell Membrane Dysfunction
Brain Cells
Cell Lysis
“ Neurotransmitter Stor
m”

Glutamate
High Nitric Oxide Cell Death
Levels

Calcium Nitric Oxide

Synthase

NMDA Disruption of normal cellular processes:

Protein Phosphorylation Membrane and
Microtubule Construction Cytoskeleton Breakdown
Enzyme Production
Intracellular Signaling
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Processes Advanced Emergency Trauma Course
 Mechanisms of Injury
 Mechanisms of Injury
• Mediators of 1o and 2o Injury
 Skull Fractures
 Extra-axial Lesions
• Epidural Hematoma
• Subdural Hematoma
 Intraparenchymal Hemorrhage
 Subarachnoid Hemorrhage
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 Radiographic Evaluation
 CT
 Imaging study of choice for initial work-up
 MRI
 More helpful later in hospital course
 Skull x-rays
 Arteriography
 Skull xray
 The presence of a skull fracture increases the risk of
having a posttraumatic intracranial lesion.
 However, the absence of a skull fracture does not
exclude a brain injury, which is particularly true in
pediatric patients due to the capacity of the skull to
bend.
 NO ROLE FOR PLAIN FILMS IN ACUTE HEAD
TRAUMA
 SKULL FRACTURES
 “Depressed”: inner table is depressed by the thickness of
the skull.
 Overlie major venous sinus, motor cortex, middle
meningeal artery
 Pass through sinuses
 Look for sutural diastasis (lambdoid)
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 CT/MRI
 CT without contrast is the modality of choice
in acute trauma (fast, available, sensitive to
acute subarachnoid hemorrhage and skull
fractures)
 MRI is useful in non-acute head trauma
(higher sensitivity than CT for cortical
contusions, diffuse axonal injury, posterior
fossa abnormalities)
Scalp Injury
 Scalp injury
 Cephalohematoma: blood between the bone and
periosteum. Cannot cross the suture lines.
 Subgaleal hematoma: blood between the periosteum
and aponeurosis. Can cross the suture lines.
 Caput Succ: swelling across the midline with scalp
moulding. Resolves spontaneously.
 Extraaxial fluid collections
 Subarachnoid hemorrhage(SAH)
 Subdural hematoma(SDH)
 Epidural hematoma
 Subdural hygroma
 Intraventricular hemorrhage
Subarachnoid hemorrage
 Basal cisterns

Cerebellopontine
Cerebellomedullary Pontine
angle
(Cisterna Magna)
 Basal cisterns

Suprasellar Interpeduncular Quadrigeminal

Ambient
 Subdural Hematoma (SDH)
 Due to disruption of
the bridging cortical
veins
 Hypodense(hyperacute
, chronic),
isodense(subacute),
hyperdense(acute)
W=33 L=41
 Epidural hematoma (EDH)
 Due to laceration of the
middle meningeal
artery or dural veins
Intraventricular hemorrhage
 Intraaxial injury
 Surface contusion/laceration
 Intraparenchymal hematoma
 White matter shearing injury/diffuse axonal
injury
 Post-traumatic infarction
 Brainstem injury
Cerebral hemorrhagic contusion

small petechial foci of hyperdensity/hemorrhages

involving the grey matter and subcortical white
matter or large cortical/subcortical bleed. 
 DAI
 Grade 1: axonal damage in WM only -67%
 Grade 2: WM + corpus callosum (posterior >
anterior) – 21%
 Grade 3: WM + CC + brainstem
 DAI
 Hours:
• hemorrhages and tissue tears
• Axonal swellings
• Axonal bulbs
 Days/weeks: clusters of microglia and
macrophages, astrocytosis
 Months/years: Wallerian degeneration
 Brainstem Injury
 By direct or indirect forces
 Most commonly associated with DAI
 Involves the dorsolateral midbrain and upper pons
and is usually hemorrhagic
 Duret hemorrhage is an example of indirect damage:
tearing of the pontine perforators leading to
hemorrhage in the setting transtentorial herniation
 <20% of brainstem lesions are seen on CT
18 biker hit by a car
Brain Herniations
 SUBFALCIAL HERNIATION
 Subfalcial: displacement
of the cingulate gyrus
under the free edge of
the falx along with the
pericallosal arteries.
 Can lead to anterior
cerebral artery infarction
 UNCAL HERNIATION
 Displacement of the medial temporal lobe through
the tentorial notch
 Displacement of the midbrain
 Effacement of the suprasellar cistern
 Displacement of the contralateral cerebral
peduncle against the tentorium
 Widening of the ipsilateral cerebello pontine angle
 Compression of the posterior cerebral artery
 TONSILLAR HERNIATION
 Inferior displacement of the cerebellar tonsils
through the foramen magnum
 Can lead to posterior cerebellar artery
infarction
 EXTERNAL HERNIATION
 Due to a defect in the skull in
combination with elevated ICP
 Venous obstruction can occur at the
margins of the defect.
 POST TRAUMATIC
SEQUELAE
 Carotid-cavernous fistula(CCF)
 Dissection/pseudoaneurysm
 Infarction
 Atrophy/encephalomalacia
 Infection
 Leptomeningeal cyst
Thank you

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