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Imaging Brain Trauma：Update 2015
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0:00
so we're going to move from the spine to
0:02
the brain and I'm going to talk a little
0:03
bit more on some different aspects of
0:06
trauma imaging and subtitle this so you
0:09
think you know everything about head
0:11
trauma imaging maybe we ought to think
0:14
again so one of my favorite movies is
0:18
called the usual suspects and this
0:21
particular Kevin Spacey movie which is
0:24
one of my favorites says in a world
0:27
where nothing is what it seems you've
0:29
got to look beyond the usual suspect and
0:33
so what we're going to do today in our
0:35
trauma imaging is to talk about looking
0:38
beyond the usual suspects from what you
0:41
usually think of for trauma
we're going to start with talking about the scalp an often neglected area of imaging it's not just a covering
we're going to learn that not all epidural hematomas are the same
we're going to look at some variations on the themes of subdural hematomas including some concepts about excited toxic brain injury that you end abusive head trauma that may be new to you
we'll talk a little bit about chronic traumatic encephalopathy
and then close with diffuse vascular imaging which diffuse vascular injury which may be a new kind of high-velocity impact injury
so let's start start with the
1:24
outside and move in let's start with the
1:26
scalp we don't need to remember all five
1:30
layers of the scalp matter of fact we
1:34
have a plain piece of paper that doesn't
1:38
have a shiny surface so that the arrow
1:41
doesn't bounce around here there are
1:43
five layers of the scalp really only two
1:45
of them are important and we're going to
1:49
be talking primarily about the gay light
1:51
daily after neurotic I think this one I
1:54
think it will show a little better good
1:57
Galia appered erotica and the sub F
2:00
earner otic tissue and the periosteum of
2:03
the skull which is the peri cranium so
2:05
we're going to be looking primarily at
2:06
big alias which we see here depicted as
2:10
this kind of gray
2:11
band and the Perry cranium which is the
2:14
periosteum of the skull right here so
2:19
with that little bit of anatomy
2:21
introduction why does all of this matter
2:24
well not all scalping McComas are the
2:27
same if you think that your residents
2:31
know everything about trauma asks them
2:32
what is the difference between a cephalo
2:35
hematoma and a sub Gallio hematoma and I
2:38
guarantee you they're going to probably
2:40
mmm a little badness if your fingers up
2:43
their nose and kind of you know weasel
2:44
around and lay words on it because they
2:47
probably don't really understand the
2:49
difference well now we will a cephalo
2:52
hematoma is basically a subperiosteal
2:56
hematoma
2:57
it's the extra cranial equivalent if you
3:00
wish of an epidural hematoma it's going
3:03
to be limited by the sutures in the
3:05
fontanel's and it's relatively small and
3:08
typically covers a single bone so here
3:11
on our anatomic diagram this smaller
3:15
hematoma is a cephalo hematoma think of
3:19
it as a subperiosteal or extracranial
3:22
quot epidural hematoma contrast that
3:25
with a subdural hematoma it's not
3:28
founded by sutures and it can become
3:31
literally huge it can extend all the way
3:35
around the skull as it does here and the
3:38
blood loss particularly in infants and
3:40
small children can literally become
3:43
life-threatening so let's first look at
3:46
our cephalo hematoma these are going to
3:49
be limited by size remember they're
3:51
limited by bounded by sutures they're
3:54
typically going to cover a single bone
3:56
and as we see in this particular case
3:58
here here is a typical cephalo hematoma
4:02
from a traumatic forceps delivery that's
4:04
a common way they happen here you can
4:07
see a skull fracture underneath and this
4:10
is a typical cephalo hematoma because
4:13
these are self-limited they're typically
4:16
and they're common and instrumented
4:17
delivery these things are rarely image
4:19
in there certainly usually not followed
4:23
up
4:24
they're self-limited they resolve
4:26
spontaneously they don't need follow-up
4:28
and chronic occasionally you can calcify
4:32
but basically we really don't see many
4:34
of these so 99 times out of a hundred
4:37
unless you're dealing with a newborn ICU
4:39
the patients that we see with scalping
4:42
McComas are going to be Sedalia FEMA
4:46
Tomah
4:46
even large cephalo hematomas and here
4:49
look at this example of an abused infant
4:52
obviously stuff is going on intracranial
4:54
II we're not going to talk about that
4:56
right now but look at this hematoma it's
4:58
an enormous
5:00
cephalo hematoma but it's only covering
5:04
one bone and it doesn't cross the
5:06
midline now look in the coronal reform
5:09
at scanned and you might see but you
5:11
just told me it doesn't cross the
5:12
midline but here it does well look very
5:14
carefully here is the elevated
5:17
periosteum and there are actually at
5:20
least two and possibly even three
5:22
steffel hematomas in this infant each
5:24
one of which is bounded by the
5:28
periosteum so here as a reconstruction
5:32
you can actually see a really nice
5:33
example of a cephalo hematoma now I'm
5:38
going to go back and show you why that
5:40
happened
5:42
anatomically now let's take our
5:45
periosteum and you'll see that the
5:47
periosteum of the skull is continuous
5:50
through the suture with the outer layer
5:54
or the periosteum layer of the dura
5:56
that's why it doesn't cross the midline
5:59
and doesn't cross the site of sutural
6:02
attachment even large cephalo hematomas
6:05
then if we look carefully we should be
6:07
able to find the shadow of the elevated
6:10
periosteum now septillion McComas are a
6:15
different story
6:16
remember septal hematoma usually
6:18
self-limited single bone typically don't
6:21
cross lines of sutural attachment sub
6:24
galio hematomas do they are basically a
6:27
sub aponeurotic hematoma and they will
6:30
cross under the aponeurosis and the
6:33
occipital frontal they are
6:36
external to the periosteum so there is
6:38
nothing that limits a Sedalia hematoma
6:41
from accumulating and accumulating and
6:44
getting bigger and bigger and bigger and
6:46
here is an autopsy case of an abused
6:49
infant with a sub Gallio hematoma in
6:52
this case you can see it crossing the
6:54
midline it's really very extensive often
6:58
bilateral crosses sutures crosses
7:00
fontanelles may spread entirely around
7:03
the skull so it looks like the child is
7:05
really surrounded by a balloon or an
7:09
inner tube if you will these can become
7:12
absolutely enormous here are two
7:14
examples
7:16
they're both extensive here's an infant
7:18
you see it crossing the midline this is
7:21
a subdural hematoma here's another one
7:24
in an adult crossing the midline
7:27
in the infant a sub Gallio hematoma can
7:30
become life-threatening in an adult with
7:33
a coagulopathy it's surprising how much
7:36
blood you can lose and just as we look
7:38
for swirl signs in epi and subdural
7:40
hematomas in older adults if they show
7:44
this kind of heterogeneity in the
7:47
density of the subdural hematoma but
7:49
where there may be active bleeding going
7:51
on and these can get absolutely enormous
7:56
okay so now we're going to move from the
7:59
outside to the inside of the skull and
8:00
we're going to talk about the epidural
8:02
hematoma yeah yeah yeah you've all heard
8:04
about the epidural hematomas there's no
8:06
mystery here typically a classic
8:09
epidural hematoma lacerates a blood
8:12
vessel usually an artery and most
8:14
commonly the middle meningeal artery and
8:16
if you're getting at effective bleeding
8:18
we get the so called swirl sign so where
8:21
there's an epidural hematoma accumulate
8:23
it accumulates between the inner table
8:25
of the skull and the outer or the
8:27
periosteum layer of the dura
8:30
very typical let's look at an autopsy
8:33
case of an epidural hematoma on the
8:36
right we have the picture of the dura
8:40
intact with the epidural hematoma as
8:43
this biconvex blood collection and here
8:47
is the skull seen from the end
8:49
and you actually can see the outline of
8:52
the epidural hematoma here to the left
8:55
is a fresh autopsy case the brain has
8:58
been removed this is a patient who died
9:00
of complications from the trauma and we
9:02
can see the comminuted partly depressed
9:04
fracture we can see the epidural
9:07
hematoma here as this acute currant
9:09
jelly clots note that epidural hematoma
9:14
may cross sites of dural attachment
9:17
particularly if they are venous they
9:20
rarely cross sutures but that is not a
9:23
hard and fast rule particularly when
9:26
you're dealing with children about 10%
9:28
of pediatric epidural hematomas actually
9:31
do cross lines of sutural attachment
9:34
most of these are unilateral and super
9:36
tutorial and have this by convex shape
9:39
you've all seen this bloody body so
9:41
we're not going to spend a whole lot of
9:42
time on your typical epidural hematoma
9:45
so one of the messages of this afternoon
9:48
is epidural hematomas we all know them
9:52
but they are not all the same we've
9:55
talked about the classic epidural
9:56
hematoma which is an arterial laceration
9:58
but there are venous epidurals there are
10:02
what are called vertex epidurals the
10:04
ones that occur right over the top of
10:07
the brain there are anterior middle
10:09
fossa epidurals and Clive alleppey girls
10:11
some of these are surgical emergencies
10:14
some of them are beware watch me
10:17
carefully and others of them are it's
10:20
there we describe it but it is not going
10:22
to matter in the patient's treatment
10:24
because they're never going to get any
10:26
bigger
10:27
so let's look now at venous epidural
10:31
hematoma
10:31
yes arterial are much more common than
10:33
Venus but now that we have the ability
10:36
to do our fast in Section C T's with
10:39
multiplanar reformatted images I think
10:42
this is going to change because we're
10:44
seeing more venous epidural hematomas
10:47
particularly in patients who have high
10:49
impact injuries and complex comminuted
10:53
fractures at the skull base remember
10:55
that fractures can be linear or
10:57
diastatic and if they cross a dural
11:00
Venus
11:00
finest particularly at the skull base or
11:03
the vertex they can produce a venous
11:06
epidural hematoma
11:08
and here on our anatomic diagram we have
11:11
drawn some kind of complicated complex
11:13
dramatic skull based fractures and we'll
11:19
see that if this one crosses the site of
11:23
dural attachment and a venous channel
11:27
here's a skull bit fracture through the
11:29
squamous part of the occipital bone it
11:31
compares the venous sinus and produce a
11:33
venous epidural here is an autopsy case
11:36
underneath here's the dura partly lifted
11:40
up here is an epidural hematoma this is
11:43
the site of attachment to the temporal
11:47
bone and you see the dura here and here
11:51
and here is the epidural hematoma
11:53
crossing the site of dural attachment
11:57
this is a venous epidural hematoma and
12:00
it can also commonly cross sutures so if
12:04
you remember people saying no no
12:05
epidural hematomas don't press B where
12:08
indeed they do
12:09
Venus epidurals are easily overlooked
12:12
our reformatted scans are absolutely key
12:15
to the diagnosis and CTA or CT v are
12:19
very helpful here's an example here's a
12:22
patient with a scalp injury the scalp
12:24
was our friend it tells us that this is
12:26
probably the site of the blow we see a
12:29
contra ku lateral contra coup in the
12:32
contralateral temporal lobe hematoma
12:34
here and then we see what appears to be
12:38
a MS it's subdural is it epidural while
12:42
I don't really know here is the skull
12:46
view and you can see there's a diastatic
12:48
fracture through the lambdoid suture and
12:50
here on the coronal and sagittal
12:53
reformatted CTV's we see this venous
12:56
epidural lifting up the dura and
12:59
crossing the site of sutural attachment
13:02
attachment classic venous epidural
13:06
hematoma involving both the Supra and
13:08
the intro tutorial compartment vertex
13:12
epidural hematomas are rare
13:14
they typically occur when there's a
13:16
linear or a die aesthetic fracture that
13:19
crosses the superior sagittal sinus and
13:22
the midline they are usually venous and
13:25
their size is grossly underestimated on
13:28
axial CT scans even relatively thin
13:31
section one it's going to be our coronal
13:34
and sagittal reformatted stance that are
13:37
most helpful in these cases these are
13:39
also difficult to diagnose clinically
13:41
the patient has may have few or very
13:44
slowly developing symptoms because
13:46
unlike an epidural hematoma of arterial
13:49
origin this guy is accumulating
13:52
relatively slowly so here's a classic
13:56
vertex epidural hematoma
13:58
how much do you see under axial
14:00
non-contrast soft tissue windows not
14:03
very much we see a big sub Gallio Pima
14:06
Toma see a little bit of air here our
14:09
fracture lines that we can see crossing
14:11
the midline but look it's the sagittal
14:14
reformatted scans and this patient has
14:16
not just has not one but two venous
14:19
epidurals and here you see it displacing
14:22
the superior sagittal sinus inferior Lee
14:26
these are venous epidural hematomas
14:28
these are watching me carefully over the
14:31
next 24 48 or 72 hours because they can
14:34
slowly accumulate blood and slowly cause
14:37
increasing mass effect on the underlying
14:39
brain these guys are dangerous they
14:42
don't require immediate evacuation
14:43
usually but they do require closed
14:47
interval follow-up and observation it's
14:50
amazing how little you can see sometimes
14:52
on our axial scans here's a patient big
14:54
huge sub gill hematoma depressed
14:57
comminuted fracture here goes here it is
14:59
across the bone we said this patient is
15:03
in danger of having a venous epidural
15:06
hematoma and we ought to do a CTA or CTV
15:10
and the neurosurgery resident on call
15:12
said no no no we don't need to do that
15:14
patients doing just fine but several
15:17
hours later began to deteriorate and for
15:20
whatever reason they ordered an MRI scan
15:22
and this one clearly shows our classic
15:24
venous epidural
15:26
so when that fracture crosses over the
15:29
top of the head and engages the superior
15:31
sagittal sinus beware it's always a good
15:35
idea you can't go wrong getting a CTA /
15:38
CTV and I always say order a CTA don't
15:41
order a CTV if you order a CTV the text
15:45
may miss the bolus if you order a CTA
15:47
you always get the V part for free and
15:50
there's not going to be a problem with
15:52
that so CTA is our friend okay here's
15:55
another type of epidural hematoma it was
15:58
described by Alyssa Jean from UCSF was
16:01
one of our very best of trauma
16:03
radiologists it's called the anterior
16:05
middle fossa epidural hematoma it's
16:08
about 10% of epidural hematoma the deal
16:11
about this one is it's anatomically
16:13
limited here we see a classic anterior
16:17
middle fossa epidural hematoma right
16:19
there it's usually small it's limited by
16:23
the scene of parietal suture laterally
16:26
and by orbital fissure immediately so
16:29
it's never going to get any bigger all
16:32
of these patients have fractures if you
16:34
do if you do bone windows you can easily
16:36
see fractures typically going across the
16:39
sphenoid wing or this I gramatical
16:41
maxillary suture these guys are venous
16:44
they're not arterial they are no
16:46
clinical importance they don't get
16:48
bigger and no reported cases in the
16:51
literature the less that I looked ever
16:53
required surgery and the reason that
16:56
these things occur is anatomically
16:59
explained by this diagram here it is the
17:01
sino parietal sinus that is curving
17:04
along the greater wing of the sphenoid
17:06
it's the sino parietal sinus to gets
17:09
torn but because the fracture because
17:12
the hematoma is limited medially by the
17:14
orbital fissure and laterally it won't
17:17
get any bigger for whatever reason the
17:19
surgeons in this case got spooked and
17:21
they ordered a CT a which we did and we
17:24
actually saw a little spot sign they got
17:27
all nervous don't worry it's not going
17:30
to get any bigger
17:31
this is anatomically limited we followed
17:33
it up 24 hours later and indeed it
17:36
hadn't yes it had a spot sign but
17:38
in this case it's so anatomically
17:40
limited it's not going to get any bigger
17:43
and finally Clive a literal hematoma and
17:46
patients with complex skull based
17:48
fractures you may be able to see them
17:50
like this but they too are anatomically
17:53
limited because the dura of the clivus
17:56
is tightly attached to it
17:58
and it's never going to get much bigger
18:00
than it is at the moment that you stand
18:03
it
18:04
now what's new with subdural hematomas
18:07
we've learned that not all acute
18:08
epidural hematomas are the same we want
18:11
to be where the venous epidurals
18:13
particularly the ones that have a
18:15
fracture crossing the midline that's the
18:17
vertex we know that the anterior middle
18:19
fossa epidural hematomas and the Clive
18:21
eleven-year-olds we can describe but
18:23
they don't really mean anything in terms
18:25
of requiring surgical intervention well
18:29
what's happened with acute subdural
18:31
hematoma there's kind of a lot going on
18:33
with subdural hematomas you know what
18:36
they look like they're going to spread
18:37
diffusely over the surface of the brain
18:39
here's an autopsy case that shows you
18:41
what we were trying to depict on our
18:43
anatomic diagram if a typical acute
18:47
subdural hematoma
18:49
and you've seen it right you've seen
18:52
this no problem
18:53
you've seen that is there anything new
18:56
that we need to learn about subdural
18:58
hematoma well first of all thank
19:01
goodness we now have our multiplanar
19:04
reformatted skin we're not going to miss
19:07
the small thin subdural hematomas over
19:11
the convexity we're not going to miss
19:13
these small sand parry tutorial hematoma
19:17
which may be difficult to see on the
19:19
axial plane now maybe there yes I think
19:22
it is but no problem on the coronal and
19:26
the sagittal note that on the sagittal
19:28
reformatted scan you're normal tantor
19:31
IAM the derp of the tentorium is going
19:34
to appear slightly denser than the
19:36
adjacent brain because it is it's
19:38
slightly denser but it's going to be
19:39
spin it's a thin white line anything
19:42
more than a thin white line it's a parry
19:44
tutorial subdural hematoma
19:49
so what else is new we decide the use of
19:51
reformatted scans well it's what's going
19:55
on with the brain under the subdural
19:57
haematoma you know about the phenomenon
20:00
of traumatic cerebral edema but we're
20:03
increasingly understanding that the
20:06
brain under subdural hematoma is
20:09
undergoing in many cases a form of
20:12
excitotoxin brain injury in which they
20:16
are going to get intracellular swelling
20:19
and that swelling may be absolutely
20:23
catastrophic so here is an autopsy case
20:26
this is one from my colleague Richard
20:29
Shula the neuro pathologist in South
20:31
Africa you can see this patient
20:33
obviously died he had a small thin
20:36
subdural hematoma this is a little
20:38
traumatic subarachnoid hemorrhage but
20:40
look at the swollen gyri what did this
20:45
patient in was not the size of the
20:47
subdural hematoma
20:49
it was the out of proportionate brain
20:52
swelling that occurred is this because
20:55
these patients actually have had a prior
20:58
brain injury and this is a form of
21:01
second impact syndrome which we'll talk
21:02
about in a moment nobody really knows
21:05
but let me alert you to an imaging
21:08
finding so let's just look at our usual
21:11
cases of cerebral edema and then we'll
21:14
look at what happens under small fin
21:16
subdural hematoma okay let us look at
21:23
this CT scan this is an older patient
21:25
who fell was not antiquated was not
21:31
really doing very well and you can look
21:34
at his scan here is the non consi T on
21:38
the left when they grab the arrow here
21:41
there is a little thin subdural hematoma
21:43
there you can see it a little bit better
21:45
on our kind of intermediate windows yes
21:48
it's extending along the inner
21:50
hemispheric fissure but this patient
21:51
isn't doing well why is this patient not
21:54
doing well well look at the brain
21:56
underlying this very physics like a 2 to
22:00
3 millimeters
22:01
dural gimmick oma not anything the
22:03
neurosurgeons are ever going to worry
22:05
about however look at the brain on the
22:08
opposite side how thick is the cortex
22:11
just a few millimeters thick
22:13
there's the gray matter white matter
22:15
interface you see the sulfite over the
22:17
surface look at how thick this cortex is
22:20
this patient is having a really bad
22:25
excited toxic brain swelling and this is
22:28
life-threatening it is not the two to
22:31
three millimeter subdural that's
22:32
life-threatening it's the brain swelling
22:34
that's going on underneath it
22:38
occasionally we will get mr scans here
22:41
the patient who is not doing well a
22:43
couple of days at three days after its
22:45
injury and here is a subdural hematoma
22:47
that's not what I call your attention to
22:50
it's the brain swelling and it's the
22:52
cortex it's in a non Van cooler
22:55
distribution this is not vascular injury
22:58
to the middle cerebral artery because
23:00
it's crossing vascular territories and
23:02
it's really not involving the white
23:03
matter
23:04
this is excited toxic brain injury in
23:09
this second impact syndrome this is
23:11
something that ELISA Jean has has
23:13
described this is when you get an
23:16
athlete typically a teenage or early 20s
23:20
male who's involved in contact sports
23:23
gets a concussion get to bell rung goes
23:27
back to playing athletics before the
23:31
brain is recovered and then gets a
23:33
second impact that now causes
23:35
catastrophic brain swelling it was been
23:38
given the name second impact syndrome so
23:44
we know about that in young athletes
23:47
most of us do but does second impact
23:49
syndrome occur in other clinical
23:51
situations and I think it does I think
23:54
it not only occurs in athletes but it
23:56
occurs in cases where there is non
23:59
sports related repetitive head injury to
24:02
ends of the age scale infants with
24:05
abusive head trauma and older patients
24:08
with repeated Falls and what I think
24:11
happens is that the first trauma or the
24:14
concussion opens this temporal window of
24:17
vulnerability during which time if there
24:19
is a second injury either abusive head
24:21
trauma with inflicted injury or another
24:24
fall then they get disproportionate
24:27
brain swelling and here's a very sad
24:29
case of a child with mixed subdural
24:31
hematomas and you can see the massive
24:33
brain swelling that's way out of
24:35
proportion to the size of the subdural
24:40
let's look at the opposite end of the
24:42
age spectrum here's an elderly patient
24:45
with repeated Falls this is a recent
24:47
case of ours first fall has a normal CT
24:51
scan second fall eight days later a
24:55
second normal CT scan third fall one
25:00
week later he's got about an eight
25:04
millimeter subdural hematoma but look at
25:06
the mass effect way disproportionate
25:09
this patient was herniating in this
25:12
patient was dying they did a
25:15
decompressive hemi craniectomy and note
25:19
that the edema is persisting even after
25:21
they removed the subdural the subdural
25:24
was not the problem it was the brain
25:26
injury underneath and that is probably a
25:28
form of excited toxic injury so what is
25:32
the take home lesson look at the size of
25:35
the subdural look at the size of the
25:37
Mass Effect if the mass effect is
25:40
disproportionate to the amount or the
25:43
thickness of the subdural suspect exciti
25:46
toxic brain injury
25:47
alert your neurosurgeons because they
25:50
may want to do almost a prophylactic
25:52
craniectomy to allow the brain swelling
25:55
to occur so it's the disproportionate
25:58
size of the Mass Effect and the cortical
26:01
swelling relative to the thin subdural
26:04
here's another example is repetitive
26:07
abusive head trauma initial CT scan
26:10
again mass effect yeah it's a pretty
26:12
decent sized subdural hematoma but way
26:15
more mass than you would expect look at
26:17
the thickness of the cortex compared to
26:19
the other side he was not doing well
26:21
after surgery they've evacuated the
26:23
hematoma and you see this diffuse non
26:26
vascular territory swelling of the
26:29
cortex and again this proportion that
26:32
brain swelling to the size of the
26:34
hematoma probably representing excited
26:38
toxic brain injury okay what else is new
26:41
about subdural compartment collections
26:44
let's call them compartment collections
26:46
three types we need to deal with
26:49
subdural hemorrhage in which blood is in
26:52
that compartment subdural hygromas in
26:55
which CSF is in that Hydra in in that
26:58
compartment and a so-called key matter
27:01
hygroma where there is mixed blood and
27:04
CSF in the subdural compartment so
27:09
here's a susceptibility weighted scan in
27:12
this infant with a team motto hide Roma
27:14
and note that in many of the cases where
27:17
the blood is in the subdural compartment
27:19
you have little or no susceptibility
27:21
effect you'll look like it's mostly CSF
27:24
and maybe a small amount of blood this
27:27
is a key motto hygroma what is the
27:30
importance of a hematoma hygroma what
27:33
about mixed density subdural hematoma
27:35
what does it mean well it can be a mix
27:39
of hyper acute and a few blood it could
27:42
be all acute cameras but with some
27:45
uncluttered acute blood it can be a sea
27:48
matter hygroma or it can be acute
27:51
chronic blood so in this case of abusive
27:54
head trauma it could be any one of those
27:58
which is an interesting conundrum for
28:01
the radiologist so let's look at what
28:04
the difference is a subdural hygroma
28:07
occurs with trauma
28:10
it is a torn arachnoid through which CSF
28:16
leaks into the subdural space and so it
28:20
typically has CSF character on both
28:22
non-contrast CT and mr and if you look
28:26
at the fluid in this subdural hygroma it
28:30
contains beta trace protein which is the
28:33
marker for CSF how does a subdural
28:38
hygroma
28:39
form weather lots of different theories
28:41
they all relate to
28:43
head trauma either surgical or closed
28:46
head injury and typically relate to an
28:49
arachnoid tear or an arachnoid impact
28:52
arachnoid in which there is some type of
28:55
meningeal injury and you get the
28:57
subdural hygroma note that in some cases
29:00
it can progress to a chronic subdural
29:04
hematoma because it will form a tamato
29:07
hygroma so what do we look for is
29:11
radiologists in when we are looking for
29:13
the potential for abusive head trauma
29:15
here is a subdural hygroma 12 hours
29:19
after a so-called normal CT scan I think
29:22
if you look carefully you see that maybe
29:24
there is a little bit of hemorrhage here
29:26
but most of this is a subdural hygroma
29:30
it's not a chronic subdural hematoma
29:35
here is the mr here's the t2 and here's
29:42
a flare
29:43
this is CSF what does that mean this
29:48
means that this infant has been injured
29:51
so the key points here and this is an AJ
29:54
in our article that appeared just a year
29:56
ago and I recommend it to you
29:58
the presence of a subdural hygroma CSF
受字符數限制，只能割愛了。
39:08
susceptibility weighted scans thank you
39:11
very much
39:12
[Applause]