Diagnosis and Etiology and Pathophysiology Diverse...
Transcript of Diagnosis and Etiology and Pathophysiology Diverse...
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Diagnosis and Diagnosis and Imaging of TBIImaging of TBI
James G. Smirniotopoulos, M.D.James G. Smirniotopoulos, M.D.Center for Neuroscience and Regenerative MedicineCenter for Neuroscience and Regenerative Medicine
Professor of Radiology, Neurology, and Biomedical InformaticsProfessor of Radiology, Neurology, and Biomedical InformaticsChair, Department of RadiologyChair, Department of Radiology
Uniformed Services UniversityUniformed Services UniversityBethesda, MDBethesda, MD
Traumatic Brain InjuryTraumatic Brain InjuryClinically heterogeneous populationClinically heterogeneous populationEtiology and Pathophysiology DiverseEtiology and Pathophysiology Diverse–– Closed InjuryClosed Injury
ConcussiveConcussiveBlast waveBlast wave
–– Penetrating InjuryPenetrating Injury
PathoanatomicPathoanatomic Assessment is ComplexAssessment is ComplexTemporal Evolution of LesionsTemporal Evolution of Lesions–– Changes over timeChanges over time
Epidemiology of TBIEpidemiology of TBIDuring 2002, the Centers for Disease During 2002, the Centers for Disease Control and Prevention (CDC) estimated Control and Prevention (CDC) estimated that more than that more than 50,000 Americans die 50,000 Americans die each year from traumatic brain injury each year from traumatic brain injury (TBI)(TBI) –– approximately oneapproximately one--third from third from motor vehicle accidents, 10% from falls, motor vehicle accidents, 10% from falls, and and 40% [20k] from penetrating wounds 40% [20k] from penetrating wounds caused by firearmscaused by firearms..
Adekoya N, Thurman DJ, White DD, Webb KW. Surveillance for Traumatic Brain Injury Deaths --- United States, 1989--1998.Morbidity and Mortality Weekly Report 51[SS10], 1-16. 2007.
Classification of TBIClassification of TBININDS NINDS ““Classification of TBI for Targeted TherapiesClassification of TBI for Targeted Therapies”” –– Oct 2007Oct 2007
Clinical (intake) Criteria Clinical (intake) Criteria –– GCS or ??GCS or ??PathoanatomicPathoanatomic ClassificationClassification–– Imaging and PathologyImaging and Pathology
Physical MechanismPhysical Mechanism–– Impact, Acceleration/DecelerationImpact, Acceleration/Deceleration–– Overpressure (Primary Blast Injury)Overpressure (Primary Blast Injury)
PathophysiologyPathophysiology–– Primary DamagePrimary Damage–– Secondary Insult (Secondary Insult (↓↓BP, BP, ↓↓ O2, O2, ↑↑pCO2, pCO2, ↑↑BP)BP)
Prognostic ModelingPrognostic Modeling
Problems with GCSProblems with GCSGCS 3 GCS 3 –– comatose to GCS 15 comatose to GCS 15 –– awakeawakeNOT a good predictor of cognitive NOT a good predictor of cognitive sequelaesequelae>80% of >80% of mTBImTBI or Concussion have or Concussion have GCS 13GCS 13--1515GCS is a poor discriminator GCS is a poor discriminator ≥≥1313GCS is a poor discriminator GCS is a poor discriminator ≤≤44
Six Patients w/ GCS < 6Six Patients w/ GCS < 6
Vasospasm
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PathoanatomicPathoanatomic TBITBI
Contusion
Diffuse Axonal Injury
SAH
Hematoma
Ball Bearing from IEDBall Bearing from IED
Ball Bearing from IEDBall Bearing from IED
Scalp hematoma, skull fracture, cortical contusion, surface fragment
IED: Penetrating InjuryIED: Penetrating Injury
Intracranial air, blood and metal fragments along wound track.
IED Penetrating Injury IED Penetrating Injury –– Brain SwellingBrain Swelling IED Penetrating Injury IED Penetrating Injury –– Brain SwellingBrain Swelling
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What is Blast TBI (What is Blast TBI (bTBIbTBI)?)?LOC, PTA, GCS probably NOT useful in LOC, PTA, GCS probably NOT useful in bTBIbTBIUnknown how they relate to Unknown how they relate to bTBIbTBIMost of these Most of these bTBIbTBI have associated have associated CxCxspine injuries.spine injuries.
Blast Related Axonal InjuryBlast Related Axonal Injury
Frontal WM Tracks Cerebellar WM Tracks
Case, after Case, after CaseCase, after Case, after CaseNormally, that would be a series Normally, that would be a series ……Often, it literally means three casesOften, it literally means three casesIn consideration of Primary Blast InjuryIn consideration of Primary Blast Injury–– It is the same case being shown by everyone, It is the same case being shown by everyone,
and shown everywhereand shown everywhere
Blast as Signature InjuryBlast as Signature Injury
Primary Blast
TBI Complications
• Hypotension
• Hypoxia
• Hemodilution
• Vasospasm
• Hyperemia
• Potentiation
TherapyBlast “Plus”
•Impact 2°
•Concussion 3°
UnderdiagnosisUnderdiagnosis of Blast TBIof Blast TBICivilian blast Civilian blast underdiagnosedunderdiagnosedCausesCauses–– Private dwelling(31), Industrial pressure(20), Private dwelling(31), Industrial pressure(20),
Industrial gas(16), Military Training(15), Industrial gas(16), Military Training(15), Home explosive(8), Fireworks(1)Home explosive(8), Fireworks(1)
Types of Types of bTBIbTBI–– Cerebral Contusion(13), SDH(8), DAI(4), Cerebral Contusion(13), SDH(8), DAI(4),
SAH(3),ICH(3),EDH(3),IVH(2)SAH(3),ICH(3),EDH(3),IVH(2)
Robust Imaging PortfolioRobust Imaging PortfolioCT CT -- Computed TomographyComputed TomographyMRI MRI –– Magnetic Resonance ImagingMagnetic Resonance Imaging–– DTI and DTI and TractographyTractography–– MRS MRS –– fMRIfMRI –– attention, memory, PTSDattention, memory, PTSD
NM NM -- Nuclear MedicineNuclear Medicine–– FDG PETFDG PET–– SPECT, New labeling agentsSPECT, New labeling agents
PathologyPathology–– Gross brain examinationGross brain examination–– HistologyHistology
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Five Easy PiecesFive Easy PiecesWho Needs Imaging?Who Needs Imaging?Skull, Scalp, and EpiduralSkull, Scalp, and Epidural–– Lucid Interval, Drain or notLucid Interval, Drain or not
SubduralSubdural–– Variable PresentationVariable Presentation–– Variable AppearanceVariable Appearance
ContusionContusion–– Coup vs. Coup vs. ContrecoupContrecoup
Shearing InjuryShearing Injury–– Deep LesionsDeep Lesions–– ComaComa
Traumatic Brain InjuryTraumatic Brain InjuryMotor deficitsMotor deficitsSeizureSeizureSensory deficitSensory deficitCoordinationCoordinationMemoryMemoryPersonalityPersonalityExecutive functioningExecutive functioning
Executive FunctionsExecutive FunctionsDefine a GoalDefine a GoalMake a PlanMake a PlanMeasure progress toward the GoalMeasure progress toward the GoalExampleExample–– Renew your driverRenew your driver’’s licenses license–– Bring flowers for MotherBring flowers for Mother’’s Days Day
Clinical Diagnosis of Head TraumaClinical Diagnosis of Head Trauma
Rising Blood PressureSlowing PulseSlowing RespirationsComa– Unconscious– UnresponsiveFundoscopic Examination – Dilated Pupil(s)– EOM’s ?
Cushing’s Triad
CNS TRAUMACNS TRAUMAImpactImpact–– CONTACT INJURYCONTACT INJURY–– Scalp/skull AbnormalScalp/skull Abnormal
InertialInertial–– NONNON--CONTACT INJURYCONTACT INJURY–– Acceleration/decelerationAcceleration/deceleration–– Scalp/skull NormalScalp/skull Normal
Types of InjuryTypes of InjuryPrimary Brain LesionsPrimary Brain Lesions–– Immediate Neurological EffectsImmediate Neurological Effects–– ContusionsContusions–– Shearing InjuryShearing Injury
Secondary Brain LesionsSecondary Brain Lesions–– Variable Delay in Symptoms and SignsVariable Delay in Symptoms and Signs–– Epidural, Subdural, Subarachnoid HemorrhageEpidural, Subdural, Subarachnoid Hemorrhage–– Mass Effect, Increased ICP, Brain HerniationMass Effect, Increased ICP, Brain Herniation–– Vasospasm, Hyperemic Swelling, Brain InfarctionVasospasm, Hyperemic Swelling, Brain Infarction
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Causes of Head TraumaCauses of Head TraumaMotor Vehicle AccidentsMotor Vehicle Accidents–– 50%50%Falls from a heightFalls from a height–– 20%20%AccidentalAccidentalNonNon--accidental (e.g. Child Abuse)accidental (e.g. Child Abuse)WorkplaceWorkplaceRecreationalRecreationalCombatCombat
TBI Educational ObjectivesTBI Educational ObjectivesWho needs brain imaging?Who needs brain imaging?What type of imaging is needed?What type of imaging is needed?Intraaxial Lesions Intraaxial Lesions »» Primary LesionsPrimary Lesions–– Contusion, Shearing InjuryContusion, Shearing Injury–– Immediate Neurological EffectsImmediate Neurological Effects
Extraaxial Lesions Extraaxial Lesions »» Secondary LesionsSecondary Lesions–– Epidural, Subdural, SubarachnoidEpidural, Subdural, Subarachnoid–– Delayed Neurological EffectsDelayed Neurological Effects
Indications for ImagingIndications for ImagingAcute Neurologic Deficit Acute Neurologic Deficit Observed L. O. C.Observed L. O. C.Persistent HA Persistent HA Severe Trauma Severe Trauma Obvious InjuryObvious Injury
Hydroplaning AccidentHydroplaning Accident9 passenger van9 passenger vanAll belted inAll belted in180 direction turn180 direction turn22--1/2 turn barrel rollover1/2 turn barrel rolloverNo one blacked outNo one blacked outEveryone walked awayEveryone walked awayShould we have been scanned?Should we have been scanned?
Minor Head Trauma:Minor Head Trauma:with Normal GCSwith Normal GCS
““CT can be safely limited to CT can be safely limited to those who have those who have …”…”–– HeadacheHeadache–– SeizuresSeizures–– VomitingVomiting–– Age > 60 yrsAge > 60 yrs–– Drug or Drug or EtOHEtOH intoxicationintoxication–– Physical trauma above claviclesPhysical trauma above clavicles
NEJM 2000;34: 100-1005
DxDx Sensitivity/SpecificitySensitivity/SpecificitymTBImTBI or Concussion may not be imagedor Concussion may not be imagedMost patients have only screening CTMost patients have only screening CT–– 85% 85% ““NormalNormal”” -- Insensitive test for Insensitive test for mTBImTBI
““Mild TBI or concussion with a normal GCS Mild TBI or concussion with a normal GCS …… CT CT …… lesions in less than 15% lesions in less than 15% …”…”–– NeurorehabilNeurorehabil Neural Repair 2008; 22: 217Neural Repair 2008; 22: 217--
227.227.
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Minor Head Trauma:Minor Head Trauma:with Normal GCSwith Normal GCS
““CT can be safely limited to CT can be safely limited to those who have those who have …”…”–– HeadacheHeadache–– SeizuresSeizures–– VomitingVomiting–– Age > 60 yrsAge > 60 yrs–– Drug or Drug or EtOHEtOH intoxicationintoxication–– Physical trauma above claviclesPhysical trauma above clavicles
NEJM 2000;34: 100-1005
We would like to add:
Post-traumatic amnesia > 30min
Anosmia
Ruptured Tympanic Membrane
Roller Coaster HeadacheRoller Coaster Headache
Roller Coasters can create 2.5 Roller Coasters can create 2.5 –– 3.5 G3.5 G’’ssGrandpa rides with Grandpa rides with GrandaughterGrandaughter–– SheShe’’s screaming with excitements screaming with excitement–– HeHe’’s subdued by a Subdural Hematomas subdued by a Subdural Hematoma
Reference:Reference:FukutakeFukutake T, Mine S, T, Mine S, YamakamiYamakami I, I, YamauraYamaura A, Hattori T. A, Hattori T. Roller coaster headache and subdural hematoma. Roller coaster headache and subdural hematoma. Neurology. 2000 Jan 11;54(1):264. Neurology. 2000 Jan 11;54(1):264. PMID: 10636168; UI: 20100123 PMID: 10636168; UI: 20100123
TBI Educational ObjectivesTBI Educational ObjectivesWho needs brain imaging?Who needs brain imaging?What type of imaging is needed?What type of imaging is needed?Intraaxial Lesions Intraaxial Lesions »» Primary LesionsPrimary Lesions–– Contusion, Shearing InjuryContusion, Shearing Injury–– Immediate Neurological EffectsImmediate Neurological Effects
Extraaxial Lesions Extraaxial Lesions »» Secondary LesionsSecondary Lesions–– Epidural, Subdural, SubarachnoidEpidural, Subdural, Subarachnoid–– Delayed Neurological EffectsDelayed Neurological Effects
Traumatic Brain InjuryTraumatic Brain InjuryNINDS NINDS ““Classification of TBI for Targeted TherapiesClassification of TBI for Targeted Therapies”” –– Oct 2007Oct 2007
Clinical (intake) Criteria Clinical (intake) Criteria –– GCS or ??GCS or ??PathoanatomicPathoanatomic ClassificationClassification–– Imaging and PathologyImaging and PathologyPhysical MechanismPhysical Mechanism–– Impact, Acceleration/DecelerationImpact, Acceleration/Deceleration–– Overpressure (Primary Blast Injury)Overpressure (Primary Blast Injury)
PathophysiologyPathophysiology–– Primary DamagePrimary Damage–– Secondary Insult (Secondary Insult (↓↓BP, BP, ↓↓ O2, O2, ↑↑pCO2, pCO2, ↑↑BP)BP)
Prognostic ModelingPrognostic Modeling
History of Imaging TBIHistory of Imaging TBIAutopsyAutopsySkull series plain filmsSkull series plain filmsAngiographyAngiography–– Gross mass lesions (EDH, SDH)Gross mass lesions (EDH, SDH)
Computed TomographyComputed Tomography–– EDH, SDH, Contusion, some DAIEDH, SDH, Contusion, some DAI
Conventional Spin Echo MRIConventional Spin Echo MRI–– More of the aboveMore of the above
GRE/MSI, DTI, MRS, GRE/MSI, DTI, MRS, fMRIfMRI–– Even moreEven more
1970s Pre1970s Pre--CTCTClinical EvaluationClinical Evaluation–– Clinical Examination of CNN 2Clinical Examination of CNN 2--1212–– Pupils evaluated for signs of herniationPupils evaluated for signs of herniation
Skull XSkull X--ray Seriesray SeriesAngiographyAngiography““Exploratory Burr HolesExploratory Burr Holes””
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Little bit of history Little bit of history ……
10 mm of pineal shift – subfalcial herniationCourtesy of Alice B. Smith and UCSF
Obvious InjuryObvious Injury
1980s1980sAll Level 1 Trauma Centers must have All Level 1 Trauma Centers must have 25X7 CT available25X7 CT availableHow do you triage patients?How do you triage patients?Who gets Who gets ““advancedadvanced”” neuroimagingneuroimaging??–– Obvious InjuriesObvious Injuries
Times Have ChangedTimes Have ChangedIn 1980 CT replaced Skull SeriesIn 1980 CT replaced Skull SeriesIn 2000 MRI complemented CTIn 2000 MRI complemented CT–– But did not replace CT as screening examBut did not replace CT as screening exam
In 2008? In 2008? ……–– MRI w/ DWI, GRE/SWI, DTI, MRSMRI w/ DWI, GRE/SWI, DTI, MRS–– fMRIfMRI w/ New paradigmsw/ New paradigms–– PET/SPECT, Biomarker ImagingPET/SPECT, Biomarker Imaging
Imaging of Head TraumaImaging of Head TraumaAutopsyAutopsyPlain RadiographsPlain RadiographsAngiographyAngiographyComputed TomographyComputed TomographySpin Echo MRISpin Echo MRIFLAIR, DWI, ADC mapsFLAIR, DWI, ADC mapsSusceptibility Imaging Susceptibility Imaging -- SWISWIDiffusion Tensor Imaging Diffusion Tensor Imaging -- DTIDTI
Newest
Oldest
Relative SensitivityRelative SensitivityMR Spectroscopy (global decreased NAA)MR Spectroscopy (global decreased NAA)Diffusion Tensor Imaging Diffusion Tensor Imaging –– (anisotropy)(anisotropy)Magnetic Susceptibility (SWI or GRE)Magnetic Susceptibility (SWI or GRE)Apparent Diffusion CoefficientApparent Diffusion CoefficientDiffusion Weighted ImagingDiffusion Weighted ImagingFLAIRFLAIRConventional SE MR (T2W > T1W)Conventional SE MR (T2W > T1W)
CT (ECT > NCT)CT (ECT > NCT)Skull RadiogramSkull Radiogram
Lower
Higher
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3 Reasons for Getting an MR3 Reasons for Getting an MR
CT fails to explain PtCT fails to explain Pt’’s Conditions Condition
CT fails to explain PtCT fails to explain Pt’’s Conditions Condition
CT fails to explain PtCT fails to explain Pt’’s Conditions Condition
Hospitalized patients need further evaluation with MR
Imaging of Head TraumaImaging of Head TraumaAutopsyAutopsyPlain RadiographsPlain RadiographsAngiographyAngiographyComputed TomographyComputed TomographySpin Echo MRISpin Echo MRIFLAIR, DWI, ADC mapsFLAIR, DWI, ADC mapsSusceptibility Imaging Susceptibility Imaging -- SWISWIDiffusion Tensor Imaging Diffusion Tensor Imaging -- DTIDTI
Thanks to Dr. Pam Schaefer, MGH
T2
DWI
SWI
Thanks to Dr. Pam Schaefer, MGH
MRI Techniques VaryMRI Techniques Vary HistoryHistory26 26 y/oy/o man transferred by airman transferred by air--evacevac after a after a helicopter crash. Upon arrival, patient was helicopter crash. Upon arrival, patient was intubatedintubated and sedated. CT of the head and sedated. CT of the head was performed as part of trauma was performed as part of trauma evaluation.evaluation.
26 26 y.oy.o. man in Coma. man in Coma Causes of ComaCauses of ComaPhysiologic/metabolic conditions:Physiologic/metabolic conditions:–– HypoxiaHypoxia–– HypotensionHypotension–– HypoglycemiaHypoglycemia–– Drugs and IntoxicantsDrugs and Intoxicants
Structural/anatomic lesions:Structural/anatomic lesions:–– Cerebral HemispheresCerebral Hemispheres–– ThalamusThalamus–– Reticular Activating System (brainstem)Reticular Activating System (brainstem)
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Causes of ComaCauses of Coma
ExpressiveCortex
AssociativeCortex
Receptive Cortex
Internal Reference Cortex
Thalamus
Reticular Activating
System
ArousalResponsiveness
Coma: Lesions and LocationsComa: Lesions and Locations
Subcortical Subcortical –– many neededmany neededWhite Matter White Matter –– many neededmany neededThalamus Thalamus –– few neededfew neededReticular Activating SystemReticular Activating System–– Dorsal BrainstemDorsal Brainstem–– Only one neededOnly one needed
Shearing Lesions are small (<15mm) and deep (subcortical, WM, Corpus callosum, Thalamus, Brain stem
26 26 y.oy.o. man in Coma. man in Coma
CT Scan MR Scan w/”blood sensitive” technique
Deep Lesions … including thalamus … “shearing injury”
… causing coma
FindingsFindingsNo Midline shiftNo Midline shiftNo explanation for GCS of 6No explanation for GCS of 6Possible Possible small hemorrhagesmall hemorrhage left occipital left occipital hornhorn–– Torn subependymal veins?Torn subependymal veins?–– Shearing Injury?Shearing Injury?
MR with a MR with a ““blood sensitiveblood sensitive”” sequencesequence–– Left occipital horn bloodLeft occipital horn blood–– Right thalamic bleedRight thalamic bleed–– Central corpus callosum bleedCentral corpus callosum bleed
Differential DiagnosisDifferential DiagnosisShearing InjuryShearing InjuryDiffuse Axonal InjuryDiffuse Axonal InjuryDiffuse White Matter InjuryDiffuse White Matter Injury
Traumatic HemorrhageTraumatic HemorrhageSubgalealSubgalealCephalohematomaCephalohematoma–– Subperiosteal Outer TableSubperiosteal Outer Table
Epidural (Extradural) Epidural (Extradural) –– Subperiosteal Inner TableSubperiosteal Inner Table
Subdural Subdural –– ‘‘EpiEpi--arachnoidarachnoid’’
SubarachnoidSubarachnoidParenchymal HemorrhageParenchymal HemorrhageIntraIntra--ventricularventricular
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TBI Educational ObjectivesTBI Educational ObjectivesWho needs brain imaging?Who needs brain imaging?What type of imaging is needed?What type of imaging is needed?Extraaxial Lesions Extraaxial Lesions »» Secondary LesionsSecondary Lesions–– Epidural, Subdural, SubarachnoidEpidural, Subdural, Subarachnoid–– Delayed Neurological EffectsDelayed Neurological Effects
Intraaxial Lesions Intraaxial Lesions »» Primary LesionsPrimary Lesions–– Contusion, Shearing InjuryContusion, Shearing Injury–– Immediate Neurological EffectsImmediate Neurological Effects
CENTRIPETAL APPROACHCENTRIPETAL APPROACH(outside to inside)(outside to inside)
––ScalpScalp––CalvariumCalvarium––EpiduralEpidural––SubduralSubdural––SubarachnoidSubarachnoid––IntraIntra--parenchymalparenchymal––IntraIntra--ventricularventricular
CNS TRAUMA CNS TRAUMA ---- SUBGALEALSUBGALEALBetween periosteum of OUTER table and Between periosteum of OUTER table and the GALEA (under scalp fat)the GALEA (under scalp fat)In CHILD, significant blood lossIn CHILD, significant blood lossSpontaneous decompression of Spontaneous decompression of intracranial (Epidural) hematomaintracranial (Epidural) hematoma
Subgaleal HematomaSubgaleal Hematoma
CENTRIPETAL APPROACHCENTRIPETAL APPROACH(outside to inside)(outside to inside)
––ScalpScalp––CalvariumCalvarium––EpiduralEpidural––SubduralSubdural––SubarachnoidSubarachnoid––IntraIntra--parenchymalparenchymal––IntraIntra--ventricularventricular
Skull FracturesSkull FracturesLinear Linear Stellate Stellate Depressed Depressed Basilar Basilar EggshellEggshell
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Linear Skull FxLinear Skull Fx
Density indicates overlapping bone – depressed skull fracture
Depressed Skull FxDepressed Skull Fx
Basilar Skull FractureBasilar Skull FractureRHINORRHEA (CSF) RHINORRHEA (CSF) OTORRHEA (CSF / OTORRHEA (CSF / HemotympanumHemotympanum) ) PNEUMOCEPHALUS PNEUMOCEPHALUS –– air in sulciair in sulci–– air and fluid/levels in sinuses air and fluid/levels in sinuses RACCOON EYESRACCOON EYES–– periorbitalperiorbital ecchymosesecchymosesBATTLE'S SIGNBATTLE'S SIGN–– RetroRetro--auricular ecchymosesauricular ecchymoses
BASILAR SKULL Fx:BASILAR SKULL Fx:CSF LEAKCSF LEAK–– InfectionInfection–– PneumocephalusPneumocephalusCNN. INJURYCNN. INJURY–– Deficit Acute or DelayedDeficit Acute or DelayedVASCULAR TRAUMA VASCULAR TRAUMA –– Laceration or dissection Laceration or dissection –– Occlusion & infarction Occlusion & infarction –– FISTULAE (CarotidFISTULAE (Carotid--Cavernous)Cavernous)
Traumatic Hemorrhage:Traumatic Hemorrhage:SubgalealSubgalealSubperiosteal Outer TableSubperiosteal Outer Table–– CephalohematomaCephalohematoma
Subperiosteal Inner TableSubperiosteal Inner Table–– Epi (Extra) DuralEpi (Extra) Dural
Subdural Subdural –– ‘‘EpiEpi--arachnoidarachnoid’’
Subarachnoid ***Subarachnoid ***Parenchymal HemorrhageParenchymal HemorrhageIntraIntra--ventricularventricular
Membrane Hematomas:Membrane Hematomas:
CephalohematomaCephalohematoma–– SubSub--periostealperiosteal, Outer Table , Outer Table
SkullSkullEpidural hematomaEpidural hematoma–– SubSub--periostealperiosteal, Inner Table , Inner Table
SkullSkullSubdural hematomaSubdural hematoma–– EpiEpi--arachnoidarachnoid
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Epidural SpaceEpidural Space
•Scalp & Skull
•Dura & Arachnoid
•Pia and Brain
•Ventricle and CSF
2 y.o. with dilated pupil2 y.o. with dilated pupil
Midline Herniation: Subfalcial and Downward Transtentorial
CNS TRAUMA EPIDURAL CNS TRAUMA EPIDURAL HEMATOMAHEMATOMA
Young Men (20Young Men (20--40's)40's)–– Head Trauma frequentHead Trauma frequent–– Also, dura (periosteum) more adherent in Also, dura (periosteum) more adherent in
older peopleolder people
Acute presentationAcute presentationSkull fracture (90%)Skull fracture (90%)BiBi--convex, hyperdenseconvex, hyperdense-- limited by sutureslimited by sutures
EPIDURAL HEMATOMAEPIDURAL HEMATOMASource of BleedingSource of Bleeding
MENINGEAL VESSELSMENINGEAL VESSELSArterial (high pressure)Arterial (high pressure)Venous (low pressure)Venous (low pressure)
DURAL SINUSDURAL SINUSHigh flow, low pressureHigh flow, low pressure
OTHEROTHERDiploic veins (Fx)Diploic veins (Fx)Marrow sinusoidsMarrow sinusoids
EPIDURAL HEMATOMAEPIDURAL HEMATOMASignificant traumaSignificant traumaFracture & concussion (l.o.c.)Fracture & concussion (l.o.c.)
Lucid IntervalLucid Interval––pt Wakes Uppt Wakes Up––40% pts.40% pts.Delayed neurologic Sx (hrs. Later)Delayed neurologic Sx (hrs. Later)Herniation, coma and deathHerniation, coma and death
EPIDURAL HEMATOMAEPIDURAL HEMATOMATrauma Trauma --> fracture & concussion> fracture & concussionTearing/stripping of both layers Tearing/stripping of both layers
from inner tablefrom inner tableLaceration of outer periosteal Laceration of outer periosteal
layerlayerLaceration of meningeal vesselsLaceration of meningeal vesselsInner (meningeal dura) intactInner (meningeal dura) intactBlood between naked bone and Blood between naked bone and
duraduraNORMAL arterial pressure NORMAL arterial pressure
continues to dissect continues to dissect periosteumperiosteum from bonefrom bone
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Epidural HematomaEpidural Hematoma
Fx Fx
t t
f
Brain Herniation SyndromesBrain Herniation Syndromes Epidural HematomaEpidural Hematoma
Epidural Hematoma Epidural Hematoma -- TreatmentTreatment
•Craniotomy
•Drain clot
•Repair the Artery!
Small EDH Small EDH –– Conservative TxConservative Tx
☺
Smile of the Quadrigeminal Cistern
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Progressive EDHProgressive EDH
8 PM10 AM
SUBPERIOSTEAL HEMATOMASUBPERIOSTEAL HEMATOMA–– CEPHALOHEMATOMACEPHALOHEMATOMA
–– (Birth trauma)(Birth trauma)–– (outer table, sub(outer table, sub--periosteal)periosteal)
–– EPIDURAL HEMATOMAEPIDURAL HEMATOMA–– (Inner table, "sub(Inner table, "sub--periosteal")periosteal")
CephalohematomaCephalohematomaBirth TraumaBirth Trauma Cephalohematoma Cephalohematoma -- CalcifiedCalcified
Membrane HematomaMembrane HematomaEpiduralEpidural–– AcuteAcute–– BiconvexBiconvex–– UnilateralUnilateral–– Skull fractureSkull fracture–– Limited by suturesLimited by sutures
SubduralSubdural–– Acute to ChronicAcute to Chronic–– Concave layerConcave layer–– BilateralBilateral–– Fracture +/Fracture +/--–– Cross suturesCross sutures
Traumatic Hemorrhage:Traumatic Hemorrhage:SubgalealSubgalealCephalohematomaCephalohematoma–– Subperiosteal Outer TableSubperiosteal Outer Table
Epidural (Extradural) Epidural (Extradural) –– Subperiosteal Inner TableSubperiosteal Inner Table
Subdural Subdural –– ‘‘EpiEpi--arachnoidarachnoid’’
SubarachnoidSubarachnoidParenchymal HemorrhageParenchymal HemorrhageIntraIntra--ventricularventricular
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Subdural HematomaSubdural Hematoma
•Scalp & Skull
•Dura
•Arachnoid
•Pia and Brain
•Ventricle and CSF
Complex Subdural Hematoma:Complex Subdural Hematoma:AdultAdult
1cm pineal shift, 3cm Right-to-Left shift and SubfalcialHerniation
Herniation: Herniation: SubfalcialSubfalcial and and TranstentorialTranstentorial
Left to Right Shift … Subfalcial herniation … Downward Transtentorial
SUBDURAL HEMATOMASUBDURAL HEMATOMAExtremes of ageExtremes of age
Infants/elderlyInfants/elderly
Subacute presentationSubacute presentationDays or weeks after traumaDays or weeks after trauma
Fracture not neededFracture not neededCrescenticCrescentic
Not hyperdenseNot hyperdenseCrosses sutures commonlyCrosses sutures commonlyInterhemispheric fissure (kids)Interhemispheric fissure (kids)
Epi Epi -- ArachnoidArachnoid
SUBDURAL HEMATOMA SUBDURAL HEMATOMA --Source of BloodSource of Blood
Laceration Of Cortical Laceration Of Cortical AaAa. and Vv.. and Vv.Direct: Penetrating InjuryDirect: Penetrating Injury
Large ContusionsLarge ContusionsDirect/indirect: "Pulped Brain"Direct/indirect: "Pulped Brain"
Torn Bridging (Cortical) VeinsTorn Bridging (Cortical) VeinsIndirectIndirectAccelerationAcceleration--decelerationdeceleration
SUBDURAL HEMATOMASUBDURAL HEMATOMA
AccelerationAcceleration--decelerationdecelerationSagittal PlaneSagittal Plane–– Causes Oscillation Of BrainCauses Oscillation Of Brain–– Brain LAGS Behind SkullBrain LAGS Behind Skull
Bridging Veins Stretch & TearBridging Veins Stretch & TearVenous Bleeding (Slow)Venous Bleeding (Slow)Multiple and Bilateral VeinsMultiple and Bilateral Veins
Dissection Of Subdural SpaceDissection Of Subdural Space–– Under Dura => Over ArachnoidUnder Dura => Over Arachnoid–– Spreads around convexitySpreads around convexity–– Into the interhemispheric fissure (child)Into the interhemispheric fissure (child)
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Bridging VeinsBridging Veins
Dural Baffles: Falx and TentoriumDural Baffles: Falx and Tentorium
C
MU
T T
t t
f
SDH SDH »» Brain HerniationBrain Herniation
BS
SDH SDH »» Brain HerniationBrain Herniation PCA Infarct Tentorial HerniationPCA Infarct Tentorial Herniation
Courtesy Mauricio Castillo, M.D. UNC
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Acute Subdural Hematoma:Acute Subdural Hematoma:Child, High AttenuationChild, High Attenuation
Subdural Hematoma StagesSubdural Hematoma Stages
Acute Subacute Chronic< 3 days 3d – 2 wks > 2 wks
Normal Brain Density
⇑
⇓
Hyperdense
Isodense to Brain
Hypodense
Complex Subdural HematomaComplex Subdural Hematoma
Mixed SubacuteMixed Subacute--acuteacuteSubdural HematomaSubdural Hematoma
Acute bloodAcute blood--brightbrightAlternating bandsAlternating bands–– rebleedingrebleeding
Mass effectMass effect–– Subfalcial herniationSubfalcial herniation–– ““TrappedTrapped”” ventricleventricle
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Child Abuse?Child Abuse? Child AbuseChild AbuseThe The ““Multiple SclerosisMultiple Sclerosis”” of trauma:of trauma:–– Lesions separated in spaceLesions separated in space–– Lesions separated in timeLesions separated in time
Ophthalmoscope Exam RequiredOphthalmoscope Exam Required–– Retinal hemorrhage highly correlated with Retinal hemorrhage highly correlated with
nonnon--accidental traumaaccidental trauma
Skeletal survey? Skeletal survey?
Arachnoid MembraneArachnoid Membrane SUBDURAL HEMATOMASUBDURAL HEMATOMASource of ReSource of Re--bleedingbleeding
NEONEO--MEMBRANESMEMBRANES–– fragile capillariesfragile capillaries
BRIDGING VEINSBRIDGING VEINS–– stretching across SDH stretching across SDH –– constant tensionconstant tension
SUBDURAL HEMATOMASUBDURAL HEMATOMA22--3 wks. to develop fully3 wks. to develop fullydevelop from outer (dural) margin develop from outer (dural) margin not from arachnoid sidenot from arachnoid side–– inner (arachnoid) border intactinner (arachnoid) border intact
fibroblasts, and new immature capillaries fibroblasts, and new immature capillaries that are fragilethat are fragile
Membrane HematomaMembrane HematomaEpiduralEpidural–– AcuteAcute–– BiconvexBiconvex–– UnilateralUnilateral–– Skull fractureSkull fracture–– Limited by suturesLimited by sutures
SubduralSubdural–– Acute to ChronicAcute to Chronic–– Concave layerConcave layer–– BilateralBilateral–– Fracture +/Fracture +/--–– Cross suturesCross sutures
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TBI Educational ObjectivesTBI Educational ObjectivesWho needs brain imaging?Who needs brain imaging?What type of imaging is needed?What type of imaging is needed?Extraaxial Lesions Extraaxial Lesions »» Secondary LesionsSecondary Lesions–– Epidural, Subdural, SubarachnoidEpidural, Subdural, Subarachnoid–– Delayed Neurological EffectsDelayed Neurological Effects
Intraaxial Lesions Intraaxial Lesions »» Primary LesionsPrimary Lesions–– Contusion, Shearing InjuryContusion, Shearing Injury–– Immediate Neurological EffectsImmediate Neurological Effects
CEREBRAL CONTUSIONCEREBRAL CONTUSIONTraumatic/mechanical disruption of small Traumatic/mechanical disruption of small (capillary) vessels(capillary) vesselsExtravasation of whole blood, plasma Extravasation of whole blood, plasma (edema) and RBC's(edema) and RBC'sAdmixture of blood mixed with native Admixture of blood mixed with native tissue (petechial hemorrhage)tissue (petechial hemorrhage)Mottled / speckled density ("salt and Mottled / speckled density ("salt and pepper" on CT)pepper" on CT)
CEREBRAL CONTUSIONCEREBRAL CONTUSION
MECHANICAL INJURY TO VESSELSMECHANICAL INJURY TO VESSELSExtravasation of whole bloodExtravasation of whole blood
PETECHIAL / PERIVASCULAR HEMORRHAGEPETECHIAL / PERIVASCULAR HEMORRHAGEAdmixture of tissue and bloodAdmixture of tissue and bloodaverage density may NOT be highaverage density may NOT be high
SWELLING/MASS EFFECTSWELLING/MASS EFFECTMAY PROGRESS TO HEMATOMAMAY PROGRESS TO HEMATOMA
If larger vessels are damagedIf larger vessels are damagedlarge confluent mass of bloodlarge confluent mass of blood
Courtesy of Alice B. Smith, UCSF
Massive ContusionsMassive Contusions
CEREBRAL CONTUSIONCEREBRAL CONTUSIONnaming conventionsnaming conventions
COUPCOUP–– SAME SIDE AS IMPACTSAME SIDE AS IMPACT–– w/fractures, small area of impactw/fractures, small area of impact
INTERMEDIATE (CENTRAL)INTERMEDIATE (CENTRAL)–– DAI/Shearing InjuryDAI/Shearing Injury
CONTRE CONTRE -- COUPCOUP–– OPPOSITE IMPACTOPPOSITE IMPACT–– w/falls, broad surface of impactw/falls, broad surface of impact
Coup vs. ContrecoupCoup vs. Contrecoup
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Coup vs. ContrecoupCoup vs. Contrecoup ContreContre--Coup ContusionCoup Contusion
ContusionContusion ContusionContusion
ContusionContusion
Cranial nerves 2-12 intact … but the patient smells badly, not bad, but badly … Anosmia
ContusionContusion
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••Crowns of GyriCrowns of Gyri
••Linear or flame shapeLinear or flame shape
••NOT in depths of SulciNOT in depths of Sulci
Cerebral Cortical ContusionCerebral Cortical Contusion Cerebral Fx ContusionCerebral Fx Contusion
Acute vs. Chronic ContusionAcute vs. Chronic Contusion TBI Educational ObjectivesTBI Educational ObjectivesWho needs brain imaging?Who needs brain imaging?What type of imaging is needed?What type of imaging is needed?Extraaxial Lesions Extraaxial Lesions »» Secondary LesionsSecondary Lesions–– Epidural, Subdural, SubarachnoidEpidural, Subdural, Subarachnoid–– Delayed Neurological EffectsDelayed Neurological Effects
Intraaxial Lesions Intraaxial Lesions »» Primary LesionsPrimary Lesions–– Contusion, Contusion, Shearing InjuryShearing Injury–– Immediate Neurological EffectsImmediate Neurological Effects
SHEARING INJURIESSHEARING INJURIESDeep lesionsDeep lesionsHigh Velocity (MVA) TraumaHigh Velocity (MVA) TraumaAcceleration/DecelerationAcceleration/Deceleration–– Especially Especially CORONAL angular momentumCORONAL angular momentum–– Side Impact (Running a Red Light)Side Impact (Running a Red Light)
Do not require an impact or Fx.Do not require an impact or Fx.““SHEARING OF AXONSSHEARING OF AXONS””–– Breaks connectionsBreaks connections–– Actual force may be tension & Actual force may be tension & excitoexcito--toxicitytoxicity
““SHEARINGSHEARING”” of Small WM VESSELSof Small WM VESSELSSmall (petechial) hemorrhagesSmall (petechial) hemorrhages
Coronal Angular AccelerationCoronal Angular AccelerationSubcorticalSubcortical –– many neededmany neededWhite Matter White Matter –– many neededmany neededThalamus Thalamus –– few neededfew neededReticular Activating SystemReticular Activating System–– Dorsal BrainstemDorsal Brainstem–– Only one neededOnly one needed
Shearing Lesions are small (<15mm) and deep (subcortical, WM, Corpus callosum, Thalamus, Brain stem
Coma: Lesions and LocationsComa: Lesions and Locations
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Deep Lesions Deep Lesions -- TerminologyTerminology
Intermediate ContusionsIntermediate ContusionsShearing InjuryShearing InjuryDiffuse WhiteDiffuse White--matter Injury (DWI)matter Injury (DWI)Diffuse Axonal Injury (DAI)Diffuse Axonal Injury (DAI)
5 MPH for Pedestrian5 MPH for Pedestrian--AutoAutoAuto weighs 2500 Auto weighs 2500 –– 4000 lbs4000 lbsOne auto hits another autoOne auto hits another auto–– Significant acceleration at 35 mphSignificant acceleration at 35 mph
Auto hits a Pedestrian (60Auto hits a Pedestrian (60--260 lbs)260 lbs)–– Significant acceleration at 5 mphSignificant acceleration at 5 mph
DWI/DAI = Deep LesionsDWI/DAI = Deep Lesions<15mm diameter<15mm diameter and and BELOWBELOW cortexcortexSubcortical and Hemispheric WMSubcortical and Hemispheric WMCorpus CallosumCorpus Callosum–– posterior bodyposterior body–– spleniumspleniumBrain stemBrain stem–– Dorsolateral Quadrant of Upper BSDorsolateral Quadrant of Upper BS–– Deep BSDeep BS–– Ventral BSVentral BS
DIFFUSE AXONAL INJURYDIFFUSE AXONAL INJURY–– Neurologic Sx Begin at ImpactNeurologic Sx Begin at Impact–– Some have Immediate L.O.C.Some have Immediate L.O.C.–– Some have Persistent Vegetative StateSome have Persistent Vegetative State–– Pathology:Pathology:
–– foci of hemorrhage in callosum, brainstem, etc.foci of hemorrhage in callosum, brainstem, etc.–– axon retraction balls (ARB)axon retraction balls (ARB)
–– LongLong--Term Survivors:Term Survivors:–– microglial clustersmicroglial clusters–– foci of demyelinationfoci of demyelination
Deep Lesions Deep Lesions –– Coronal ForcesCoronal Forces
Angular momentum in the Coronal Plane:
Running a Red Light … T-Bone the cars
WM WM –– Axonal Axonal TransectionTransection
Axon Retraction Balls – Cytoplasm leaking from transected axons and disrupted axolemma.
DTI - Diffusion Tensor Imaging:Detects loss of anisotropy in areas where axons are disrupted and disconnected.
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DAI or DWIDAI or DWINon limited to White MatterNon limited to White Matter–– Basal Ganglia and ThalamusBasal Ganglia and Thalamus
Some patients in Some patients in ““ComaComa””–– Different types of Different types of ““ComaComa””
Global lesionsGlobal lesionsSmall focal lesions (e.g. Reticular formation)Small focal lesions (e.g. Reticular formation)
Some patients have only subtle changes Some patients have only subtle changes on specialized psychometric testson specialized psychometric tests
Mouse – no
Rat – no
Cat – no
Monkey – no
Chimpanzee – no
Great Ape – yes
Politician - no
Experimental Model:Experimental Model:Requires Hemisphere >> BrainstemRequires Hemisphere >> Brainstem
University of Wisconsin and Michigan State Comparative Mammalian Brain Collections
Dorsolateral BrainstemDorsolateral Brainstem Corpus CallosumCorpus Callosum
Dense, compact, white matter, bundles of axons
Corpus Callosum Corpus Callosum --> Ventricle> Ventricle Corpus Callosum and BGCorpus Callosum and BG
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LetLet’’s Catchs Catch--up with our Pt up with our Pt ……26 26 y/oy/o man transferred by airman transferred by air--evacevac after a after a helicopter crash. Upon arrival, patient was helicopter crash. Upon arrival, patient was intubatedintubated and sedated. CT of the head and sedated. CT of the head was performed as part of trauma was performed as part of trauma evaluation.evaluation.
26 26 y.oy.o. man in Coma. man in Coma
CT Scan MR Scan w/”blood sensitive” technique
Deep Lesions … including thalamus … “shearing injury”
… causing coma
Corpus CallosumCorpus Callosum
T2W SWI
Deep Lesions … including thalamus … “shearing injury”
… causing coma
Diffuse Axonal Injury Diffuse Axonal Injury -- SWISWI
Thanks to Pam Schaefer
MSIDWI ADCFLAIR
Diffuse WhiteDiffuse White--Matter InjuryMatter Injury
Thanks to Pam Schaefer, MGH
Shearing Injury vs. ContusionShearing Injury vs. Contusion
Contusions are surface lesions