Imaginga(ertrauma-cbraininjury

JYGauvrit,LRiffaudRadiology&Neurosurgerydepartment,Rennes

Hanoi,Nov2015

Trauma-cBrainInjury(TBI)inFrance

•  200000TBI/year

•  12000deaths/year

•  5‰among15-25year-olds

•  50%deathsamong<25-year-olds

•  Causesasmanydisabili-esasstroke

Objec-ves

•  Understandingtheindica-onsforcerebralimaginga(ercranio-encephalictrauma

•  Understandingtheprimarylesionsandsecondarycomplica-onsofcranio-encephalictrauma

•  Understandingpost-trauma-cvascularlesions•  Facialfracturesandcomplica-ons

InjurymechanismsScalp

Bone

Meninges

Brain

Wounds

Fractures,Depressedskullfractures

ExtraduralhematomasSubduralhematomas

Hemorrhages

ContusionsEdema

Thebump

•  SubgalealHematoma

GalealAponeurosis

Scalp

SkullFracture

•  CT•  Tellsastory•  Uptoskullvertex•  Bones– Laminaexterna(externaltable)– Diploë– Laminainterna(internaltable)

SkullFracture

SkullFracture

3DVolumeRenderingReconstruc-ons

SkullFracture

openskullfracture=sepsisrisk=surgeryinemergency

Surgicalemergency=Majordisplacement-hernia-on-skinopening

SkullFracture

Epidural-extraduralhematoma•  Betweenthelaminainternaandduramater•  Arterial(mayinvolvesinusbutnotbonesuturelines)•  Venous(lacera-onofdiploicveinsandduralsinus)Middlecranialfossa•  TBIwithlossofconsciousness•  Lucidinterval•  Secondaryclinicalsigns

•  Riskfactors:youngage,directimpactonfragileareas(temporalandoccipital)BenignAnteriorTemporalEpiduralHematoma:IndolentLesionwithaCharacteris<cCTImagingAppearancea=erBluntHeadTrauma

AlisaD.Gean,MD,,NancyJ.Fischbein,MD,,DerkD.Purcell,MD,,AshleyH.Aiken,MD,GeoffreyT.Manley,MD,PhD,andShirleyI.S<ver,MD,PhD,

Epidural-extraduralhematoma

CT=Biconvexhyperdense"lens"

monstrous bilateral plane

minimal Infra-tentorial supra-tentorial

Epidural-extraduralhematoma

Uptoskullvertex

Subduralhematoma

•  Betweencerebralconvexityandinnersurfaceoftheduramater

•  Veintearordetachmentfromthebrainsurface(concussion)

Cor-coduralveinstornbridgingfromtheirfixedpointsoutintothesubduralspace

Subduralhematoma

•  Involvesthebonesuturelinesbutnotthesinuses

•  Acutesubduralhematoma(SDH)displayshighestmortalityrateofallheadinjuries

Subduralhematoma

Acuteinter-hemisphericsubduralhematoma

Extremelylargeacutesubduralhematomawithsignificantmasseffect

EDH SDH

Loca-on Facingthetraumaimpact Directimpactordecelera-on/accelera-on

Shape Biconvexhyperdense"lens" Hyperdensecrescentblade

Extension Involvesthefalxcerebriandtentoriumbutnotthesuturelines

Crossesthesuturelinesbutnotthetentoriumorfalx

Origin 90%arterial 90%venous

Side Unilateral Unilateralorbilateral

Associatedinjury 90%:cranialvaultfractures 70%:intra-axialinjury(contusions)

Evolu-onin-me Lucidintervalsin50%ofcases Immediatelypresent

Other Swirledappearance=ac-vebleedingIfpresenceofair:mastoidorsinusfracture

Inchildren:suspicionofabuse

Epidural/subduralhematoma

Subarachnoidhemorrhage

•  O(en"counter-blow"injurya(erdirectimpact•  Associatedwithparenchymalcontusions

Subarachnoidhemorrhage

CT MRIFLAIR

Cerebralcontusions•  "Blow"

•  "Counter-blow"++

•  Intypicalareaswherethebrainbouncesagainstaduralridgeorbonyprotrusion:–  Temporallobes–  Inferiorsurfaceoffrontallobes–  Lateralsulcus

Cerebralcontusions

•  Edema•  Hemorrhagicedema

•  Hemorrhage

Contusionsœdémateuses

CerebralContusions

CT MRIFLAIR

MRIT2*

Occipitallobeinjury

•  O(enseveretrauma•  Cranialimpactunprotected

byhandsorface•  Bifrontalcerebral"counter-

blow"injury(cogni-vedysfunc-on+++anosmia)

•  Risktobrainstemduetoshockwave

Cerebralcontusions

Diffuseaxonalinjury

•  Kine-c•  Decelera-on-accelera-on– Shearing

•  Grayandwhitemakerjunc-on– Cor-cal-subcor-cal– Basalganglia– Mesencephalic

•  SevereprognosisParizelPMetalEurRadiol2005;15:589-81NakayamaN,etalJneurolneurosurgPsychiatry2006;77:850-55

Diffuseaxonalinjury

•  CTscanunderes-matesso….MRI•  PerformMRIeach-methescanresultsandneurologicalworkup(GCS)areconflic-ng

•  Diffusion:acute•  SWI:subacute,chronic

•  CorpuscallosumParizelPMetalEurRadiol2005;15:589-81NakayamaN,etalJneurolneurosurgPsychiatry2006;77:850-55

CT

MRISWI

Diffuseaxonalinjury

MRISWI

MRIFLAIR

Hernia-on

•  Supratentorialhernia-ons1.  Cingulate(subfalcial)2.  Central3.  Uncal(innersidetemporallobe)4.  Transcalvarial

•  Infratentorialhernia-ons5.  Transtentorial:superiorcerebellumvermis5.  Tonsillar

Hernia-on

•  Transtentorialhernia-ons– Subarachnoidperimesencephalicspaces

•  Visible:safe•  Effaced:danger

Secondarycomplica-ons

•  Vascularinjury

•  Infec-ons

•  Hydrocephalus

Unfavorableoutcomes

Secondarycomplica-ons

•  Vascularcomplica-ons– Dissec-on– Venousthrombosis– Caro-d-cavernousfistula

Dissec-on

Denvercriteria•  Cervicalspine

fracture•  Centralneurologic

deficit,unexplainedwithCT

•  CBHsyndrome•  Naso-orbito-Ethmoid

fractures•  Skull-baseFracture•  Expandingneck

hematoma

Venousthrombosis

Caro-d-cavernousfistula

Anyheadtraumarepresentsapoten-altraumatothespine

WhattoRemember?•  Thebump•  Thefracturetellsastory•  EDH=mainlyarterial,butsome-mesvenous•  Uptoskullvertex•  ChronicSDH=highestmortalityrateofallencephalicinjuries

•  "Blow"and"counter-blow"injuries•  MRIwhenclinical(GCS)andCTdisagree•  Subarachnoidperimesencephalicspaces•  Secondarycomplica-ons=unfavorableprognosis•  Anyheadtraumarepresentspoten-altraumatothespine

EuropeanprojectTBI