Radiology of the Head and C-Spine

HEAD AND CERVICAL SPINE- Emergency Radiologic Approach -

Ranieri Falcão AguiarRadiology Fellow

Radiology DepartmentSir Charles Gairdner Hospital

11-12-2014

Fundamentals of Diagnostic Radiology, 3rd ed.

HEAD - INITIAL STUDIES

What to look for?

• Fractures• Hemorrhage• Epidural hematoma• Subdural hematoma• Subarachnoid• Intraventricular• Intracerebral hematoma

• Cortical contusions• Diffuse axonal injury• Stroke


Head ct - approach

1. Midline2. Symmetry3. Basal cisterns4. Ventricles


Head ct - approach

1. Midline2. Symmetry


Head ct - approach

1. Midline2. Symmetry3. Basal cisterns


Head ct - approach



Head ct - approach


EMERGENCY CT CHECKLIST1.Is the middle of the brain in the middle of the head?2.Do the two sides of the brain look alike?3.Can you see the smile and the pentagon or Jewish star?4.Is the fourth ventricle in the midline and roughly symmetrical?5.Are the lateral ventricles enlarged, with effaced sulci?


fractures


Epidural hematomas


Subdural hematomas


Subarachnoid hemorrhage


Diffuse axonal injury


Cortical contusions


STROKE

-NECT to exclude

hemorrhage/mass

-Look for:• Hyperdense vessel

• Loss of gray-white matter distinction

• Parenchymal hipodensity

• Gyral swelling + sulcal effacement

Pictures from Statdx.com © 2005-2014, Amirsys, Inc.

CERVICAL SPINE

Cervical spine - RADIOGRAPHS

STANDARD VIEWS•Lateral

•Antero-posterior

•Open mouth

CERVICAL SPINE - ANATOMY

• SPECIFIC ANATOMY• C1• C2• SUBAXIAL

SPECIFIC FRACTURES

Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006

X-ray adequacy


alignment


Diag. and Surgical Imaging Anatomy Brain, Head&Neck, Spine. 2006

alignment

ALIGNMENT

ROTATED

measures


> 3 mm highly suggestive of transverse ligament rupture = instability! 5 mm in children

measures


ABOVE C4 < 1/3rd OF VERTEBRAL BODY

BELOW C4 < 1 VERTEBRAL BODY

*NOT SENSITIVE

TEARDROP FRACTURE

A-Z of Emergency Radiology, 1st ed. 2004

JEFFERSON’S FRACTURE


A B

A + B > 6,9 mm indicates transverse ligament tear = instability!

HANGMAN’S FRACTURE


LOCKED FACETS


SHOULD I WORRY ABOUT VERTEBRAL ARTERIES?

1. Vertebral Artery Injury Associated With Blunt Cervical Spine Trauma. Spine. 2013 Jul;38(16):1352–61.

• Vertebral arteries injury (VAI)• 0,09% – 0,63% of cervical blunt trauma• Present in 19%-39% of all cervical spine fractures• Neurological deficits in 0-24%• Posterior stroke• Cortical blindness• Quadriplegia• Death

• Retrospective review of 1204 cervical spine injuries1

• 21% underwent screening for VAI (253 patients)• VAI in 17% (42 of 253)• 14% with neurological symptons (6 of 42)• 4,8% stroke-related mortality (2 of 42)

SHOULD I WORRY ABOUT VERTEBRAL ARTERIES?• Existing screening indications (2013)

• Expanding neck haematoma• Penetrating trauma in the vicinity of the vertebral artery• Preoperative planning for complex cervical spinal surgery• Symptoms of vertebrobasilar ischemia

• High-Risk injuries1

• Basilar skull fracture• Extension to the transverse foramen with displacement > 1

mm• Facet subluxation/dislocation• Occipitocervical dissociation• Fracture + Ankylosing Spondylitis or DISH

1. Vertebral Artery Injury Associated With Blunt Cervical Spine Trauma. Spine. 2013 Jul;38(16):1352–61.

C-spine

TO SUM UP

1.3 STANDARD VIEWS2.XRAY QUALITY3.ALIGNMENT 3 LINES AND C1 LATERAL MASSES4.FOLLOW BONE CORTICES5.DISTANCES• ATLANTO-DENS INTERVAL• PRE VERTEBRAL SOFT TISSUE

6.CT7.MRI LIGAMENTOUS OR MEDULLARY INJURIES

THANK YOU!

Radiology of the Head and C-Spine

Health & Medicine

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