Brain and Cervico-Medullary Injury : Patterns and Mechanisms
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1 Brain and Cervico-Medullary Injury : Patterns and Mechanisms P. Ellen Grant MD Associate Professor of Radiology, HMS Director, Center for Fetal-Neonatal Neuroimaging & Developmental Science Children s s Hospital Boston Chair in Neonatology Children s s Hospital Boston 1
2 Radiological Manifestations of Abusive Head Trauma Skull Fractures Subdural Collections Brain Injury Spinal Injury 2
3 Patterns of Brain Injury Cardiorespiratory Arrest Respiratory Arrest Anoxia Normal imaging Contusional Tears Big Black Brain Associated Spinal Injury Infant Brain is different Delayed cell death 3
4 Infant Brain Very Different Relative size head to body(10% vs 2% wt) Weak neck Soft pliable calvarium Open sutures and fontanelles Lack of myelination Cell death mechanisms Receptors, biochemical cascades
5 Cardiorespiratory Arrest 18h T2 DWI ADC 2 year old choked on candy, no one knew heimlich maneuver Imaging suggests minimal injury?.
6 46h Cardiorespirator y Arrest 8.5h 57h 18h 4d 14.5h Grant PE, Yu D. Radiol Clin North Am Jan;44(1):63 77
7 Mechanisms of Cell Death 1. Acute Necrosis 2. Necrosis like 3. Apoptosis (Type I) 4. Autophagic (Type II) Programmed Cell Death REALLY A SPECTRUM... Leist M, Jaatela M. Four Deaths and a Funeral: From Caspases to Alternative Mechanisms. Nature Reviews 2001;2:1-10. Blomgren K, Leist M, Groc L. Pathological apoptosis in the developing brain. Apoptosis 1007;12:
8 Mechanisms of Cell Death Ferriero D. N Engl J Med, 2004;351:
9 Patterns of Brain Injury Cardiorespiratory Arrest Respiratory Arrest Anoxia Normal imaging Contusional Tears Big Black Brain Associated Spinal Injury Infant Brain is different Delayed cell death 9
10 Abusive Head Trauma ADC Evolution 18hrs ~2d (59h) ~4d (93h) ~8d (184h) 2 month F/U Respiratory Arrest ADC T2
11 Patterns of Brain Injury Cardiorespiratory Arrest Respiratory Arrest Anoxia Normal imaging Contusional Tears Big Black Brain Associated Spinal Injury Infant Brain is different Delayed cell death 11
12 Abusive Head Trauma CT at Presentation 6 mo old, Seizures, Unresponsive
13 un responsive ~12h Abusive Head Trauma T2 DWI ADC
14 Abusive Head Trauma Initial ADC ~ 12 hrs ADC 3 Days ADC 4 Days
15 Confessed Shaking On Admission Hypoxic Ischemic Pattern 18 Days Later
16 Abusive Head Trauma MRI 6 Months Later Acute DWI can miss injury
17 Mechanisms of Cell Death 1. Acute Necrosis 2. Necrosis like 3. Apoptosis (Type I) 4. Autophagic (Type II) Programmed Cell Death REALLY A SPECTRUM... Leist M, Jaatela M. Four Deaths and a Funeral: From Caspases to Alternative Mechanisms. Nature Reviews 2001;2:1-10. Blomgren K, Leist M, Groc L. Pathological apoptosis in the developing brain. Apoptosis 1007;12:
18 Patterns of Brain Injury Cardiorespiratory Arrest Respiratory Arrest Anoxia Normal imaging Contusional Tears Big Black Brain Associated Spinal Injury Infant Brain is different Delayed cell death 18
19 Contusional Tears 3D Surface Reconstruction CT Scan at Presentation
20 T2 SWI DWI ADC blood Injured tissue
21 Evolution of Injury T2 Day of Admission 3 Days 14 Days 20 Days Presentation 3 days 14 days 20 days
22 Mechanisms of Cell Death Ferriero D. N Engl J Med, 2004;351:
23 Contusional Tears Confusing if pathology not known Characteristic of blunt head trauma in infants < 5 months Slit-like like cleft in white matter +/- hemorrhage Horizontal cortical tears at gyral crests May be associated with diffuse white matter injury Jaspan et al. Pediatric Radiology 1992;22:
24 Choudhary AK, et al. Radiology 2012;262(1): Associated Spinal Injury > 60% of children with abusive head trauma who underwent spinal imaging have associated spinal injury
25 Abusive Head Trauma Admission 24 hrs later 5 weeks old Metaphyseal 25 and multiple rib #, suspicion of liver laceration
26 Evidence of Spinal Trauma Later the same day Later 26 the same day
27 Patterns of Brain Injury Cardiorespiratory Arrest Respiratory Arrest Anoxia Normal imaging Contusional Tears Big Black Brain Associated Spinal Injury Infant Brain is different Delayed cell death 27
28 Big Black Brain CT concerning Hypoxic Ischemic Pattern mo fall from couch 28
29 Abusive Head Trauma MRI Confirms Hypoxic Ischemic Pattern 29 25
30 MRI Confirms Hypoxic Ischemic Pattern 30 26
31 BBB + Spinal Trauma courtesy Michelle Silvera
32 Secondary Impact Syndrome Class IV, case series 10 cases Initial head injury +/- LOC leading to post concussive symptoms Second direct or indirect (acceleration) impact while still symptomatic (hours to weeks) leads to rapid decline repetitive injury affect CT shows thin SDH, massive swelling Does repetitive presentation in AHT? 32 Cantu and Gean. J of Neurotrauma 2010;27:1557
33 Neurometabolic Cascade Ionic shifts Altered brain metabolism Impaired neuronal connectivity Disruption of normal neurotransmission Giza and Hovda. J Athle Train 2001;36:228-35
34 Can ASL Improve Detection? Normal routine MRI, 67 d, visual tracking concerns but normal on follow up. Normal routine MRI, 101 d, multiple rib # of at least 2 ages, bruising in multiple regions. Skull fracture. T2 TSE ADC T2 TSE ADC CT MIP
35 Can ASL Improve Detection? Mean Cerebral Perfusion 27.2 ml/100g/min Mean Cerebral Perfusion 71.1 ml/100g/min
36 Can NIRS Improve Detection? Frequency Domain (FD) NIRS Diffuse Correlation Spectroscopy (DCS) NIRS detected brain injury in neonatal hypoxic ischemic injury What about NAT? 36 Quantitative StO2 CBV CBFi CMRO2 Grant, Franceschini
37 Patterns of Brain Injury Cardiorespiratory Arrest Respiratory Arrest Anoxia Normal imaging Contusional Tears Big Black Brain Associated Spinal Injury Infant Brain is different Delayed cell death 37
38 Mechanisms of Abusive Brain Injury Window of Opportunity 38
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