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Computed tomographic scan findings in closed head trauma
Figure 1. Supra- and infratentoriat chronic epidural hematoma at the right occipital pole. Scans demonstrate fourth ven. tcicle deviation from the infratentorial portion of the lesion and clear evidence of supratentorial extension. Slight enhancement of the membranes is also noted (lop right and bottom right). Scans were made approximately 3 weeks after the original trauma. Female patient, age 56. with both homonymous hemianopia and cerebellar signs, recovered promptly follow 79 surgical drainage.
diffuse edema Of the fatal C~SC’S,rr~ultiplc nIii,j,>r ahnormalitit-s were found in I2 cm3. whole hemisphere contusions in 2 cases and brltiiistclll contusions without other tindings in 2 cases. Eight fatalities showed fractures on plain films. and seven showed deviation of the anterior falx. henliItoI~~X+
:ll~ne
without other
Allen 116
in 2 patients;
findings
in
and
SPECIFIC OBSERVATIONS
I patient.
Brainslem Trauma
A total of seven cases showed findings suggesting brainstem contusions. These consisted of various combinations of density changes, consistcut with the appearance of’ blood and edema, within the
brainstem at various levels, with varying degrees of obliteration of the cisterns around the midbrain, usually by increased density streaks considered to represent blood. and with evidence of bleeding and edema adjacent to the area. In some cases this has been difficult to separate from manifestations of transtentorial herniation, which may also be present in many of these cases. Findings of brainstem contusion may be minimal and easily obscured by motion and/or bone artifacts at the base of the skull. In this group of seven patients, three were fittalities, two of these showing no other apparent abnormality on CT scan. Of the four nonfatal cases, one was apparently an isolated abnormality without other lesions. Another developed post-traumatic Parkin-
sonism in the sixth ucek (Figure 2). and one case was associated with bitro;ltal contusions (Figure .3). Cl tindjngs wet-C questionable in the sevcnrh cast!. but strongly posilivc clin,cally, in a patient \vilh trittlnl;LtiC pneumocephalus at the base and enlargcmcnr and distonicln of the fourth sentrich!. Deviation
of Anterior
l’ht~ lhlx. wmposed
Fals iIS it is ol’ I
douhlc
Inyl-
r,t
durn. has long been thought lo rcsisl. displaccmcnt under all circurmti~mw. This and other scrics have shop that the latter is in fact quite conunon. Anterior fals deviation away from the side of hemisphere enlargement was noted in I2 cil>c.‘\. onlv 7
Figure 2. Brainstem contusion. Blood density area shown on orIgInal CT scan 1 day after trcluma. on the right We with subsequent clearing (fop /elf and bottom Ieft). Clearmg shown on fflms made 2 weeks later (top rrght and bollom r/gbll. Patlent, a 60.year-old male, developed postencephalitic Parkinson&m 6 weeks after original trawna. Closed Head Trauma 117
Figure 3. Typical contusion abnormality. Films show extensive bifrontal mixed density contusion effects, clearly visible despite motion and bone artifacts at the base. General swelling is manifested by virtually complete obliteration of the ventricular outlines. Extensive left subgaleal blood collection (associated with a left-sided fracture) and a small left temporal subcortical blood collection are also visible. Typical contusion abnormality, clinical grade 3. Male, age 21. CT scan performed on day of trauma. Patient recovered completely over a a-week period.
were fatalities. True rupture of the falx is apparently quite rare except in extensive crush injuries where patients usually do not survive long enough for radiologic examination. Hence, this tinding is presumed to represent a true pressure deviation of the falx from a marked expansion of one hemisphere, not specific for trauma situations. Routine use of contrast material would probably uncover more of these.. as the falx is frequently invisible without it, unless it is outlined by blood or cerebral spinal fluid accumulation.
of which
Allen 118
Epidural Wematomas There were seven confirmed epidural hematomas. five of which were examinecl within the first 2 days following trauma. All of trtese showed typical biconvex shape and middle fJ,ssa locations with density of 35 to 40 Hounsfield units. A sixth case was examined 4 days post-trauina; this showed similar increased attenuation, and w.as situated at the frontal pole in association with a ,subdural hematoma, as shown at surgery (Figure 4). The seventh case was encountered 3 weeks after trauma, and was situated
Figure 4. Subdural hematoma. A 62..year-old female with history of trauma approximately 2 weeks prior to scan. CT indicates extenisve area of decreased attenuation in the extracerebral right frontal temporal region, with angulation and left deviation of the interhemispheric fissure and falx anteriorly. Patient made good recovery following surgery for right sub. dural hematoma.
at the occipital pole. This was also biconvex in shape, both supratentorial and infratentoriat in position, and showed slight decreased attenuation.
ed
trscere
as
In addition to the case reported above. two cases were encountered with large intracerebral hernatomas whose clinical manifestations developed from 4 to 6 weeks after the original trauma. and which were cscluded because of the time interval. Neither of’ the cases had had previous CT scans.
1. One hundred fifty carefully defined cases ot closed head trauma were grouped into four categories retlecting the gravity of their clinical presentations. 2. During the I&month period of’ study, 6 cases not included in the series were attempted unsuccessfully. and of the 150 series cases, 8 were considered of poor quality, possibly obscuring findings. 3. As shown in the first two clinical groups, entitled ‘minor” and “moderate” trauma, which were Closed Head
Trauma 149
associated with little or no loss of consciousness and no abnormal neurologic Gndings, the Cl’ scan added Ii: tie or nothing to the traditional management and could be dispettsed with in most of tlhe siruations.
UEFERENCE 1. MerinodcVillasantc
tomography CII
3.
Twau
JM:
Computerized Am J Med 126(4):765. 1976
in acute head trauma.
Roentgenol Rad Ther N&l
diffuse edema Of the fatal C~SC’S,rr~ultiplc nIii,j,>r ahnormalitit-s were found in I2 cm3. whole hemisphere contusions in 2 cases and brltiiistclll contusions without other tindings in 2 cases. Eight fatalities showed fractures on plain films. and seven showed deviation of the anterior falx. henliItoI~~X+
:ll~ne
without other
Allen 116
in 2 patients;
findings
in
and
SPECIFIC OBSERVATIONS
I patient.
Brainslem Trauma
A total of seven cases showed findings suggesting brainstem contusions. These consisted of various combinations of density changes, consistcut with the appearance of’ blood and edema, within the
brainstem at various levels, with varying degrees of obliteration of the cisterns around the midbrain, usually by increased density streaks considered to represent blood. and with evidence of bleeding and edema adjacent to the area. In some cases this has been difficult to separate from manifestations of transtentorial herniation, which may also be present in many of these cases. Findings of brainstem contusion may be minimal and easily obscured by motion and/or bone artifacts at the base of the skull. In this group of seven patients, three were fittalities, two of these showing no other apparent abnormality on CT scan. Of the four nonfatal cases, one was apparently an isolated abnormality without other lesions. Another developed post-traumatic Parkin-
sonism in the sixth ucek (Figure 2). and one case was associated with bitro;ltal contusions (Figure .3). Cl tindjngs wet-C questionable in the sevcnrh cast!. but strongly posilivc clin,cally, in a patient \vilh trittlnl;LtiC pneumocephalus at the base and enlargcmcnr and distonicln of the fourth sentrich!. Deviation
of Anterior
l’ht~ lhlx. wmposed
Fals iIS it is ol’ I
douhlc
Inyl-
r,t
durn. has long been thought lo rcsisl. displaccmcnt under all circurmti~mw. This and other scrics have shop that the latter is in fact quite conunon. Anterior fals deviation away from the side of hemisphere enlargement was noted in I2 cil>c.‘\. onlv 7
Figure 2. Brainstem contusion. Blood density area shown on orIgInal CT scan 1 day after trcluma. on the right We with subsequent clearing (fop /elf and bottom Ieft). Clearmg shown on fflms made 2 weeks later (top rrght and bollom r/gbll. Patlent, a 60.year-old male, developed postencephalitic Parkinson&m 6 weeks after original trawna. Closed Head Trauma 117
Figure 3. Typical contusion abnormality. Films show extensive bifrontal mixed density contusion effects, clearly visible despite motion and bone artifacts at the base. General swelling is manifested by virtually complete obliteration of the ventricular outlines. Extensive left subgaleal blood collection (associated with a left-sided fracture) and a small left temporal subcortical blood collection are also visible. Typical contusion abnormality, clinical grade 3. Male, age 21. CT scan performed on day of trauma. Patient recovered completely over a a-week period.
were fatalities. True rupture of the falx is apparently quite rare except in extensive crush injuries where patients usually do not survive long enough for radiologic examination. Hence, this tinding is presumed to represent a true pressure deviation of the falx from a marked expansion of one hemisphere, not specific for trauma situations. Routine use of contrast material would probably uncover more of these.. as the falx is frequently invisible without it, unless it is outlined by blood or cerebral spinal fluid accumulation.
of which
Allen 118
Epidural Wematomas There were seven confirmed epidural hematomas. five of which were examinecl within the first 2 days following trauma. All of trtese showed typical biconvex shape and middle fJ,ssa locations with density of 35 to 40 Hounsfield units. A sixth case was examined 4 days post-trauina; this showed similar increased attenuation, and w.as situated at the frontal pole in association with a ,subdural hematoma, as shown at surgery (Figure 4). The seventh case was encountered 3 weeks after trauma, and was situated
Figure 4. Subdural hematoma. A 62..year-old female with history of trauma approximately 2 weeks prior to scan. CT indicates extenisve area of decreased attenuation in the extracerebral right frontal temporal region, with angulation and left deviation of the interhemispheric fissure and falx anteriorly. Patient made good recovery following surgery for right sub. dural hematoma.
at the occipital pole. This was also biconvex in shape, both supratentorial and infratentoriat in position, and showed slight decreased attenuation.
ed
trscere
as
In addition to the case reported above. two cases were encountered with large intracerebral hernatomas whose clinical manifestations developed from 4 to 6 weeks after the original trauma. and which were cscluded because of the time interval. Neither of’ the cases had had previous CT scans.
1. One hundred fifty carefully defined cases ot closed head trauma were grouped into four categories retlecting the gravity of their clinical presentations. 2. During the I&month period of’ study, 6 cases not included in the series were attempted unsuccessfully. and of the 150 series cases, 8 were considered of poor quality, possibly obscuring findings. 3. As shown in the first two clinical groups, entitled ‘minor” and “moderate” trauma, which were Closed Head
Trauma 149
associated with little or no loss of consciousness and no abnormal neurologic Gndings, the Cl’ scan added Ii: tie or nothing to the traditional management and could be dispettsed with in most of tlhe siruations.
UEFERENCE 1. MerinodcVillasantc
tomography CII
3.
Twau
JM:
Computerized Am J Med 126(4):765. 1976
in acute head trauma.
Roentgenol Rad Ther N&l