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MR Imaging of Head Trauma: Review of the Distribution and Radiopathologic Features of Traumatic Lesions

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MR Imaging of Head Trauma: Review of the Distribution and Radiopathologic Features of Traumatic Lesions 101 MR Imaging of Head Trauma: Review of the Distribution and Radiopathologic Features of Traumatic Lesions Lindell R. Gentry 1.2 The distribution and extent of traumatic lesions were prospectively evaluated with John C. Godersky3 MR imaging in 40 patients with closed head injuries. Primary intraaxial lesions were Brad Thompson 1 classified according to their distinctive topographical distribution within the brain and were of four main types: (1) diffuse axonal injury (48.2%), (2) cortical contusion (43.7%), (3) subcortical gray-matter injury (4.5%), and (4) primary brainstem injury (3.6%). Diffuse axonal injury most commonly involved the white matter of the frontal and temporal lobes, the body and splenium of the corpus callosum, and the corona radiata. Cortical contusions most frequently involved the inferior, lateral, and anterior aspects of the frontal and temporal lobes. Primary brainstem lesions were most commonly seen in the dorsolateral aspects of the rostral brainstem. The pattern and distribution of primary lesions seen by MR were compared with those expected from previous pathologic studies and found to be quite similar. Our data and review of the literature would also indicate that MR detects a more complete spectrum of traumatic lesions than does CT. Secondary forms of injury (territorial arterial infarction, pressure necrosis from increased intracranial pressure, cerebral herniation, secondary brainstem injury) were also visible by MR in some cases. The level of consciousness was most impaired in patients with primary brainstem injury, followed by those with widespread diffuse axonal injury and subcortical gray-matter injury. The best MR imaging planes, pulse sequences, and imaging strategies for evaluating and classifying traumatic lesions were evaluated, and the mechanisms by which traumatic stresses result in injury were reviewed. MR was found to be superior to CT and to be very effective in the detection of traumatic head lesions and some secondary forms of injury. While T2-weighted images were most useful for lesion detection, T1-weighted images proved to be most useful for anatomic localization and classification. In the last decade CT has played a critical role in the diagnostic evaluation of patients with closed head trauma, providing an accurate means of diagnosing This article appears in the January/February potentially reversible intracranial hematomas [1-10]. Despite fulfilling this important 1988 issue of AJNR and the March 1988 issue of AJR. role, CT has been less helpful in the detection and characterization of many types Received February 18, 1987; accepted after re­ of traumatic lesions. It is apparent from pathologiC studies that CT underestimates vision July 23, 1987. the severity of many forms of cerebral injury such as primary brainstem injury, Presented at the Symposium Neuroradiologi­ non hemorrhagic cortical contusion , and diffuse axonal injury [3, 5, 10-18]. Although cum , Stockholm, June 1986. autopsy studies have been helpful in characterizing the distribution and morphology 1 Department of Radiology, University of Iowa of these lesions, they only reflect the nature of the disease in the most severely Hospitals and Clinics, Iowa City, IA 52242. injured patients. 2 Present address: Department of Radiology, Since CT cannot accurately assess the full spectrum of lesions in patients, it has University of Wisconsin Hospital and Clinics, 600 Highland Dr., Madison, WI 53792. Address reprint not been possible to develop clinically useful CT imaging criteria for classifying and requests to l. R. Gentry. staging the severity of cranial trauma [10 , 13, 16-18]. MR , however, has been 3 Department of Surgery, Division of Neurosur­ shown to be highly sensitive in detecting both hemorrhagic and non hemorrhagic gery, University of Iowa Hospital and Clinics, Iowa lesions [16]. With this new method, it should now be possible to accurately identify City, IA 52242. all types of traumatic lesions, classify them, and stage their extent in the living AJNR 9:101-110, January/February 1988 0195-6108/88/0901-0101 patient. © American Society of Neuroradiology The purpose of this study was to determine the ability of MR to prospectively 102 GENTRY ET AL. AJNR:9, January/February 1988 identify and characterize the traumatic intraaxiallesions found TABLE 1: Classification of Traumatic Intracranial Lesions in 40 patients with closed head trauma by using a simple Types and Locations of Lesions anatomic and topographic method of classification. The lo­ cation, frequency, and distribution of all visualized lesions Primary lesions: Intraaxial: were compared with that expected from postmortem and Diffuse axonal injury animal studies. The best imaging planes and pulse sequences Cortical contusion for evaluating each category of traumatic lesion were as­ Subcortical gray-matter injury sessed. We also reviewed the mechanisms by which trau­ Primary brain stem injury Extraaxial hematomas: matic stresses result in cerebral injury. Subdural Epidural Diffuse hemorrhage: Subjects and Methods Subarachnoid Intraventricular A prospective MR study of 40 patients with acute closed head Secondary lesions: trauma was initiated after approval of the protocol by our hospitals' Pressure necrosis (secondary to brain displacement and herniation) institutional review board. A more complete description of the study Territorial arterial infarction methodology is provided in the first article in this two-part report Diffuse hypoxic injury [16]. The ages of the patients ranged from 1 month to 82 years Diffuse brain swelling (mean, 26.6 years). The severity of injury, as measured by the Boundary and terminal zone infarction admission Glascow Coma Scale (GCS), varied from 3 to 14 (mean, Other (e.g., fatty embolism, secondary hemorrhage, infection) 9.8). MR scans were obtained as soon as possible after injury, unless the patients were medically or neurologically unstable. Twelve pa­ relaxation enhancement caused by either deoxyhemoglobin or met­ tients were examined with MR while being mechanically ventilated hemoglobin within intact RBCs. with a nonferromagnetic fluidic ventilator, as described by Dunn et The MR and CT examinations were initially analyzed separately al. [19]. and then compared to determine the relative sensitivities of the Contiguous nonenhanced 8-mm CT scans were obtained in all imaging studies. These data constitute the substance of an accom­ patients within the first 24 hr of admission with a fourth-generation panying report [16]. The frequency, anatomic distribution, and extent scanner .. MR scans were obtained with a 0.5-T system. t Contiguous of all the major types of primary traumatic lesions were assessed on 10-mm scans were obtained by using an interleaved multislice tech­ the MR images and compared with that expected from postmortem nique with two-dimensional Fourier reconstruction. Both T1- and T2- and animal studies [3, 11-15, 17, 21-30] to determine their conform­ weighted pulse sequences were used in most patients. T2-weighted ity with previously hypothesized mechanopathologic theories of in­ images were obtained by using a spin-echo sequence with a repetition jury. The best MR imaging planes, pulse sequences and imaging time (TR) of 2300- 2900 msec and echo time (TE) of 80-120 msec. strategies were determined from analysis of the data. T1-weighted images were obtained with either an inversion-recovery sequence with TR = 2000- 2300 msec and inversion time (TI) of 500- 600 msec or a spin-echo sequence with TR = 400-1000 msec, TE Classification, Characterization, and Localization of = 25- 40 msec. Thirty-four patients were examined with two or more Primary Traumatic Lesions imaging planes, while six were studied with only one plane of imaging. Thirty-nine patients were studied in the transverse plane, while 31 Diffuse Axonal Injury and five patients, respectively, were studied in the coronal and sagittal planes. The most common type of primary lesion identified in this An attempt was made to differentiate primary lesions (resulting series was diffuse axonal injury [11, 14-17, 21-28]. Lesions from the initial traumatic force) from secondary ones (caused by classified in this category had to spare the overlying cortex diffuse brain swelling and edema, brain displacement and herniation, and be localized to the white matter or gray fwhite-matter delayed hemorrhage, cerebral infarction, diffuse hypoxic injury) (Table interface (corticomedullary junction). Diffuse axonal injury typ­ 1) [11-13]. In many cases distinction between primary and secondary ically was characterized by diffuse, small, focal abnormalities lesions was difficult. For purposes of statistical analysis, however, all focal abnormalities that were not obviously secondary in nature were limited to white-matter tracts. These lesions constituted classified as primary lesions. Primary intracranial lesions were clas­ 48.2% of all traumatic lesions in this series (Table 2) (Figs. 1 sified according to the method outlined in Table 1. Primary intraaxial and 2). When present they tended to be multiple, with 50.3% lesions were further subclassified by their location: (1) diffuse axonal of lesions found in the 15 patients with the most severe initial injury (white-matter "shear" injury) (Figs. 1 and 2), (2) cortical contu­ impairment of consciousness. Although most of the lesions sion (Figs. 1-4), (3) subcortical gray-matter injury (Fig. 4), and (4) were nonhemorrhagic, 18.8% did contain small central foci of primary brain stem injury (Fig . 5) [16]. blood. Hemorrhage
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