Radiology of the Head and C-Spine
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HEAD AND CERVICAL SPINE- Emergency Radiologic Approach -
Ranieri Falcão AguiarRadiology Fellow
Radiology DepartmentSir Charles Gairdner Hospital
11-12-2014
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HEAD
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Fundamentals of Diagnostic Radiology, 3rd ed.
HEAD - INITIAL STUDIES
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What to look for?
• Fractures• Hemorrhage• Epidural hematoma• Subdural hematoma• Subarachnoid• Intraventricular• Intracerebral hematoma
• Cortical contusions• Diffuse axonal injury• Stroke
Fundamentals of Diagnostic Radiology, 3rd ed.
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Head ct - approach
1. Midline2. Symmetry3. Basal cisterns4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.
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Head ct - approach
1. Midline2. Symmetry
Fundamentals of Diagnostic Radiology, 3rd ed.
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Head ct - approach
1. Midline2. Symmetry3. Basal cisterns
Fundamentals of Diagnostic Radiology, 3rd ed.
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Head ct - approach
1. Midline2. Symmetry3. Basal cisterns
Fundamentals of Diagnostic Radiology, 3rd ed.
![Page 9: Radiology of the Head and C-Spine](https://reader034.fdocuments.net/reader034/viewer/2022052602/559eec291a28ab54438b4598/html5/thumbnails/9.jpg)
Head ct - approach
1. Midline2. Symmetry3. Basal cisterns4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.
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Head ct - approach
1. Midline2. Symmetry3. Basal cisterns4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.
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Head ct - approach
1. Midline2. Symmetry3. Basal cisterns4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.
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Head ct - approach
1. Midline2. Symmetry3. Basal cisterns4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.
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Head ct - approach
1. Midline2. Symmetry3. Basal cisterns4. Ventricles
EMERGENCY CT CHECKLIST1.Is the middle of the brain in the middle of the head?2.Do the two sides of the brain look alike?3.Can you see the smile and the pentagon or Jewish star?4.Is the fourth ventricle in the midline and roughly symmetrical?5.Are the lateral ventricles enlarged, with effaced sulci?
Fundamentals of Diagnostic Radiology, 3rd ed.
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fractures
Fundamentals of Diagnostic Radiology, 3rd ed.
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fractures
Fundamentals of Diagnostic Radiology, 3rd ed.
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Epidural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.
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Subdural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.
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Subdural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.
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Subdural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.
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Subdural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.
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Subarachnoid hemorrhage
Fundamentals of Diagnostic Radiology, 3rd ed.
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Diffuse axonal injury
Fundamentals of Diagnostic Radiology, 3rd ed.
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Cortical contusions
Fundamentals of Diagnostic Radiology, 3rd ed.
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STROKE
-NECT to exclude
hemorrhage/mass
-Look for:• Hyperdense vessel
• Loss of gray-white matter distinction
• Parenchymal hipodensity
• Gyral swelling + sulcal effacement
Pictures from Statdx.com © 2005-2014, Amirsys, Inc.
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CERVICAL SPINE
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Cervical spine - RADIOGRAPHS
STANDARD VIEWS•Lateral
•Antero-posterior
•Open mouth
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CERVICAL SPINE - ANATOMY
• SPECIFIC ANATOMY• C1• C2• SUBAXIAL
SPECIFIC FRACTURES
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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X-ray adequacy
Fundamentals of Diagnostic Radiology, 3rd ed.
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alignment
Fundamentals of Diagnostic Radiology, 3rd ed.
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Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006
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alignment
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ALIGNMENT
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ROTATED
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measures
Fundamentals of Diagnostic Radiology, 3rd ed.
> 3 mm highly suggestive of transverse ligament rupture = instability! 5 mm in children
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measures
Fundamentals of Diagnostic Radiology, 3rd ed.
ABOVE C4 < 1/3rd OF VERTEBRAL BODY
BELOW C4 < 1 VERTEBRAL BODY
*NOT SENSITIVE
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TEARDROP FRACTURE
A-Z of Emergency Radiology, 1st ed. 2004
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JEFFERSON’S FRACTURE
A-Z of Emergency Radiology, 1st ed. 2004
A B
A + B > 6,9 mm indicates transverse ligament tear = instability!
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HANGMAN’S FRACTURE
A-Z of Emergency Radiology, 1st ed. 2004
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LOCKED FACETS
A-Z of Emergency Radiology, 1st ed. 2004
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SHOULD I WORRY ABOUT VERTEBRAL ARTERIES?
1. Vertebral Artery Injury Associated With Blunt Cervical Spine Trauma. Spine. 2013 Jul;38(16):1352–61.
• Vertebral arteries injury (VAI)• 0,09% – 0,63% of cervical blunt trauma• Present in 19%-39% of all cervical spine fractures• Neurological deficits in 0-24%• Posterior stroke• Cortical blindness• Quadriplegia• Death
• Retrospective review of 1204 cervical spine injuries1
• 21% underwent screening for VAI (253 patients)• VAI in 17% (42 of 253)• 14% with neurological symptons (6 of 42)• 4,8% stroke-related mortality (2 of 42)
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SHOULD I WORRY ABOUT VERTEBRAL ARTERIES?• Existing screening indications (2013)
• Expanding neck haematoma• Penetrating trauma in the vicinity of the vertebral artery• Preoperative planning for complex cervical spinal surgery• Symptoms of vertebrobasilar ischemia
• High-Risk injuries1
• Basilar skull fracture• Extension to the transverse foramen with displacement > 1
mm• Facet subluxation/dislocation• Occipitocervical dissociation• Fracture + Ankylosing Spondylitis or DISH
1. Vertebral Artery Injury Associated With Blunt Cervical Spine Trauma. Spine. 2013 Jul;38(16):1352–61.
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C-spine
TO SUM UP
1.3 STANDARD VIEWS2.XRAY QUALITY3.ALIGNMENT 3 LINES AND C1 LATERAL MASSES4.FOLLOW BONE CORTICES5.DISTANCES• ATLANTO-DENS INTERVAL• PRE VERTEBRAL SOFT TISSUE
6.CT7.MRI LIGAMENTOUS OR MEDULLARY INJURIES
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THANK YOU!