Traumatic Brain Injury (TBI) night fear happy end. G. Adam, R. Radeva, G. Kirova
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1 Traumatic Brain Injury (TBI) night fear happy end G. Adam, R. Radeva, G. Kirova
2 Chapter 1 Night
3 10 th June hot summer night resident on call for 12 h Saturday Night 22:00 h call from the emergency department shouting... WE NEED A RADIOLOGIST FOR A CT IMMEDIATELY
4 Chapter 2 Fear Everything worth doing starts with being scared
5 While driving I wondered about several questions 1. What have happened? 2. Is it a child? 3. Is it going to be CT of: head abdomen /ileus/ aortic dissecation or? 4. Am I going to spot everything quickly? pexels
6 no information in the hospital system his name wasn t written > Unknown In the diagnostic imaging department (because no identity was presented) 10 people personnel came to the CT unit a little nightmare... Amazon.com
7 car accident 2 victims: 1 st conscious; 2 nd unconscious random people saw crashed car & stopped to help The story Patient (man, 23 y) was taken in car s truck & brought up in the nearest hospital Tokuda He was in coma, unstable hemodynamics, If you can t beat fear do it scared! non effective breathing, hematemesis GCS 3: wide nonreactive pupils; NO verbal/motor response Anesthesiologist intubated him
8 CT protocol traumatic patient Banksy 1. Head NATIVE 2.5 mm & mm reconstruction for bones VR (Volume Rendering) bones identify any focal intracranial lesions for neurosurgical intervention! 2. Cervical spine NATIVE From above C1 to T1 bottom + axial/sagittal/coronal view analysis 3. Chest /Abdomen/Pelvis (+ to knees in hemod. unstable) 2.5 mm CT + Contrast (because non contrast is of NO value) ALL (soft tissue/lung/bone) windows + Cor/Sag reconstruction for thoracic & lumbar spine
9 CT protocol traumatic patient Banksy Chest /Abdomen/Pelvis 1. NATIVE 2. + CONTRAST 1 st inject 70 ml 2 nd wait 20 sec. 3 rd inject 60 ml 4 th Scan In this way we have 2 in 1 (both arterial & venous phase)
10 Parents came & wanted to transfer their son in another hospital Police was expected to investigate the case Continued in the radiology department If the patient was going in another hospital than he needed CD with the CT examination Residents could not finish or sign examinations! And what if the patient died & the CT examination is confirmed & signed by a specialist on Monday (2 days later)?!
11 Then Or The Boss HELP call a friend the toast.net
12 Meanwhile what did I see?
13 Head CT of patient 10/06 Fractures calvaria & base: R parietal/temporal bone bilateral pyramid fractures sphenoidal bone clivus occpital bones sphenoidal sinus, ethmoidal cells & nose cavity with blood Intracranial changes: Pneumocephally Subarachnoid hemorrhage Brain edema; Mass effect
14 Fractures linear fracture R parietal bone
15 Fractures linear fracture R parietal/temporal bone
16 Fractures linear fracture R mastoid
17 Fractures linear fracture Left mastoid
18 Fractures multiple shpenoid bone
19 Fractures occipital till foramen magnum
20 Pneumocephally
21 lood content thmoid cells axillar sinus phenoid sinus
22 Blood content Mastoid cells
23 Subarachnoid hemorrhage
24 Brain edema
25 Mass effect effacement of basal cisterns
26 Neck CT C1 air in vert. canal T1
27 Control Head CT 1 day after 11/06 In comparison with the previous CT Better depicted fracture lines of calvaria, cranium s base bilaterally, through the mastoid processes to foramen magnum Blood dense content in sphenoid, maxillar sinuses & ethmoid cells Reduction of pneumocephally (frontal; sellar) Insignificant hemorrhage subarachnoid over tentorium & intraventricular under 3 rd ventricle Reduction of brain edema
28 Mastoid Sphenoid Clivus Occipital Control CT
29 Sinuses Blood content Control CT
30 Reduced: - brain edema - mass-effect - pneumocephally -SAH Control CT
31 MRI 3 days after 13/06/17 Post contusion brain parenchyma changes Hemorrhagic changes in subacute phase Contusion: changed SI, restriction of diffusion Small SAH Hemorrhage: mesencephalon pons hypophysis suspicious (T1 high SI; T2 loss of SI) Reduced brain edema
32 frontal MRI parietal Postcontusion changes in brain parenchyma + Reduced brain edema occipital
33 MRI SAH tentor. R subdural
34 MRI SWI Hemorrhage Black mesencephalon pons Sonypictures.com hypophysis
35 MRI Blood content mastoid cells
36 Tonsillar position normal
37 Follow-up after 3 months 28/09/17 EEG Severe partial axonal damage of 3rd & 7th cranial nerve L
38 Chapter 3 Happy End
39 Follow-up after 1 month 03/10/17 EEG In norm for the age Small diffuse non specific changes
40 Follow-up after 1 month 15/11/17 Neurological examination control because of 3 rd & 7 th L cranial nerves deficit mouth angle is going upright persistence of left eye ptosis & double vision with subjective improvement GCS 15 Coordination & gait in norm No incontinence... for control MRI after 1 year
41 Don t stop dreaming just because you had a nightmare
42 Causes of TBI alteration in brain function or other evidence of brain pathology caused by an external force 1. falls 0 14 y; y 2. traffic acidents y 3. sports 4. military conflict situations (terrorist attacks) rise; blast injuries = complex injuries The Lancet Neurology Commission online Nov. 6, (17)30371 X
43 TBI Fall more often cause bruises (contusions) Traffic related injuries result in immediate shearing of connecting nerve fibres or progressive loss of connectivity over time 1. primary damage at the time of injury 2. secondary damage evolves over hours months/years; driven by host responses to the primary injury The Lancet Neurology Commission
44 15 (max.) GOOD Goergen S, Varma D, Tavender E, Rosenfeld JV, Cho S M, Whiteman I, et al. Adult Head Trauma. Education Modules for Appropriate Imaging Referrals: Royal Australian and New Zealand College of Radiologists; 2015
45 In our patient GCS 3 3 (min.) BAD Goergen S, Varma D, Tavender E, Rosenfeld JV, Cho S M, Whiteman I, et al. Adult Head Trauma. Education Modules for Appropriate Imaging Referrals: Royal Australian and New Zealand College of Radiologists; 2015
46 1. Mild (70 90% of pts) do not require surgery 2. Moderate 3. Severe high mortality rate (57,000/y in EU) risk factor for epilepsy, stroke, late life neurodegenerative disease The Lancet Neurology Commission online Nov. 6, (17)30371 X
47 Modality of choice for brain trauma in adults & children! Head CT in TBI NATIVE LOOK for: 1. Fractures 2. Hematomas 3. Mass effect
48 Head CT in TBI angiography only in cases: To diagnose blunt injury to vertebral or carotid arteries following: evidence of acute stroke on native CT scan fractures involving vertebral foramen transversarium
49 Acute trauma approach Outside in: (subcutaneous fractures hematomas brain) Fluid in sinuses > think of fractures Repeat CT when needed MRI after 1 week for DAI check
50 Gives greater anatomic detail of brain! DAI/TAI MRI (Diffuse axonal injury/traumatic axonal injury) Contusions Ischemia MRI CT VS.
51 Outside In Subcutaneous emphysema Subcutaneous hematoma
52 Outside In Fractures calvaria/base
53 Outside In Hematomas 1.Extra-axial Epidural arterial (LEns) can expand rapidly Subdural venous (crescent) +bruised underlying brain Subarachnoid hemorrhage (Intraventricular)
54 1. Contusion: a focal area of parenchymal disruption (frontal & temporal) Intra-axial brain injury 2. Intraparenchymal hemorrhage 3. Diffuse Axonal Injury (MRI SWI) detecting scattered small hemorrhagic/nonhemor. lesions
55 1. Midline shift Mass effect 2. Cisternal compression 3. Stem compression
56 Take Home Messages Traumatic Brain Injury Be informed about the patient = Be well prepared! CT protocol: NATIVE: head Reconstruct in 0,625 & VR; cervical spine head+c only in suspicious carotid/vertebral pathology NATIVE + C: chest+abdomen+pelvis Reconstruct spine Don t forget to send the reconstructions in PACS Act quickly BUT think carefully
57 Have an approach for head injury Outside In Take Home Messages Traumatic Brain Injury 1. Fractures? 2. Hematomas/Hemorrhages? 3. Edema? 4. Mass effect? (hemorrhage/mass/edema) Look for SUBTLE changes Analyze in different windows & planes!
58 Take Home Messages Traumatic Brain Injury Do FOLLOW UP examinations: Head CT to notice changes Head MRI SWI after 1 week to detect DAI
59 Take Home Messages Traumatic Brain Injury Do NOT panic it won t help ;) patient s management is a complex process with many people involved > you are not alone in the decision making To err is human! Call a specialist when you hesitate better to share the nightmare Believe in yourself!
60 G. Adam, R. Radeva, G. Kirova
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