Neuroradiological Findings in Non- Accidental Trauma

36 Pages·2016·3.06 MB·English

by  Katkar, Amol

Neuroradiological Findings in Non-
Accidental Trauma — Educational Pictorial
Review
M B Moss, MD; L Lanier, MD; R Slater;
C L Sistrom, MD; R G Quisling, MD;
I M Schmalfuss, MD; and D Rajderkar, MD
Contact: [email protected]
College of Medicine - University of Florida, Gainesville, FL, United States.
Disclaimer: We do not have any conflict of interest or financial gain to disclose
Outline
1. Simulation-SIM as assessment tool
2. Clinical and Neuroradiolgical findings of Non-
Accidental Trauma (NAT)
3. Pitfalls
Congenital infections
Birth related injuries e.g. subdural tentorial hematomas
4. Search pattern to prevent observational errors
5. Assertive guidelines to call NAT to avoid cognitive
errors
6. Recommended imaging plan for a follow up
Background
➢Computer aided simulation (SIM) was developed and
designed to test residents for readiness for call
➢8 hour simulation of 65 emergent & critical care cases of
varying degrees of difficulty, including normal studies
using full DICOM image sets
➢SIM was taken by 127 first (R1) & second (R2) year
residents from 16 USA radiology training programs
Results
➢75% of the residents either called the study normal
(observational error) or gave an incorrect diagnosis
(cognitive error)
➢No significant difference between R1 and R2 residents
with an average scores of 17 versus 25% respectively
Conclusion: Significant observational and
cognitive gap exists in detecting and
differentiating NAT from other disease entities
Neuro NAT Manifestations
Brain:
 Axial loading injury - Skull fracture
 High impact trauma - Skull base fracture & brain injury
 Penetrating trauma
 Shaking Injury - Diffuse axonal injury & SDH
 Shearing injury
 Venous tethering
 Asphyxiation/Hypoxic brain injury
 Long term sequelae - Global atrophy
Spine
 Axial loading injury - Vertebral compression fracture
 Spinal cord injury
SIM Case
1 2
75% of the
residents failed
to make the
diagnosis
indicating the
need to revisit
4
3
the radiology
of NAT
Fig 1 - Extensive scalp hematoma (white arrows) with associated skull fracture (red arrows)
Fig 2 - Right sided posterior rib fractures (yellow arrows), better identified on zooming (Fig
3) and changing windows (Fig 4)
Traditional Radiology Teaching of Neuro NAT
Prominent extra-axial spaces (between Larger subdural hemorrhage (SDH) (white
purple arrows) predispose for extra-axial arrows) is an uncommon spontaneous event
bleeding after getting shaken. Repetitive in infants. Other types of blood collections
shaking leads to mixed age of extra-axial include: subpial (yellow arrow) & intradural
blood products (white arrows). (pink arrow) hemorrhage and subdural
hygromas (purple arrows)
Traditional Radiology Teaching of Neuro NAT
Fig 1 & 2 - Axial loaded skull fracture (red arrows) Typical transverse fracture of the temporal
bone (red arrows)
1 2
3 4
Axial CT (Fig 3) shows transverse oriented fracture
(pink arrow) with its complete extent better
demonstrated with on the 3D reformation (Fig 4)
A complete review of the additional
findings in NAT
Cervical Spine/Cord Injury
 Most commonly from a shaking/”whiplash” type
mechanism
 May damage the lower brainstem and upper
cervical cord
• Could present as apnea and hypoxia.
 Subdural and epidural cord hematomas, cord
contusion and ligamentous rupture
 Cervical spine MRI must be performed if there is
any clinical suspicion of shaking-type injury
Spinal Trauma
Axial loaded associated
Long segment spinal cord
spinal column injury
edema
1 2
Sagittal (Fig 1) & axial (Fig
2) T2 images reveal spinal
cord edema extending from Lateral lumbar spine X-ray shows
the foramen magnum to C7 typical compression deformity of
level (red arrows) a vertebral body (white arrow)
Teaching point: Cervical spine CT without bony injury is clearly
underestimates the extent of cord injury