To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all. Structures from above downwards: falx cerebri, frontal horns of lateral ventricles, third ventricle, basal cistern, skull, scalp & again the falx cerebri
CT is a vital tool in the assessment of patients with serious head injury & revolutionized management when it was introduced. It is the investigation of choice even following the advent of MRI, due both to the ease of monitoring of injured patients & the better demonstration of fresh bleeding and bony injury. This scan is a slice through the human brain and you should imagine that you are viewing it as if looking up from the patient's feet. Thus, the patient's left is to your right & vise versa. The shape of the ventricles is quite distinctive. Each lateral ventricle has 2 frontal & 2 occipital horns. The presence of the third ventricle (slit-like) in the midline is one of the first things to look for. If the third ventricle is either not visible, or shifted away from the midline, this suggests that there is an abnormality. The basal cistern is the CSF-filled space around the back of the midbrain. Blood clots or swelling of the brain may cause this to become narrowed or not visible at all.
Subdural hematoma
They arise between the dura & arachnoid matter, usually from ruptured veins crossing this potential space. This space enlarges as the brain atrophies (due to aging) and so subdural hematomas are more common in the elderly due to senile brain atrophy. Acute subdural hematomas have high attenuation (hyperdense); this
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decreases with time, becoming isodense after a week (subacute subdural hematoma) and hypodense after 2 weeks (chronic subdural hematoma).
A.
C.
On CT, the hematoma is hyperdense Crescent-shaped (concave) & may contain hypodense foci due to active bleeding. It has more irregular inner margin & does not cross dural reflections. Blood may spread more widely in the subdural space (e.g. interhemispheric in the falx cerebri as in the third figure).
They are hypodense crescentic collections (hemolyzed blood) & may be loculated.
D.
B.
Rebleeding may occur in chronic subdural hematomas with accumulation of the layering of the chronic hematoma anteriorly & the hyperdense fresh blood posteriorly (fluid-fluid level).
As the hemorrhage is reabsorbed, it becomes isodense to the normal gray matter. A subacute SDH should be suspected when you identify shift of the midline structures without an obvious mass.
A.
They are the most common primary lesions. They occur due to impaction of the brain against the skull or dural fold. The inferior frontal lobes and anterior temporal lobes are common sites after a blow to the back of the head.
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B.
Brain edema
Focal edema may be seen as localized poorly defined areas of low density. Diffuse edema may develop, especially in children. This may be difficult to detect on CT.
Multiple contusions may be present throughout the cerebral hemispheres. They are often small and visible at the gray/white matter interface. They are due to a shearing injury with rupture of small intracerebral vessels, and in a comatose patient with no other obvious cause they imply a severe diffuse brain injury with a poor prognosis (diffuse axonal injury). Adjacent foci of petechial hemorrhage may coalesce later into a big hematoma.
A.
These are indicative of the severity of the injury, and uncomplicated fractures are not of great significance otherwise, except that temporal bone fractures may predispose to extradural hematoma due to injury of the middle meningeal artery. They have to be differentiated from suture lines & vascular markings
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B.
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