Neurotrauma: the role of CT angiogram

Imaging of head trauma

Imaging is an indispensable part of the initial assessment and subsequent management of patients with head trauma. Initially, it is important for diagnosing the extent of injury and the prompt recognition of treatable injuries to reduce mortality. Subsequently, imaging is useful in following the sequelae of trauma. In this chapter, we review indications for neuroimaging and typical computed tomography (CT) and magnetic resonance imaging (MRI) protocols used in the evaluation of a patient with head trauma. We review the role of CT), the imaging modality of choice in the acute setting, and the role of MRI in the evaluation of patients with head trauma. We describe an organized and consistent approach to the interpretation of imaging of these patients. Important topics in head trauma, including fundamental concepts related to skull fractures, intracranial hemorrhage, parenchymal injury, penetrating trauma, cerebrovascular injuries, and secondary effects of trauma, are reviewed. The chapter concludes with advanced neuroimaging techniques for the evaluation of traumatic brain injury, including use of diffusion tensor imaging (DTI), functional MRI (fMRI), and MR spectroscopy (MRS), techniques which are still under development.

Angiographic detection of carotid and vertebral arterial injury in the high-energy blunt trauma patient

BACKGROUND AND OBJECTIVE

Injury to the carotid and vertebral arteries is an identified risk to patients after blunt high-energy cranio-cervical trauma with an associated risk of thromboembolic stroke. We sought to determine the incidence, features, and risk factors of arterial injury using selective cerebral angiography in a high-risk trauma patient subset.

METHODS

Blunt trauma patients with a high-energy mechanism were selected to undergo screening cerebral angiography if they met one of the following criteria: (1) cervical spine hyperextension/hyperflexion injury, (2) skull-base or facial fracture, (3) lateralizing neurologic deficit, ischemic deficit, or cerebral infarction, or (4) hemorrhage of arterial origin.

RESULTS

Of 69 screened patients 20 were found to have a vascular injury (28.9%), including 13 carotid and 15 vertebral; 9 of the 20 patients with vascular injury were symptomatic (45%). The most frequent injuries were intimal dissections (8/28), pseudoaneurysms (6/28), and vessel occlusions (5/28); 8 lesions were intracranial and 20 cervical. Displaced facial fractures (P<0.02) but not skull-base fracture were predictive of carotid injury; multilevel cervical spine fractures (P<0.001) and transverse foraminal fractures (P<0.02) were associated with vertebral injury.

CONCLUSIONS

Cerebral angiography in a selected group of trauma patients was found to yield a significant rate of carotid and vertebral arterial injury, a finding that had implications to subsequent clinical management.

Neuroimaging in traumatic brain imaging

Traumatic brain injury (TBI) is a common and potentially devastating clinical problem. Because prompt proper management of TBI sequelae can significantly alter the clinical course especially within 48 h of the injury, neuroimaging techniques have become an important part of the diagnostic work up of such patients. In the acute setting, these imaging studies can determine the presence and extent of injury and guide surgical planning and minimally invasive interventions. Neuroimaging also can be important in the chronic therapy of TBI, identifying chronic sequelae, determining prognosis, and guiding rehabilitation.