Normal Findings in a Cranial CT

Kidney Stones Radiology

Fig. 14.21 a This is a normal CT of a 50-year-old. The inner and outer CSF spaces are well appreciated. Gray and white matter are easily differentiated from each other and are of normal density. b The basal and posterior fossa cisterns are also well seen.

I Generalized Brain Edema Due to Head Trauma

I Generalized Brain Edema Due to Head Trauma

Brain Finding Csf

Fig. 14.22 This 40-year-old patient was hit by a wooden plank falling from a building. The pupils had already become unreac-tive to light in the ambulance helicopter. a In comparison to the normal CT (see Fig. 14.21a), the inner and outer CSF spaces are completely obliterated and differentiation between the gray and white matter is impossible. The sylvian fissure and the frontal sulci are outlined with dense material (blood). The midline is not displaced, however. These findings are compatible with severe generalized brain edema and subarachnoid hemorrhages. b A more cranial CT section in a bone window shows the reason for the extensive changes: a burst fracture of the skull. As the cranial

Fig. 14.22 This 40-year-old patient was hit by a wooden plank falling from a building. The pupils had already become unreac-tive to light in the ambulance helicopter. a In comparison to the normal CT (see Fig. 14.21a), the inner and outer CSF spaces are completely obliterated and differentiation between the gray and white matter is impossible. The sylvian fissure and the frontal sulci are outlined with dense material (blood). The midline is not displaced, however. These findings are compatible with severe generalized brain edema and subarachnoid hemorrhages. b A more cranial CT section in a bone window shows the reason for the extensive changes: a burst fracture of the skull. As the cranial vault does not permit sufficient expansion of an edematous brain, the intracranial pressure consequently increases. In less severe states of edema, a conservative antiedematous therapy or a wide surgical fenestration of the skull may be successful—in this patient any help comes too late. c A CT image at the level of the posterior fossa demonstrates a complete lack of external CSF space. The fourth ventricle is filled with blood (compare Fig. 14.21b). This patient was later transferred to the intensive care ward for the determination of brain death (24-hour flatline EEG, neurological examination). Hopefully, organ donation is an option in this case to help someone else in need.

develop, resulting in death or permanent brain damage. A similar diffuse edema may be the sequel of a longer-lasting brain hypoxia, for example, in prolonged shock, drowning, suffocation, or strangulation (Fig. 14.23). The consequences are identical.

Epidural hematoma: An epidural hematoma (Fig. 14.24) carries a high risk for the patient. It is often an arterial, fracture-induced bleed. It fills the space between the skull bone and its periostium, the dura mater. This space is, of course, limited by the cranial sutures where the periosteum is tightly fixed. Any blood in this space will elevate the dura, assuming the shape of an expanding cushion. Relatively little blood can thus result in quite a pulsating space-occupying lesion affecting the adjacent brain like a "steam hammer." This development can be very swift and is naturally accelerated by a successful circulatory stabilization. Immediate neurosurgical intervention is life-saving!

Subdural hematoma: A subdural hematoma (Fig. 14.25a), induced by tearing of bridging veins, can spread relatively freely underneath the dura mater (from the viewpoint of the neurosurgeon opening the skull)—subdurally. The bony sutures do not hinder the spread. Frequently, however, an acute subdural hematoma goes along with brain contusions that significantly worsen the prognosis. Considerably better are the chances of patients in whom a subacute subdural hemorrhage manifests itself only after an interval free of neurological symptoms. The longer

Generalized Brain Edema Due to Strangulation

Brain Cranial Stability

Fig. 14.23 This unhappy young man strangled himself in an effort to commit suicide. The hypoxia has led to a generalized edema. There are no hemorrhages to note on the precontrast image (not shown). The normal bright structure in the midline is the falx cerebri. The contrast-enhanced CT shows the superior sagittal venous sinus dorsally. The bright spots ventrally in the midline are the anterior cerebral arteries; the very dense midline spots a little dorsal to the center are typical calcifications in the pineal gland.

Fig. 14.23 This unhappy young man strangled himself in an effort to commit suicide. The hypoxia has led to a generalized edema. There are no hemorrhages to note on the precontrast image (not shown). The normal bright structure in the midline is the falx cerebri. The contrast-enhanced CT shows the superior sagittal venous sinus dorsally. The bright spots ventrally in the midline are the anterior cerebral arteries; the very dense midline spots a little dorsal to the center are typical calcifications in the pineal gland.

I Epidural Hematoma

I Epidural Hematoma

Images Clinical Radiology

Fig. 14.24a The initial CTwas performed immediately after the polytraumatized patient had reached the emergency unit. There is a considerable right-sided scalp hematoma. There is no evidence for cerebral edema; the midline structures are not shifted. b A few hours later, the patient has become comatose. Repeat study reveals a typical epidural hematoma in the right frontal region. The bleed does not traverse the coronal suture (arrow) posteriorly. The brain surface appears considerably indented ("steamhammer effect"). The midline is now shifted to the left by more than 1.5cm. Not only the brain but also the supplying cerebral arteries are displaced and consequently squeezed against the falx cerebri and the tentorium. Immediate relief by craniotomy is needed to save this patient. c The follow-up study after the craniotomy documents the detrimental consequences of the midline shift. The vascular territories of the anterior and posterior cerebral artery as well as parts of the territory of the medial cerebral artery on the right are swollen and decreased in density—all of this is indicative of brain infarction. Parietally on the right there is an additional brain hemorrhage—due either to a traumatic contusion or to a hemorrhagic infarction. There is some residual postsurgical air seen in the epidural space. The midline shift has decreased only minimally—by now it is caused by the pronounced edema of the right hemisphere. d In this neonate who fell off the table during a diaper change, a right frontal epidural hematoma is accompanied by severe global edema.

| Subdural Hematoma_

Fig. 14.25 a This patient was involved in a high-speed motor vehicle accident and suffered a head trauma. As a consequence, a large subdural hematoma developed on the left that spread over the surface of the brain and led to a substantial midline shift. The brain contusion has resulted in an intraparen-chymal hemorrhage, which is seen frontally on the left. Faint subarachnoid blood is seen bilaterally (see Fig. 14.27 for comparison). Immediate neurosurgical intervention is also necessary in this patient. b This woman complained about a continuing headache since she hit her head against a low ceiling in her basement. The cranial CT shows a right-sided chronic subdural hematoma that has a fluid-fluid level (serum above and the erythrocytes in the dependent part of the hematoma) and very little resulting mass effect.

Subdural Hematoma With Midline ShiftBrain Fluid Pocket Name
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