A.

Traumatic Brain Injury

3. Mechanisme Traumatic Brain
Injury
PRIMARY LESION
PROJECTILE (MISSILE ) INJURY
GUNSHOT WOUNDS
EXTRAAXIAL HEMORRHAGE
SPEAR INJURY
BLUNT INJURY (SUDDEN
SUBARACHNOID HEMORRHAGE
DECELERATION OR ROTATION)
SUBDURAL HEMATOMA
AUTOMOBILE ACCIDENTS
FALL FROM HEIGHTS
EPIDURAL HEMATOMA
DIRECT BLOW
INTRAAXIAL HEMORRHAGE
4. Glasgow Coma Scale
DIFFUSE AXONAL INJURY
MINOR HEAD INJURY SCORE
13-15
CORTICAL CONTUSION
MODERATE HEAD INJURY
SUBCORTICAL GRAY MATTER INJURY
SCORE 9-12
SEVERE HEAD INJURY SCORE
PRIMARY BRAINSTEM INJURY
LESS 8
FRACTURES

1. Classification of Injury

SECONDARY LESION
BRAIN HERNIATIONS
TRAUMATIC ISCHEMIA
DIFFUSE CEREBRAL EDEMA
HYPOXIC BRAIN INJURY
2. General Information
IMAGING APPEARANCE ;
MR = CT FOR DETECTION OF HEMORRHAGE INJURY OLD LESION
CONTAINED HEMOSIDERIN,WITH LOW SIGNAL ON T2(MR)
MR > CT FOR DETECTION OF NON HEMORRHAGE, LESION AND
EXTRAXIAL FLUID COLLECTIONS
ACUTE LESION : LOW SIGNAL ON T1WI ,HIGH SIGNAL ON
T2WI
(EDEMA))
CHRONIC LESION : - HIGH SIGNAL ON T2WI
( DEMYELINISATION,
GLIOSIS )
ANGIOGRAPHY
BLUNT TRAUMA RESULT IN INTIMAL TEAR, PSEUDOANEURYSM
DISSECTION,THROMBOSIS,OR EMBOLIZTAION
PENETRATING
TRAUMA-CAN
RESULT
IN
INTIMAL
TEAR,LACERATION,PSEUDOANEURYSM,
ARTERIOVENOUS
FISTULAE,OR OCCLUSION

5. Score

EYE OPENING
SPONTANEUS = 4
TO SOUND
=3
TO PAIN
=2
NONE
=1

BEST MOTOR RESPONS

OBEYS COMMAND
=6
LOCALIZES PAIN = 5
NORMAL FLEXION
=4
ABNORMAL FLEXION = 3
EXTENSION
=2
NONE
= 1

BEST VERBAL RESPONSE

Subarachnoid Hemorrhage (SAH)
ORIENTED
=5
CONFUSED
=4
INAPPROPRIATE WORDS
=3
INCOMPREHENSIBLE
=2
NONE
=1
B. PRIMARY BRAIN INJURY
SUBARACHNOID HEMORRHAGE
CEREBRAL CONTUSION
SHEAR INJURY
EXTRA-AXIAL HEMORRHAGE
1. General Information
CORTICAL CONTUSION
BRUISE OF BRAIN SURFACE- INFERIOR FRONTAL AND ANTEROINFERIOR TEMPORAL LOBE VULNERABLE
COUP INJURY LIES BENEATH AREA OF IMPACT
CONTRECOUP OCCUR REMOTE FROM INJURY,IN DIRECT LINE
OPPOSITE SITE OF IMPACT,CAUSED BY ACCELERATION EFFECT
2. Subarachnoid Hemorrhage (SAH)
CT CONFIRM DIAGNOIS IN 95 % IF WITHIN 48 HOURS OF THE BLEED
BLOOD MAY DSTRIBUTED :
BASAL CISTERN,SYLVIAN,INTERHEMISPHERIC FISSURES.
OVER CORTICAL SULCI
MORE LOCALISED AIDING INDENTIFICATION THE SITE OF RUPTURE
ANEURYSM
WITHIN SYLVIAN FOR MIDDLE CERBRAL ANEURYSM
INTERHEMISPHERIC FISSURE ANTERIOR COM.ANEURYSME
PERIMESENCEPHALIC
PATTERN

BLOOD
RESTRICTED
TO
INTERPEDUNCULAR REGION AND NOT EXTEND TO SYLVIAN OR
INTERHEMISHEREIC FISSURE
MRI NOT ROUTINELY USED

3. Epidural Hematoma (EDH)

TYPE :
1.ARTERIAL EDH ,90 % (MIDDLE MENINGEAL ARTERY)
2.VENOUS EDH ,10 % (SINUS LACERATION,MENINGEAL VEIN )

POSTERIOR FOSSA : TRANSVERSE OR SIGMOID SINUS

LACERATION.

PARASAGITAL : TEAR OF SUPERIOR SAGITAL SINUS.

LARGE EDH NEUROSURGICAL EMERGENCY.
SMALL EDH (LESS 5 MM THICK) DO NOT REPRESENT A CLINICALLY
EMERGENCY
95% EDH ARE ASSOCIATED WITH FRACTURES.
4. EDH Radiographic Features
ARTERIAL EDH
95% UNILATERAL,TEMPOROPARIETAL
BICONVEX,LENTICULAR SHAPE
DOES NOT CROSS SUTURE LINE
MAY CROSS DURAL REFLECTION (FALX TENTORIUM )
ASSOCIATED WITH SKULL FRACTURE
HETEROGENEITY DENSITY PREDICT RAPID EXPANSION, AREA LOW
DENSITY REPRESENT ACTIVE BLEEDING
CT EXAM OF CHOICE-QUICK,INSENSITIVE TO MOTION
MR MORE SENSITIVE FOR COEXISTING PARENCHYMAL BRAIN INJURY
VENOUS EDH
MORE VARIABLE IN SHAPE (LOW PRESSURE BLEED)
OFTEN REQUIRED DELAYED IMAGING BECAUSE DELAYED ONSET OF
BLEED AFTER TRAUMA
5. Subdural Hematoma (SDH)
CAUSED BY TRAUMATIC TEAR OF BRIDGING VEIN
NO CONSISTENT RELATIONSHIPS TO THE PRESENCE OF SKULL
FRACTURE
INFANT COMMON 80%CHILD ABUSE ARE BILATERAL OR INTERHEMISPHERIC
ELDERY 20% ARE BILATERAL
6. SDH Radiographic Features
MORPHOLOGY HEMATOMA
95% SUPRATENTORIAL,CRESCENTIC SHAPE ALONG BRAIN
SURFACE,CROSSES SUTURE LINES,DOES NOT CROSS DURAL
REFLECTION (FALX,TENTORIUM)
HEMATOMA CLASSIFIED : ACUTE (1-7 DAYS) ; SUBACUTE (7-21
DAYS) ; CHRONIC (>21 DAYS).
HEMATOMA APPEARANCE :
CT
: ACUTE = DENSE; SUBACUTE = ISODENSE;
CHRONIC = HYPODENSE
T1WI : ACUTE =ISOINTENS;SUBACUTE HYPERINTENSE;

CHRONIC = HYPOINTENS
T2WI : ACUTE =HYPOINTENS;SUBACUTE=HYPERINTENS;
CHRONIC = ISOINTENS
MR CAN IDENTIFY AGE OF LESION DUE TO SIGNAL INTENSITY
DEOXYHEMOGLOBIN VS INTRACELLULAR METHEMOGLOBIN VS
EXTRACELLUALR METHEMOGLOBIN)
CHRONIC SUBDURAL DIFFER FROM PARENCHYMA HEMATOMASISOINTENSE WITH BRAIN ON T1 AND DO NOT DEMONSTRATE
HEMOSIDERIN DEPOSITION (UNLESS RECURRENT).

7. Comparison
EDH :
SDH :
a. INCIDENCE LESS 5% OF TBI
b. CAUSE FRACTURE
a. 10-20 % OF TBI
c. LOCATION BETWEEN SKULL AND DURA
b. TEAR OF CORTICAL VESSEL
d. SHAPE BICONVEX
c. BETWEEN DURA AND
e. CT 70% HYPER-30% ISODENSITY
SUBARCHNOID
f. T1W MRI ISOINTENS
d. CRESCENTIC
e. VARIABLE DEPENDING ON

8. Subdural Hygrom
AGE
f. VARIABLE
DEPENDING ON
ACCUMULATION OF CSF IN SUBDURAL SPACE
AFTER TRAUMATIC
ARACHNOID TEAR.
RADIOGRAPHIC FEATURES ;
CSF DENSITY
DOES NOT EXTEND INTO SULCI
MAIN DIFFERENTIAL DIAGNOSIS :
a. CHRONIC SDH
b. FOCAL ATROPHY WITH WIDENED SUBARCHNOID SPACE
9. Cerebral Contusion
a. FOCAL HEMORRHAGE /EDEMA IN GYRI SECONDARY TO BRAIN
IMPACTION OR ROTATIONAL FORCES ON BONE OR DURA
b. LOCATION
: ANTERIOR TEMPORAL POLES ,INFERIOR FRONTAL
OLES,PARASAGITAL HEMIPHERES,BRAINSTEM
c. CT INITIAL CT IS OFTEN NORMAL,LATER LOW DENSITY (EDEMA )
WITH IREGULER AREAS OF HIGH DENSITY (HEMORRHAGES)
DEVELOP.

Cerebral Contusion

10.
a.
b.
c.
d.

Shear Injury
DISRUPTION OF AXON FROM THE CELL BODY CAUSED BY
ACCELERATON OR DECELERATION FORCES.
LOCATION : GM / WM JUNCTION,CORPUS CALOSAL, BRAINSTEM
CT EDEMA AND PETECHIAL HEMORRHAGE DEVELOPS LATER,
INITIAL EXAMINATION MAY ALSO APPEAR NORMAL
MRI IS BETTER EXAMINATION BUT IS NOT FEASIBLE IN ACUTE
SETTING

11.

Diffuse Axional
Injury