|Year : 2015 | Volume
| Issue : 2 | Page : 420-425
Acute head trauma - a multidetector computed tomography scanning study
Ousama Abdelmohsen Youssef Elsayes1, El-Sayed El-Mekkawy El-Sayed2
1 Department of Diagnostic Radiology, Kafr El-Dawar General Hospital, Behira, Egypt
2 Department of Diagnostic Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||09-May-2014|
|Date of Acceptance||05-Nov-2014|
|Date of Web Publication||31-Aug-2015|
Ousama Abdelmohsen Youssef Elsayes
Gamal Abdel-Naser St., Miami, Alexandria
Source of Support: None, Conflict of Interest: None
The present work was designed to evaluate the role of multidetector computed tomography (CT) scanning in the diagnosis of sequelae of acute head trauma.
Head trauma is a major cause of death and disability. CT of the head is commonly considered to be the imaging modality of choice for the diagnosis of sequelae of acute head trauma. CT imaging has vastly improved from single-section scanning to the present multidetector row CT (MDCT). MDCT has improved the diagnostic value through the availability of postprocessing techniques such as multiplanar reformation and three-dimensional reconstruction imaging.
We studied 63 patients, aged between 12 days and 70 years (mean age, 20 years), presenting to the Emergency Department of Kafr El-Dawar General Hospital with a history of acute head trauma from May 2013 to January 2014. All patients were examined using an MDCT scanner and showed positive findings on head MDCT.
MDCT (Multiplanar reconstruction (MPR) and three-dimensional reconstruction images) added more information to the routine axial images alone in 32 (27%) of the 118 CT findings. It better demonstrated the type and extension of skull fractures in 18 patients (36% of patients with skull fractures and 28.6% of all patients), added more diagnostic value in 10 patients with extra-axial hemorrhages (22.7% of patients with extra-axial hemorrhages and 15.9% of all patients), and better demonstrated the contusions in four patients (21% of patients with hemorrhagic contusions and 6.3% of all patients).
MDCT was successful in the adequate characterization of the extent and type of hemorrhages and skull fractures in cases of acute head trauma.
Keywords: acute head trauma, fractures, hemorrhages, multidetector computed tomography
|How to cite this article:|
Elsayes OA, El-Sayed ESE. Acute head trauma - a multidetector computed tomography scanning study. Menoufia Med J 2015;28:420-5
| Introduction|| |
Trauma is the leading cause of death among individuals aged between 1 and 24 years. In patients with multiple trauma, the head is the most common organ involved. The annual incidence of head trauma is estimated to be 200 in a population of 100 000. Head trauma is a very brief event that occurs in less than 200 ms, and often in less than 20 ms  .
The primary causes of traumatic brain injury (TBI) vary according to patient age. Falls are the leading cause of TBI in children up to 4 years of age and in elderly individuals older than 75 years of age. Among adolescents, motor-vehicle accidents are the chief cause of TBI  .
Computed tomography (CT) of the head is commonly considered to be the imaging modality of choice for the rapid and reliable diagnosis of neurocranial traumatic lesions, such as skull fractures, epidural and subdural hematomas, and both hemorrhagic and nonhemorrhagic contusions  .
Since the invention of CT in 1971 by Sir Godfrey Hounsfield, CT imaging has vastly improved from being a time-intensive single-section scanning procedure to the present day multidetector row CT procedure. The availability of these volumetric data has heralded the development of exciting new data processing techniques, including maximum-intensity projections, volume-rendered three-dimensional (3D) reformations, and multiplanar reformations  .
There is a consensus that patients identified as having a moderate risk or high risk for intracranial injury should undergo early noncontrast CT for evidence of intracerebral hematoma, mild line shift, or increased intracranial pressure  .
This study evaluates the role of multidetector CT (MDCT) scanning in the diagnosis of sequelae of acute head trauma.
| Patients and methods|| |
In the present work, we studied 63 patients with a history of acute head trauma and positive findings on head MDCT scanning between May 2013 and January 2014.
- Patients of all ages, sexes, and occupations were included.
- Only patients with positive findings on head MDCT scanning after exposure to acute head trauma were included in the study.
All patients were subjected to the following:
Multidetector computed tomography technique
- Complete history talking.
- General and local examination (Glasgow coma score was calculated) by the Emergency Department staff.
- CT of the head using a multidetector row CT scanner, without intravenous contrast media.
The examinations were performed using a six-row MDCT scanner with no specific preparatory advice. Axial section images (1.25 mm slice thickness), with a high spatial frequency reconstruction algorithm. On an MDCT scanner, volumetric acquisition of high-resolution CT data sets was performed in the supine position.
For adequate multiplanar reconstruction, scanning was performed to cover the region from the canthomeatal line to above the vertex. The slices were sent to the workstation, where MRP images were obtained in axial, coronal, and sagittal planes whenever needed. Shaded surface display (SSD) images were obtained in front, back, right, left, top, bottom, and oblique views when needed (according to the findings from the original images).
| Results|| |
In this study, the total number of patients was 63; these included 49 male and 14 female patients, with a male : female ratio of 3.5 : 1. Their ages ranged from 12 days to 70 years, with a mean age of 20 years. The peak age was targeting the first decade including 26 patients with average 41.3% from the total number of patients [Table 1].
|Table 1 Age and sex distribution among the studied 63 patients with acute head trauma|
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The majority of the 63 patients presented with acute head trauma caused by car accidents (40%), followed by falling from a height (33%), being hit by a hard object (16%), and motor cycle accidents (11%; [Table 2].
The studied patients presented with different symptoms and signs. Scalp injury/wound was the most common complaint, reported in 45 patients (71%), followed by headache, reported in 39 patients (62%). Vomiting was reported in only 20 patients, whereas confusion was reported in nine patients, suspected open/depressed skull fracture in six patients, loss of consciousness in five patients, seizures in three patients, and antegrade amnesia/short-term loss of memory in two patients [Table 3].
|Table 3 Clinical presentation among the studied (63 patients) with acute head trauma|
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Most of the examined patients showed more than one lesion. Fifty (79%) of the 63 patients presented with skull fractures. Twenty-three patients had subdural hematomas (37%), 19 had brain contusions, 11 had subarachnoid hemorrhages, 10 had epidural hematomas, and five had intraventricular hemorrhages (8%; [Table 4].
|Table 4 MDCT findings among the 63 studied patients with acute head trauma|
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MDCT in the form of MPR (coronal and sagittal reformats) and 3D reconstruction images added diagnostic information to 32 (27%) of the 118 MDCT findings. In patients with skull fractures, MPR and 3D reconstruction images better demonstrated the type and extent of the fracture in 18 patients (36% of patients with skull fractures and 28.6% of all patients). In addition, in patients with extra-axial hemorrhages, MPR added diagnostic value in 10 patients (22.7% of patients with extra-axial hemorrhages and 15.9% of all patients), and in patients with hemorrhagic brain contusions, MPR better demonstrated contusions in four patients (21% of patients with hemorrhagic contusions and 6.3% of all patients; [Table 5]; [Figure 1] [Figure 2] [Figure 3] [Figure 4]).
|Table 5 Distribution of patients according to value of MDCT (MPR and 3D reconstruction) in the final diagnosis|
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| Discussion|| |
CT is routinely used to assess all patients with acute head injury who require admission and observation within the hospital. This imaging technique allows early assessment of the extent of the injury, and the images can be obtained quickly using modern multidetector high-resolution scanners that are widely available. The images can be visualized using brain or bone contrast windows and the data can be reconstructed into 3D CT data sets to demonstrate bony and intracranial injuries  .
Since the invention of CT, evaluation for neurological injury after head trauma has been ubiquitously performed through axial CT scanning. CT is limited in the evaluation of the posterior fossa, the middle cranial fossa, and the inferior frontal lobes. These anatomic locations can be obscured by Hounsfield (beam-hardening) artifacts, and coronal and sagittal CT reconstructions allow more detailed evaluation of these areas  .
Before proceeding with the discussion of the value of multidetector CT, we need to know the real difficulties that are faced with standard axial cuts. The most important problem is the presence of artifacts. Among the different types of artifacts encountered in CT, the beam-hardening bone artifact and the motion artifact remain the main obstacles, especially in certain anatomical areas.
Barrett and Keat  discussed the various types of artifacts and stated that artifacts can seriously degrade the quality of CT images, sometimes to the point of making them diagnostically unusable.
Schmalfuss and Camp  stated that the skull base is a complex anatomical structure and therefore radiologists often use 'side-to-side' comparisons for the detection of abnormalities. This approach is compromised by the high frequency of anatomical variations involving the skull base and the common presence of flow-related artifacts within vessels at the skull base, which might mimic true lesions.
Alberico et al.  concluded that reformatted CT significantly decreases skull base-related artifacts in the brain, improving observer confidence in evaluation of the brain base.
Boas and Fleischmann  stated that motion (patient, cardiac, respiratory, bowel) causes blurring and double images, as well as long-range streaks. The streaks occur between high-contrast edges and the radiographic tube position when motion occurs. Faster scanners reduce motion artifact because the patient has less time to move during the acquisition. More detector rows allow a greater volume to be imaged in a single gantry rotation, thus increasing the distance between step-off artifacts from motion on coronal or sagittal reformats.
Osborn et al.  reported that CT scanning is the screening tool if there is any clinical suspicion of a calvarial fracture. They added that the imaging recommendation for calvarial fractures is NECT and advised that the protocol should include coronal/sagittal reformations.
Medina  stated that conventional axial CT images may miss fractures of the calvaria, especially if they are parallel to the axis of sectioning. Yildirim et al.  concluded in his study that 3D images must be obtained and evaluated for all trauma cases.
In addition, Swadron and Majoewsky  stated that in patients with head injury, head CT will readily identify skull fractures, although fractures of the thinnest areas of the base of the skull may be missed in the axial cuts.
Mazziotti et al.  studied the usefulness of coronal reconstruction CT reformation for the completion of standard CT examination of the temporal bone through axial images. The conclusion was that coronal CT reformation should not be considered as an alternative to standard CT examination; however, it can represent a valid integration that provides additional information on particularly crucial regions of the temporal bone.
Jeffrey et al.  stated that for temporal bone fractures, the best imaging tool is CT and that the protocol advice for these fractures is bone algorithm axial helical CT with coronal reformats.
In our study, 50 patients had skull fractures, and MPR and 3D reconstruction images added diagnostic value in 18 of these patients (36% of patients presented with skull fractures). Fractures near the vertex were easily described, especially when loose bone fragments were found. In addition, depressed fractures were easily described, with accurate measurements of the depression. Fractures at the base of the anterior, middle, and posterior cranial fossae, as well as of the temporal bone, were described in the axial cuts, but with better confidence in the presence of MPR and 3D images.
Wagner  reported that CT scanning may fail to depict small hemorrhages because of the similarity in attenuation between blood and adjacent bone and because of streak artifacts in the posterior fossa and the inferior middle cranial fossa.
Messori et al.  stated that vertex epidural hematomas are well-known entities but are uncommon, may have a misleading clinical presentation, and may be missed by routine CT axial scanning; therefore, there may be a delay in their diagnosis, with possibly fatal consequences. Even with a definite diagnosis of cranial trauma, routine imaging techniques may fail to show an epidural hematoma at this rare location. Coronal and sagittal reconstructions of axial CT data can show even small vertex epidural hematomas.
In addition, Sodickson et al.  stated that subdural hematomas are most commonly missed when located at the vertex or the parafalcine and tentorial regions. This is related, in part, to the reduced conspicuity of thin hematomas adjacent to other high-attenuation structures such as the calvarium or dura (e.g. falx or tentorial leaflets), as well as to volume averaging of near-axial plane hematomas with the calvarial vertex or tentorial leaflets.
In our study, we had 44 patients with extra-axial hemorrhages (23 patients with subdural hematomas, 11 patients with subarachnoid hemorrhages, and 10 patients with epidural hematomas). In addition, our MPR images showed better demonstration in 10 patients (22.7% of patients presented with extra-axial hemorrhages). In these patients, the hemorrhages were near the vertex or the base of the anterior, middle, or posterior cranial fossae.
These findings are comparable to those of Wei et al.  , who in their study of 213 patients also showed that MDCT (coronal reformations) improved the detection of ICH compared with axial images alone in 29/104 (28%) findings.
According to Davis  , CT limitations include insensitivity in detecting small and nonhemorrhagic lesions such as contusions, particularly adjacent to bony surfaces. In addition, Osborn et al.  reported that hemorrhages near the vertex can be difficult to see on axial NECT scans.
Jeffrey et al.  reported that most cerebral contusions occur in the inferior anterior frontal lobes. They also stated that mixed density contusions can be mistaken for common artifacts caused by the orbital roof.
In our study, there were 19 patients (30%) with brain contusions distributed among the various brain compartments. MPR images improved the sensitivity and diagnostic confidence while making the final diagnosis in four patients (21% of patients presented with hemorrhagic contusions). The MPR images were better when the contusions were seen in the area near the vertex and the high parietal lobes. Also the contusions encountered in the frontal lobes adjacent to the orbital roof, the contusions found on the axial images were better and confidently described with the added values of the MPR. In the contusions near the greater wings of the sphenoid bone, the beam-hardening artifact was no longer a major concern. In general, contusions in areas near the bone were more accurately described along with MPR images rather than by axial images alone.
Our study also showed that MDCT in the form of MPR (coronal and sagittal reformats) and 3D reconstruction images provides additional diagnostic information in 32 (27%) of 118 MDCT findings.
These data are comparable to the results of a study by Zacharia and Nguyen  , who investigated the advantages of coronal and sagittal reformations obtained with CT in patients with acute head trauma. They reported that coronal and sagittal reformations confirmed subtle findings, which were undetected initially on transverse images in 10 (18.2%) of 55 cases with acute traumatic intracranial abnormalities. The better results in our study (27%) may be due to the added value of the 3D reconstruction images, which were not used in their study.
In a recent study by Kim et al.  designed to assess the value of 3D reformations to radiology residents in interpreting unenhanced emergency cranial CT scans, they stated that the main drawback of 3D reformations is the increased number of images necessary to review and the increase in the interpretation time for the readers. Their results showed that all readers took significantly longer to read 3D images than transverse images. However, they mentioned that abnormalities were somewhat or definitely better seen on 3D images versus transverse images in most lesions and concluded that the use of 3D reformations can improve diagnostic performance and reader confidence among radiology residents in the evaluation of emergency cranial CT.
| Conclusion|| |
The MPR and 3D reconstruction images allowed better visualization of skull fractures. With regard to extra-axial hemorrhages, MPR added more value to their diagnostic imaging. In addition, MPR better demonstrated parenchymal brain contusions.
Hence, for all patients with acute head trauma who showed negative axial images, MPR and 3D reconstruction images should be carefully examined before the final diagnosis is confirmed.
We recommend that MDCT be the prime consideration for imaging in every patient with acute head trauma.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]