Cranial
Computed
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ROBERT
Tomography
A. ZIMMERMAN,’
in Diagnosis Head Trauma
and Management
T. BILANIUK,’
GENNARELLI,2
LARISSA CAROL
DOLINSKAS,’
THOMAS
AND
Review of the computed tomographic findings in 286 patients with acute craniocerebral trauma revealed several types of lesions: hemorrhagic contusion, intracerebral and extracerebral hematomas, general and focal cerebral swelling, and shearing injury of the cerebral white matter. Hemorrhagic contusions are the most frequent lesion and may result in focal neurologic deficits. General cerebral swelling occurs frequently in children and necessitates prompt medical management for complete recovery. Mortality rates for intracerebral, subdural, and epidural hematomas were lower for this
series
than for series
Because
was
of the
an 84%
surgical phy.
that preceded
availability
reduction
intervention,
computed
of computed
in arteriography, and
a 24%
58%
reduction
July
netrating
the
presenting
episode
were
of
acute
immediately of acute
the
286
Philadelphia
course
are
not
entirely
mography investigation
(CT) of
represents head
promptly, accurately, lated abnormalities only
by
invasive
a major injuries.
It
and noninvasively that were previously radiology
methods,
be the to-
trauma-related
Application trauma has [2],
Ambrose
evident
et al. [3],
that
various
CT
shows
traumatic
trauma
and
others
patients.
lesions Still,
and
the
[4-15].
in the
question
It has
of
2 year
period.
CT
selective
arteriography,
ies)
performed
were
sies
examination
clinically
radionuclide if clinically
during
the
reexamined patients
(clinical
lated with deals with under the Pennsylvania Received This
were
were
course CT.
I
March 20, 1978; accepted was supported
Department
Address reprint 2 Department
Am J Roentgenol © 1 978 American
of Radiology,
by contract
Hospital
after revision NS-5-2316
sectioned
Serial
were
and,
July 1978 Ray Society
were
severely
and
Autop-
in most
instances
to the planes
were
revised.
The
The
CT
findings
trauma
in
the
are summarized
by several conferences
interpreted
in some
cases,
diagnostic
on-line for this
CT and Clinical
acute
more
CT examination.
to correspond
studies
impressions
corre-
and
148
3 and 4) and the 138 less 1 and 2), 80% and 48%,
28 deaths,
examinations
preceding
with
studevalu-
of section radiologists and review
by
comparison
initial
diagnostic
interpretations
re-
working diagnoses prospective investi-
Findings
286
patients
in table
examined
3. They
with
are subdi-
April 6, 1978. from
of the University
requests to A. A. Zimmerman. of Neurosurgery, Hospital of the University 131 :27-34, Roentgen
the
by sequential
in 15 of the
flow were
of hospitalization
(grades
studied
radiography, and
Patients
Among
using
CT scans.
sessions,
clinical and laboratory findings. This report the results obtained on 286 patients studied protocol at the Hospital of the University of during the past 2 years.
work
of the
conscious-
carried
scan
indicated.
The CT examinations were evaluated and neurosurgeons at frequent clinical
CT
of
then
brain
grades
patients
obtained
the brains of the
by
injured
were
was
gation.
and
were
50%
I scanner with a 160 x 160 matrix. radiographic studies (skull and spine
examinations
compared
remaining
disturbance
ported in this paper are the final accepted by the group responsible
systematically
The
significant
=
also carries prognostic value. To investigate this point, a protocol was set up under contract from the National Institutes of Health whereby the results of sequential CT were
(49.7%)
out
injured
of
whether
142
were
3
deficit.
severely
the
management
remains
1.
patients,
neurologic
routinely
become
diagnosis
in table
trauma
problems.
deficit:
respectively,
in the
was of it.
and 4 = (4A) focal
ated
CT to acute craniocerebral by de Villasante and Taveras
is indispensable
CT examination or within a few days
initial
ness, with (3B) or without (3A) neurologic deficit; comatose with pain response, with (4B) or without an EMI Mark Additional
processes.
of cranial been reported
the
injuries
neurologic
neurologic
intracranial abnormalities that were previously recognized only at autopsy. Thus the visualization of gross neuropathology is possible during life. Moreover, through sequential studies, CT reveals the time course of various
In 286
traumatic
patients were evaluated clinically on presentation at the hospital and assigned a clinical grade from 1 to 4: 1 = minimal to no disturbance on consciousness: 2 = minimal to moderate disturbance of consciousness, with (2B) or without (2A) focal
in the reveals
also
is given
CT. the
All
the trauma-redemonstrated but
trauma
and
not examined by CT because the had only minimal or no disturbance of consciousness: for CT examinations was given to patients with more
urgent
under-
breakthrough not only
The
after head
during head
priority
Craniocerebral trauma is one of the most frequent and grave forms of neurologic disease [1]. Its etiology is obvious, yet the biomechanics of its production and the its
origin.
with nonpe-
by
and 144 (50.3%) were children (17 years of age or under). The age and sex distribution of this group of patients is given in table 2. Pediatric patients represented 50% of the patients with acute head injuries hospitalized at the Children’s Hospital of
patients
of
studied
adult
pediatric
pathophysiology
were
symptomatology
injury
acute
320 patients
1977,
trauma
both
mode
BRUCE,2
Methods
June
craniocerebral
Of
and
through
patients,
The
there in radiogra-
stood. Proper therapeutic management can only based on correct diagnosis and appreciation of temporal course of the disease process. Computed
1975
performed
reduction
in skull
DEREK
UZZELL’
Subjects From
tomography.
tomography,
BARBARA
of Acute
the National
Institutes
of Pennsylvania
of Health.
and Children’s
of Pennsylvania
and
27
Children’s
Hospital Hospital
of Philadelphia,
Philadelphia,
Pennsylvania
19104.
of Philadelphia,
Philadelphia,
Pennsylvania
19104.
0361
-803X/78/0700
-
0027
$00.00
ZIMMERMAN
28
TABLE Mode
of Injury
AL.
eccentric
1
in Acute
ET
Head
cerebral
and, Mode
of
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Injury
Total
Pediatric
Adult
Patients
Patients
hemorrhage
diffuse
Trauma
less frequently
the third juncture,
No.
71
42
113
39.5
Four
patients
died
40
83
29.0
logic
deficits,
and
Hit
24
37
61
21.3
state.
6 144
23 142
29
10.1 100
.
Unknown Total 5truck
-
286
Focal
by or within.
TABLE
2
Age and Sex Distribution
-
Intracerebral
No.
%
three
hemorrhage
have
2),
around
medullary ventricles.
significant
in a persistent
neurovegetative
Abnormality
spersed
between
blood
were
(fig.
hemorrhage,
cerebral cortical and in the lateral
remains
contusion. a cortical
39% AgeandSex
(50%), one
Hemorrhagic findings showed tissue and contusions
callosum
but importantly,
43
.
corpus
subarachnoid
,
ventricle, at the in the brain stem,
Fell
Automobile
in the
swelling
In 61 patients (21 .3%) area of heterogeneously more
lucent
areas
edema. These were identified (fig. 3). In 29% the contusions associated
with
another
of
the CT internecrotic
as hemorrhagic
were
significant
multiple; focal
mass
28 72 44
19 50 31
lesion (e.g., subdural hematoma). The hemorrhagic contusion was three times as common in the adult as in the child. Of the patients with hemorrhagic contusions (with or without associated mass lesions), 72% were clinically
18-30
55
39
of the
31-50 50+
43 44
30 31
was
101
70
112
79
43 30
30 21
Pediatric
(years):
0-2 3-10 11-17
grade
Adult (years)
Male: Pediatric
Adult Female: Pediatric Adult
3 or 4; 75%
general
had
skull fractures
trauma
population.
compared
In 20%
to 51%
the
fracture
depressed.
The overall mortality for 37 patients who only had contusion was 19%. The mortality for those with associated mass persistent
lesion was neurologic
uncomplicated
45%. deficit
contusions
Similarly, increased
to 50%
the
incidence from 16%
for those
with
of for
associ-
ated mass lesions. lntracerebral hematoma.
vided into three groups: (1) no intracerebral focal abnormality; focal abnormality. The outcome with and
respect with
to clinical
respect
Nonfocal
grades
is given
to CT findings
in table
a definable
other
than
fracture,
patients,
25%
initially
focal
focal
5
extension.
teration
of the
cephalic
neurologic
lateral
in
and
five of 10. Shearing patients
injury
(2.8%),
third
accidents,
had
of the
14%
were
no
incidence
persisted
the
or obli-
and
perimesen-
in
in one was
cerebral 4 and
CT findings
white
which
46
all
reflecting
matter.
two
patients
child
(3%).
of 36,
white injured
Eight
the
patients
were
adult,
and
be
due
to
infarction
or contusion.
Of these
and two-thirds were grade Two patients had persistent
3
deficit.
of
Extracerebral
Abnormality
Acute subdural hematoma. Thirty-six patients (12.5%) had CT findings of an acute subdural hematoma-a peripheral crescentric band of blood encapsulating a portion of the cerebral hemisphere (fig. 5). In half of these
patients
hemorrhagic other half,
CT
demonstrated
contusion there were
obvious
an
area
of
underlying
and/or laceration. Among the many instances where a swelling
hemorrhage
underlay
the
subdural
he-
matoma, so that the mass effect was disproportionately large compared to the size of the subdural hematoma (fig. 5). Of the patients with subdural hematomas, 75% were
traumatic
consisted
may
neurologic
without
in automobile
a diffuse
These
The
in adults
matter.
of
patients, 75% were children or 4. There were no deaths.
Focal Compression
Two-thirds
78% of the patients were clinically grade 3 or 4. Overall mortality was one-third. Neurologic deficit persisted in 17%. Focal cerebral swelling. Twelve patients (4.2%) had CT findings of focal cerebral swelling, presumably edema
of
17 years of age or under. Of the initially grade 3 or 4. Of the neurologic deficits at presenta-
all grade
cerebral
There
ventricles
patients
of
4, and
a 2.5%
demonstrated
deficit pediatric
deOf these
deficit.
was
Neurologic
only
swelling.
(16.1%) (fig. 1); 36 were 46 patients, 83% were children, 19% had focal mortality
3 and
deficits.
and
cerebral
cisterns
abnormality
hemorrhage,
grades
neurologic
general
traumatic
pneumocephalus.
clinically
deaths, focal
Acute
limited
were
had
persistent
or diffuse subarachnoid
or
trauma-related
injury
4 and
6.
abnormality. A total of 1 1 9 patients CT examination or one that did not
minimal
pressed
tion.
in tables
Injuries
Normal or minimal (41 .6%) had a normal show
focal abnormality; (2) and (3) extracerebral in terms of mortality
Eighteen patients (6.3%) had a relatively large homogeneous well defined mass of blood density (fig. 4) demonstrated by CT. These were identified as hematomas and distinguished from hemorrhagic contusions. The masses were usually frontal or temporal, and in one-third there was intraventricular
patients
adult
and
with
75%
acute
were
clinically
subdural
grade
hematomas,
3 or 4. Of the
31%
died.
CT
IN ACUTE
HEAD
TABLE CT Findings
TRAUMA
29
3
According
to Clinical Clinical
Grade
Grade
T tel N
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Finding
of Patients
Patients
1
2
3
42
38
23
6
1 19
41.6
8
21
17
46
16.1
8
8
2.8
4
Examined
Nonfocal:
Normal
or minimal
General cerebral Diffuse shearing white matter
abnormality* swelling injury of cerebral
.
Focal abnormality: Intracerebral: Hemorrhagic contusion Intracerebral hematoma Focal cerebral swelling
-
Minimal
Pediatric
.
.
.
11 2 4
11 5 6
33 9 2
61 18 12
21.3 6.3 4.2
2 2
7 2
8 5
19 5
36 14
12.6 4.9
patient may have more than one finding. subarachnoid hemorrhage, depressed fracture,
or limited
TABLE Acute
,
6 2
Extracerebral: Acute subdural hematoma Epidural hematoma Note-A
.
pneumocephalus.
4
TABLE
Head Injury Patients According Clinical Grade and Mortality
to Admission
Mortality
Related
6 to CT Findings
#{149}#{149}y1#{149}#{149}#{149}#{149} Trauma
Patients
% of
Admission
in
.
No. Patients
.
Finding
Pattants
I
Nonfocal: Normal or minimal abnormality General cerebral swelling Diffuse
144
8
100
5.6
shearing
TABLE Head Injury Clinical Admission Cr i I Grade
43 35 26 38 142
Total
to Admission
and Mortality % of Ad I Patients
No. Patients
1 2 3 4
According
No. Deaths
Patients in Clinical
rhagic and
solely
to the
contusion
0 2 0 18 20
100
underlying
epidural
hematoma,
contributed swelling
to the
to the mass
.
.
45% with associated
19
36 (child) 10(adult)
0
6 50
of cerebral
contusion
mass lesion,
8
50
61
26*
18 12
33 0
36 14
31 7
19% without.
Dying(%)
30.3 24.6 18.3 26.8
0 5.7 0 47.4 14.0
Neurologic deficits persisted in one-third of the suvors. Epidural hematoma. Fourteen patients (4.9%) had epidural hematomas. In 13, the collections were biconvex, peripheral, and demarcated by either sutures or the edge of the stripped dura (fig. 6). In 57%, the mass effect was due
.
Intracerebral hematoma Focal cerebral swelling Extracerebral: Acute subdural hematoma Epidural hematoma
5
Patients Grade
injury
.
white matter Focal abnormality: Intracerebral: Hemorrhagic
Acute Adult
Mortality
(%)
Dying(%)
Total
Related to
whereas
mass effect
effect in 14%.
hemor-
in 29%, Adults
constituted 64% of this group, and 79% were grade 3 or 4. One patient died (7%) and two have persistent neurologic deficit (14%).
Other Skull
Findings
Radiography
Skull radiography was performed on 76% of patients with acute head injuries. Films were normal in 31% of the children and in 33% of the adults with significant intracranial abnormality demonstrated by CT. Skull films were positive for fracture in 32% of children and 23% of adults in whom there was no significant intracranial abnormality on CT. Skull fractures were associated with significant intracranial lesions demonstrable by CT in 69% of children and in 67% of adults (table 7). Arteriography
Angiographic procedures were performed on 16 adults and three children as part of the initial diagnostic evaluation. Of the 19 studies, 13 were performed at hospitals without CT equipment prior to transfer of the patient. Of the 19 arteriographic procedures, 58% were performed during the first quarter of the study.
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30
ZIMMERMAN
in 6-year-old female struck by car A, Day of injury. Compression of lateral ventricles bilaterally. Subarachnoid hemorrhage is present in interhemispheric fissure (arrows). B. 36 days after injury. Lateral ventrides are top normal in size. Patient is clInically normal. and
ET
AL.
Fig.
4. -Intracerebral
Fig. 1 . -General cerebral swelling rendered immediately comatose.
year-old with right hematoma of lateral horn. B, focal left enlargement
hematoma
with
intraventricular
extension
in 35-
male who fell while drunk and was admitted in stuporous state hemiparesis. A, Day of injury. Large left frontal intracerebral within white matter, with extension into frontal horn (arrows) ventricle. Blood is present in third ventricle and opposite frontal 173 days after injury and surgical evacuation of hematoma. Note frontal encephalomalacia (arrowheads) and left frontal horn (arrows). Patient has right-side weakness 1 year after injury.
Fig. 2.-Diffuse shearing injury of cerebral white matter in 4-year-old female in coma after automobile injury. Day of injury. Hemorrhage eccentrically on left side of corpus callosum. Bilateral cerebral swelling is present. Patient died.
Fig. 3.-Hemorrhagic contusion in 22-year-old male with moderate disturbance of consciousness and left-side weakness after severe beating. MultipIe right frontal and temporal skull fractures were present. Day of injury. Extensive right frontal and temporal areas of hemorrhagic contusion (arrows). Patient is neurologically normal 5 months after injury.
Fig. 5.-Acute subdural coma, with pain response left subdural hematoma
hematoma in 36-year-old male admitted in only. after fall. A, Day of injury. Small acute (arrows) with disproportionate mass effect (compression left lateral ventricle). B, 83 days after injury. Bilateral atrophic ventricular enlargement. Patient has marked recent memory loss and spastic hemiparesis.
hematomas, rhagic
four
negative
the
the 286 patients with acute clinical criteria for arteriography
clinical with
grades focal
injuries, [16].
2B, 3B, 4B (disturbance
neurologic
findings),
and
120 They
satisfied fell into
of consciousness 4A (coma
with
pain
response only, without focal neurologic findings). In the pre-CT era, all of these patients would have undergone arteriography. In 13 cases (68%), the CT scans and arteriograms demonstrated the same abnormality (five acute subdural
one
but
information.
had
been
was
made
rhagic
on
by CT information
patients,
inasmuch
farction
was
epidural
and
graphic sion
(two
contusions,
one
was as
(26%),
whereas
cerebral
gave
to
CT
carotid CT
one better
the diagnosis examination but two
injury).
superior
hemor-
and
hematomas, shearing
a traumatic
demonstrated of the
the
five
the
two
hematoma, CT scan
cases arteriographic
In
missed
hematomas,
epidural
examination),
quality
Of
intracerebral
contusions,
hemor-
The in
angio-
one
artery
merely
of
showed
hemisphere.
Ventriculography One
adult
patient
ary to herniation
with
from
a brain
cerebral
stem
hematoma
swelling
and
19
occlu-
second-
hemorrhagic
in-
CT
IN
ACUTE
HEAD
31
TRAUMA
ium
and
cranial
base
skull radiography, unless depressed,
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by blood
obvious
at autopsy,
and
often
on
were usually not identified by CT separated, or secondarily suggested
in the
sinuses
or mastoid
air cells.
Discussion Clinical
Findings
and
CT
The patients with acute nonpenetrating cerebral injury can be prognostically subdivided on the basis of clinical findings into three categories: (1) those with cerebral and (or) bodily injury incompatible with survival: (2) those in a persistent vegetative state: and (3) those who recover Fig. 6. -Acute epidural hematoma in 52-year-old male who suffered right temperoparietal skull fracture after falling. Neurologic examination was normal and patient was wide awake at time of CT examination. A, Day of injury. Large right temperoparietal epidural hematoma with compression and shift of right lateral ventricle. B, Day after injury (and evacuation of epidural hematoma). Scan is normal and patient was normal clinically.
carbia)
Incidence
of Skull
CT Finding and Patienf Group
appear
identical disruption. absence
lesion
Fractures
Fractures
the
by revealing when
already
labile
In the
first
Adult
77
23
disruption
69
they either succumb to the hospital. The
67
impact,
Note-Data
based
on 218 of 286 patients
(76%)
contusion was studied by emergency ventriculography. The ventriculographic findings confirmed the CT demonstration of brain stem enlargement.
of the
and
severe wherein
with into
are
Craniotomy was performed on nine children and 24 adults; 13 epidural, 14 acute subdural, and six intracerebral hematomas were evacuated. All patients with epidural, 83% of those with intracerebral, and 64% of those with acute subdural hematomas who underwent surgery survived. Numerous other patients had elevation of depressed skull fractures, insertion of subarachnoid bolts or intraventricular cannulas for intracranial presand
closure
of scalp
lacerations.
had
vehicular by a
typical
There was excellent correlation between all gross lesions identified on the CT scan (intraand extracerebral hematomas, hemorrhagic contusions, swelling) and the neuropathologic findings. A portion of the small, very superficial, and usually minimally hemorrhagic contusions of the outer cortex was not identified by CT. Review of the CT examinations in these patients demonstrated that these contusions could often not be appreciated even in retrospect. Linear fractures of the calvar-
to secondary In this
more
invasive
procedures,
with
The of
can
so severe
little
clinical
group
results
with
most
significant
white injury.
the
injury
type of
of injury
high
lesion
injury was a small (fig. 2). It is significant
4,
in persistent
this time
the
severe with
biomechanical
at the
speed revealed
hemorrhage because
shearing
of
alter
the cerebral category of
which
patients
of
to
apparent the patients
injury of clinical
that
after admission at the time
do
force
manifestation
surgery, effect on
biomechanical
system
sustained
All eight
or
patient.
patients
degree
type
because
injury
in it is which
occurs in this region [18]. Seven of the eight patients in this series passed through a persistent vegetative state. Half of the patients died and the survivors showed poor recovery.
Autopsy
diswith
severe
in management
injury fell into deaths occurred.
a severe
collision.
with
due
the clinically this series,
In
who
CT in this type corpus callosum
the
initial
a major role parenchy-
reversible.
of the
shearing the second
state.
still
nervous
to severe
sustained
of
attention
patients
vegetative
those
CT plays significant
prior to or shortly damage is sustained
medical
of moderate
for
central
biomechanical 93% of the
Patients matter fall
to
helpful
are
outcome. CT demonstrates biomechanical injury.
These Surgery
monitoring,
are
condition
32
31
the
often cannot groups. Patients
ventriculography, could have a deleterious
category
68
.pIt
During
changes
they
as angiography, in themselves
Pediatric Positive:
sure
and
at a time
such which
[17].
forms of mechanical injury and superimposed injury (due to hypoxia, hypoperfusion, hyper-
of injury, CT may be very it may obviate the need
Fracture
time
examination in these
clinically
Negative:
Pediatric
of
forms of biomechanical by demonstrating the injury
7
a period
period, neurologic between patients
nonfatal secondary
mal TABLE
within
acute tinguish
Recognition
immediately The
after
pediatric
patients
(fig. 1) represent different course adults) small swelling
with focal
of trauma
with
CT
pattern
of
prognosis bilateral
general
cerebral
children
lesions.
cerebral
is
most
likely
injury
swelling
patients patients
associated
swelling Acute
this
possible.
a distinct group. These and outcome from the
hemorrhagic in
the makes
general due
to
have (mostly
a
with cerebral
secondary
The most widely accepted explanation of the swelling is that a primary change in the cerebrovascular resistance occurs (due to traumatic stimulus, hypercarinjury.
32
ZIMMERMAN
bia and/or hypotension), resulting in increased cerebral blood flow, intraparenchymal vasodilatation increased cerebral blood volume, and reduced cerebral compliance. This produces bilateral cerebral swelling which may lead to edema, or on its own may produce sufficient mass effect to result in herniation and death. The most common pathologic finding in children who die from acute head injury [19] is diffuse cerebral swelling with obliteration of cerebrospinal fluid spaces and with venous congestion of the cortex. Statistical comparison cannot be made between our series and studies performed before CT because no prior diagnostic method was capable of demonstrating cerebral swelling as definitively as CT. The low mortality (6%) and the low morbidity (3%) for cerebral swelling in the present series, notwithstanding the high frequency of swelling in the pediatric population (24%), indicates that cerebral swelling need no longer be the most frequent autopsy finding following acute pediatric head trauma. Early detection by CT and early control of secondary injury are the two major factors contributing to a favorable recovery (fig. 1). All epidural hematomas, a number of large intracerebral hematomas, and large subdural hematomas are lifethreatening focal mass lesions often amenable to surgical correction. Prior to CT, radiologic evaluation of head trauma was directed toward detection of these mass lesions. By circumventing the delays and risks encountered with arteriography, CT permits more rapid and accurate identification of these lesions. Also, the general condition of the entire brain can be assessed. The patient can be taken from the CT scanner to the neurosurgical operating room, and definitive surgery can be performed. Nowhere is this more clearly demonstrated than in the case of the acute epidural hematoma, where the primary threat to life is due to the hematoma itself (fig. 6). In case of an epidural hematoma that is not associated with parenchymal injury [1], the patient may be temporarily asymptomatic while the extracerebral life-threatening mass expands. Prompt surgical evacuation of the epidural hematomas in our series resulted in a 100% postoperative survival. The low mortality rate in this series (table 6) lies well within the 10% figure advanced by Hooper [20] as the ideal goal of early diagnosis and treatment. Jameison and Yelland [21] reported a mortality of 15.6% for epidural hematomas in the pre-CT era. The surgical mortality in our series for acute subdural hematomas was 36%. The mortality for the nonoperated acute subdural hematomas was 27%, which compares favorably with the 63%-68% mortality reported prior to CT [22, 23]. To a certain degree, this also reflects the greater degree of accuracy of CT in identifying less symptomatic small acute subdural hematomas that might otherwise have gone undetected clinically or by other diagnostic studies. It is the parenchymal injury that accounts for the mass effect being disproportionately large compared to the size of the subdural hematoma,
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,
when
the
hematoma,
subdural
surgical
is small
(fig.
evacuation
5). In the
seems
small
to
be
subdural
unneces-
ET AL. sary, and treatment should be directed at the medical management of the parenchymal injury and its mass effect [15]. The underlying parenchymal damage accounts for the frequent late finding of atrophic ventricular enlargement (fig. 5). Intracerebral hematomas (fig. 4) can usually be differentiated from hemorrhagic contusions (fig. 3) by CT. The surgical mortality in this series for intracerebral hematomas was only 13%, which compares favorably with the pre-CT mortality figure of 25.4% reported by Jameison and Yelland [21]. Hemorrhagic contusion is the most frequent focal acute parenchymal abnormality identified by CT (21%) in head trauma patients. Its significance during the acute period lies in its association with other mass lesions and in its contribution to the mass effect, as edema develops during the first few days after injury [11].
Its
permanent psychologic Economic
ultimate
significance
neurologic aberration. Aspects
is
that
dysfunction,
focal
it
may
produce
seizures,
and
CT
The variables in the analysis of cost factors in the management of acute head injury are considerable, especially with inflation in the cost of hospital care and the changing methods of management of acute head trauma (many prompted by the information now available from CT). An attempt at a retrospective study of cost factors for pre-CT trauma patients was undertaken (10 years, 1964-1973), but an accurate comparison to the data corresponding to the period following the advent of CT (1974) could not be made. One current method of analysis of CT costs [24] uses the concept of the cost per positive diagnostic study. On the basis of a charge of $225 per CT examination and a CT positive incidence rate in this study of 48.4%, the cost per positive CT examination was $464.85. This can be compared to the per positive cost rate when the indications for an examination are symptoms such as headache, with a yield of 0.8% positive studies [24]. What this method of analysis does not indicate is the value
of negative
or minimally
abnormal
CT examination
in the grade 4 comatose trauma patient, wherein the clinical evaluation is not capable either of diagnosis or prognosis but CT is decisive. Cost can also be analyzed in terms of dollars saved because of elimination of other diagnostic methods. In this study, clinical symptomatology would have warranted emergency arteriography in a minimum of 120 patients had CT not been available. This does not include patients with clinical grades 2A and 3A, whose neurologic status deteriorated over several days after injury. These patients would also have undergone arteriography. The prevailing cost for a carotid arteriogram is around $415. The cost of arteriography for all 120 patients would have been $49,800. The 19 arteriograms performed cost $7,885. In 13 studies, arteriography was performed at other hospitals primarily because they lacked CT facilities. In 101 of 107 patients evaluated at the Hospital of the University of Pennsylvania, arteriography was felt to be unnecessary after CT. In these 101
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CT
IN ACUTE
patients, the difference between the cost of the CT examination and arteriography (101 x $190) amounted to a saving of $19,190. Analysis of the 19 cases where both carotid arteriography and CT were performed revealed that the same primary diagnosis was reached in 63%; CT was more accurate than arteriography in 26%, and provided less information than arteriography in 5% (one case). Skull radiographs were performed in 76% of the acute head injury population. Prior to CT, 100% of the hospitalized head trauma patients would have had skull radiography as the first radiologic procedure. The mcidence with which skull radiography is performed on patients has progressively decreased during the course of this study. Presently, skull examinations are performed when the patient’s condition is sufficiently stabilized, frequently days after injury, and then for the evaluation of facial injury, depressed calvarial fracture, or fracture of the cranial base associated with cerebrospinal fluid oto- or rhinorrhea. A certain proportion of the present skull radiographic examinations are done because of the referring physician’s adherence to traditional ways of evaluating trauma patients. The results in our series indicate that CT is the procedure of choice in the initial evaluation of cerebral parenchymal injury, and that skull radiography should be reserved for the indications mentioned above. Skull radiographic costs are about $50 per examination. The savings on the 68 patients not examined in this series is 68 x $50, or $3,400. Prior to CT, patients with significant head injury associated with focal mass effect and midline shift (demonstrated by arteriography or ventriculography) have undergone craniotomy, surgical exploration, and decompression in many trauma centers [25]. Of the 85 patients with significant head injury and CT evidence of focal mass effect and midline shift, 79 survived long enough to be considered for surgery. As a consequence of the CT findings (hemorrhagic contusion, focal swelling, small acute subdural hematoma, small intracerebral hematoma), surgery was avoided in 46 of the 79 patients (58%) who were then managed medically. The approximate neurosurgical fee for craniotomy with exploration (excluding operating room and anesthesia) is $1 300. This represents a savings in this series of 46 x $1 300, or $50,400. Ambrose et al. [3] reported a 94% reduction in the number of craniotomies for acute head injury since using CT.
HEAD
to the results of neurosurgical series before CT, show a significant improvement in mortality rate for intracerebral, subdural, and epidural hematomas. There has been a progressive decrease in the use of arteriography, skull radiography, and in surgical intervention. REFERENCES AD, Victor M: Craniocerebral trauma, in Principles New York, McGraw-Hill, 1977, pp 562-585 2. de Villasante JM, Taveras JM: Computerized tomography 1.
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3.
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puted
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consecutive
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Svendsen
The
AL:
tomography.
head trauma. 8.
AB:
LaRoque
JH:
in the manage-
scan
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D: EMI 1 :847-848,
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AH,
Uttley
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puted 7.
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6.
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AB, French
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extracere-
1976 B,
Svendsen
subdural
and
P:
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epidural
hema-
tomas: variation of attenuation related to time and clinical events such as rebleeding. J Comput Assist Tomogr 1 :449455,
10.
1977
Forbes
GS,
puted mas. 11.
Sheedy
tomography
Bruce
DG,
evaluation 48,
Bilaniuk
Houser
of
OW:
subdural
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hemato-
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LT,
Dolinskas
C,
B: Computed
tomography contusion. Comput
hemorrhagic
1 :271-280,
II, Piepgras the
1 26 : 1 43-1 RA,
D, Uzzell
rebral
PF in
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Zimmerman
Genneralli
of acute Axial
T,
intraceTomogr
1977
12. Kobrine Al, Timmins E, Aajjoub AK, Rizzoli HV, Davis DO: Demonstration of massive traumatic brain swelling within 20 minutes after injury. J Neurosurg 46:256-258, 1977 13. Zimmerman RA, Bilaniuk LT, Bruce D, Dolinskas C, Obrist W,
14.
tomography
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trauma: acute general 126:403-408, 1978
KuhI
cerebral
swelling.
D:
Dolinskas
Computed
AA,
C,
arachnoid pediatric
Zimmerman
Bilaniuk
bleeding on cranial head trauma patients.
pediatric
LT:
computed
head
Radiology A sign
of
sub-
tomograms
Radiology
of
126:409-411,
1978 15.
Dolinskas
C,
Cranial
computed
Zimmerman
hematomas:
RA,
tomography
LT,
Gennarelli
and
from
17.
Northfield
System,
Zimmerman
AA,
mography
Care Med. In press, 1978 in The Surgery of the Central
,
Bilaniuk
LT,
of shearing injuries In press, 1978
Radiology. 19.
injury. Crit
clinical
DWC: Head injury, Oxford Blackwell,
Nervous 18.
with
T:
extracere-
examination
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correlation
Bilaniuk
of post-traumatic
neuropathology.J Trauma. In press, 1978 16. Bruce DA, Gennarelli TA, Langfitt TW: Resuscitation coma
By accurately differentiating the various forms of gross neuropathologic lesions resulting from trauma to the brain, CT leads to prompt and more effective treatment. Frequently the prognosis can be implied from the CT findings. Patients with CT findings consistent with shearing injury invariably have a poor prognosis. However, the pediatric patient with general cerebral swelling has a good prognosis when the entity is recognized and treated early. The results in this series, when compared
head
1976
bral
Conclusions
33
TRAUMA
1973, pp 753-830
Gennarelli
T:
of the cerebral
Strich SJ: Cerebral trauma, in Greenfield’s ogy, edited by Blackwood W, Corsellis JAM, ett Arnold, 1976, pp 327-360
20. Hooper
A: Observations
47:71-87,
1959
on extradural
Computed
white
to-
matter.
Neuropathol-
London,
hematoma.
BrJ
EverSurg
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34
ZIMMERMAN
21. Jameison KG, Yelland JDN: Traumatic intracerebral hematoma. Report of 63 surgically treated cases. J Neurosurg 37:528-532, 1972 22. Jameison KG, Yelland JDN: Surgically treated traumatic subdural hematomas. J Neurosurg 37 : 1 37-1 49, 1972 23. Talalla A, Morin MA: Acute traumatic subdural hematoma: a review of one hundred consecutive cases. J Trauma 11 :771-776,
1971
ET AL. 24.
Knous WA, Davis cost effectiveness university
hospital.
of the American
DO, Young of cranial Paper
Society
5, Gulati computed
presented
at
of Neuroradiology,
A: Utilization tomography
the annual New
and at a
meeting Orleans,
February 1978 25. Miller JD, Becker DP, Ward JD, Sullivan HG, Adams Aosner MJ: Significance of intracranial hypertension severe head injury. J Neurosurg 47 : 503-51 6, 1977
WE, in
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This article has been cited by: 1. Ray Bradford, Arabinda K. Choudhary, Mark S. Dias. 2013. Serial neuroimaging in infants with abusive head trauma: timing abusive injuries. Journal of Neurosurgery: Pediatrics 12:2, 110-119. [CrossRef] 2. Andy S. Jagoda, Stephen V. Cantrill, Robert L. Wears, Alex Valadka, E.John Gallagher, Steven H. Gottesfeld, Michael P. Pietrzak, Jason Bolden, John J. Bruns, Robert Zimmerman. 2002. Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Annals of Emergency Medicine 40:2, 231-249. [CrossRef] 3. M. Zumkeller, R. Behrmann, H. E. Heissler. 1996. CT-Kriterien und Überlebensrate bei Patienten mit akutem Subduralhämatom. European Surgery 28:5, 308-312. [CrossRef] 4. I. Semih Keskil, M. Kemali Baykaner, Necdet �eviker, Memduh Kaymaz. 1995. Assessment of mortality associated with mild head injury in the pediatric age group. Child's Nervous System 11:8, 467-473. [CrossRef] 5. J. Windolf, R. Inglis, A. Pannike, U. Inglis, U. Gerlach, S. Gottschalk, J. Kieseleczuk, M. Krieger, H. Langwara, M. Schnabel, M. Siemsen, V. Studtmann, O. Trentz, Ch. Wendler, A. Zabel, Th. Zimmermann. 1992. Röntgenuntersuchungen des Schädels bei Kopfverletzungen—eine Multicenterstudie. Unfallchirurgie 18:1, 10-18. [CrossRef] 6. Stuart J. Masters, Philip M. McClean, Joseph S. Arcarese, Reynold F. Brown, John A. Campbell, Howard A. Freed, George H. Hess, Julian T. Hoff, Arthur Kobrine, Dennis F. Koziol, Joseph A. Marasco, David F. Merten, Harry Metcalf, James L. Morrison, Jay A. Rachlin, John W. Shaver, John R. Thornbury. 1987. Skull X-Ray Examinations after Head Trauma. New England Journal of Medicine 316:2, 84-91. [CrossRef] 7. John C. M. Brust, P. C. Taylor Dickinson, Edward B. Healton. 1981. Failure of CT Sharing in a Large Municipal Hospital. New England Journal of Medicine 304:23, 1388-1393. [CrossRef]
Computed
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ROBERT
Tomography
A. ZIMMERMAN,’
in Diagnosis Head Trauma
and Management
T. BILANIUK,’
GENNARELLI,2
LARISSA CAROL
DOLINSKAS,’
THOMAS
AND
Review of the computed tomographic findings in 286 patients with acute craniocerebral trauma revealed several types of lesions: hemorrhagic contusion, intracerebral and extracerebral hematomas, general and focal cerebral swelling, and shearing injury of the cerebral white matter. Hemorrhagic contusions are the most frequent lesion and may result in focal neurologic deficits. General cerebral swelling occurs frequently in children and necessitates prompt medical management for complete recovery. Mortality rates for intracerebral, subdural, and epidural hematomas were lower for this
series
than for series
Because
was
of the
an 84%
surgical phy.
that preceded
availability
reduction
intervention,
computed
of computed
in arteriography, and
a 24%
58%
reduction
July
netrating
the
presenting
episode
were
of
acute
immediately of acute
the
286
Philadelphia
course
are
not
entirely
mography investigation
(CT) of
represents head
promptly, accurately, lated abnormalities only
by
invasive
a major injuries.
It
and noninvasively that were previously radiology
methods,
be the to-
trauma-related
Application trauma has [2],
Ambrose
evident
et al. [3],
that
various
CT
shows
traumatic
trauma
and
others
patients.
lesions Still,
and
the
[4-15].
in the
question
It has
of
2 year
period.
CT
selective
arteriography,
ies)
performed
were
sies
examination
clinically
radionuclide if clinically
during
the
reexamined patients
(clinical
lated with deals with under the Pennsylvania Received This
were
were
course CT.
I
March 20, 1978; accepted was supported
Department
Address reprint 2 Department
Am J Roentgenol © 1 978 American
of Radiology,
by contract
Hospital
after revision NS-5-2316
sectioned
Serial
were
and,
July 1978 Ray Society
were
severely
and
Autop-
in most
instances
to the planes
were
revised.
The
The
CT
findings
trauma
in
the
are summarized
by several conferences
interpreted
in some
cases,
diagnostic
on-line for this
CT and Clinical
acute
more
CT examination.
to correspond
studies
impressions
corre-
and
148
3 and 4) and the 138 less 1 and 2), 80% and 48%,
28 deaths,
examinations
preceding
with
studevalu-
of section radiologists and review
by
comparison
initial
diagnostic
interpretations
re-
working diagnoses prospective investi-
Findings
286
patients
in table
examined
3. They
with
are subdi-
April 6, 1978. from
of the University
requests to A. A. Zimmerman. of Neurosurgery, Hospital of the University 131 :27-34, Roentgen
the
by sequential
in 15 of the
flow were
of hospitalization
(grades
studied
radiography, and
Patients
Among
using
CT scans.
sessions,
clinical and laboratory findings. This report the results obtained on 286 patients studied protocol at the Hospital of the University of during the past 2 years.
work
of the
conscious-
carried
scan
indicated.
The CT examinations were evaluated and neurosurgeons at frequent clinical
CT
of
then
brain
grades
patients
obtained
the brains of the
by
injured
were
was
gation.
and
were
50%
I scanner with a 160 x 160 matrix. radiographic studies (skull and spine
examinations
compared
remaining
disturbance
ported in this paper are the final accepted by the group responsible
systematically
The
significant
=
also carries prognostic value. To investigate this point, a protocol was set up under contract from the National Institutes of Health whereby the results of sequential CT were
(49.7%)
out
injured
of
whether
142
were
3
deficit.
severely
the
management
remains
1.
patients,
neurologic
routinely
become
diagnosis
in table
trauma
problems.
deficit:
respectively,
in the
was of it.
and 4 = (4A) focal
ated
CT to acute craniocerebral by de Villasante and Taveras
is indispensable
CT examination or within a few days
initial
ness, with (3B) or without (3A) neurologic deficit; comatose with pain response, with (4B) or without an EMI Mark Additional
processes.
of cranial been reported
the
injuries
neurologic
neurologic
intracranial abnormalities that were previously recognized only at autopsy. Thus the visualization of gross neuropathology is possible during life. Moreover, through sequential studies, CT reveals the time course of various
In 286
traumatic
patients were evaluated clinically on presentation at the hospital and assigned a clinical grade from 1 to 4: 1 = minimal to no disturbance on consciousness: 2 = minimal to moderate disturbance of consciousness, with (2B) or without (2A) focal
in the reveals
also
is given
CT. the
All
the trauma-redemonstrated but
trauma
and
not examined by CT because the had only minimal or no disturbance of consciousness: for CT examinations was given to patients with more
urgent
under-
breakthrough not only
The
after head
during head
priority
Craniocerebral trauma is one of the most frequent and grave forms of neurologic disease [1]. Its etiology is obvious, yet the biomechanics of its production and the its
origin.
with nonpe-
by
and 144 (50.3%) were children (17 years of age or under). The age and sex distribution of this group of patients is given in table 2. Pediatric patients represented 50% of the patients with acute head injuries hospitalized at the Children’s Hospital of
patients
of
studied
adult
pediatric
pathophysiology
were
symptomatology
injury
acute
320 patients
1977,
trauma
both
mode
BRUCE,2
Methods
June
craniocerebral
Of
and
through
patients,
The
there in radiogra-
stood. Proper therapeutic management can only based on correct diagnosis and appreciation of temporal course of the disease process. Computed
1975
performed
reduction
in skull
DEREK
UZZELL’
Subjects From
tomography.
tomography,
BARBARA
of Acute
the National
Institutes
of Pennsylvania
of Health.
and Children’s
of Pennsylvania
and
27
Children’s
Hospital Hospital
of Philadelphia,
Philadelphia,
Pennsylvania
19104.
of Philadelphia,
Philadelphia,
Pennsylvania
19104.
0361
-803X/78/0700
-
0027
$00.00
ZIMMERMAN
28
TABLE Mode
of Injury
AL.
eccentric
1
in Acute
ET
Head
cerebral
and, Mode
of
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Injury
Total
Pediatric
Adult
Patients
Patients
hemorrhage
diffuse
Trauma
less frequently
the third juncture,
No.
71
42
113
39.5
Four
patients
died
40
83
29.0
logic
deficits,
and
Hit
24
37
61
21.3
state.
6 144
23 142
29
10.1 100
.
Unknown Total 5truck
-
286
Focal
by or within.
TABLE
2
Age and Sex Distribution
-
Intracerebral
No.
%
three
hemorrhage
have
2),
around
medullary ventricles.
significant
in a persistent
neurovegetative
Abnormality
spersed
between
blood
were
(fig.
hemorrhage,
cerebral cortical and in the lateral
remains
contusion. a cortical
39% AgeandSex
(50%), one
Hemorrhagic findings showed tissue and contusions
callosum
but importantly,
43
.
corpus
subarachnoid
,
ventricle, at the in the brain stem,
Fell
Automobile
in the
swelling
In 61 patients (21 .3%) area of heterogeneously more
lucent
areas
edema. These were identified (fig. 3). In 29% the contusions associated
with
another
of
the CT internecrotic
as hemorrhagic
were
significant
multiple; focal
mass
28 72 44
19 50 31
lesion (e.g., subdural hematoma). The hemorrhagic contusion was three times as common in the adult as in the child. Of the patients with hemorrhagic contusions (with or without associated mass lesions), 72% were clinically
18-30
55
39
of the
31-50 50+
43 44
30 31
was
101
70
112
79
43 30
30 21
Pediatric
(years):
0-2 3-10 11-17
grade
Adult (years)
Male: Pediatric
Adult Female: Pediatric Adult
3 or 4; 75%
general
had
skull fractures
trauma
population.
compared
In 20%
to 51%
the
fracture
depressed.
The overall mortality for 37 patients who only had contusion was 19%. The mortality for those with associated mass persistent
lesion was neurologic
uncomplicated
45%. deficit
contusions
Similarly, increased
to 50%
the
incidence from 16%
for those
with
of for
associ-
ated mass lesions. lntracerebral hematoma.
vided into three groups: (1) no intracerebral focal abnormality; focal abnormality. The outcome with and
respect with
to clinical
respect
Nonfocal
grades
is given
to CT findings
in table
a definable
other
than
fracture,
patients,
25%
initially
focal
focal
5
extension.
teration
of the
cephalic
neurologic
lateral
in
and
five of 10. Shearing patients
injury
(2.8%),
third
accidents,
had
of the
14%
were
no
incidence
persisted
the
or obli-
and
perimesen-
in
in one was
cerebral 4 and
CT findings
white
which
46
all
reflecting
matter.
two
patients
child
(3%).
of 36,
white injured
Eight
the
patients
were
adult,
and
be
due
to
infarction
or contusion.
Of these
and two-thirds were grade Two patients had persistent
3
deficit.
of
Extracerebral
Abnormality
Acute subdural hematoma. Thirty-six patients (12.5%) had CT findings of an acute subdural hematoma-a peripheral crescentric band of blood encapsulating a portion of the cerebral hemisphere (fig. 5). In half of these
patients
hemorrhagic other half,
CT
demonstrated
contusion there were
obvious
an
area
of
underlying
and/or laceration. Among the many instances where a swelling
hemorrhage
underlay
the
subdural
he-
matoma, so that the mass effect was disproportionately large compared to the size of the subdural hematoma (fig. 5). Of the patients with subdural hematomas, 75% were
traumatic
consisted
may
neurologic
without
in automobile
a diffuse
These
The
in adults
matter.
of
patients, 75% were children or 4. There were no deaths.
Focal Compression
Two-thirds
78% of the patients were clinically grade 3 or 4. Overall mortality was one-third. Neurologic deficit persisted in 17%. Focal cerebral swelling. Twelve patients (4.2%) had CT findings of focal cerebral swelling, presumably edema
of
17 years of age or under. Of the initially grade 3 or 4. Of the neurologic deficits at presenta-
all grade
cerebral
There
ventricles
patients
of
4, and
a 2.5%
demonstrated
deficit pediatric
deOf these
deficit.
was
Neurologic
only
swelling.
(16.1%) (fig. 1); 36 were 46 patients, 83% were children, 19% had focal mortality
3 and
deficits.
and
cerebral
cisterns
abnormality
hemorrhage,
grades
neurologic
general
traumatic
pneumocephalus.
clinically
deaths, focal
Acute
limited
were
had
persistent
or diffuse subarachnoid
or
trauma-related
injury
4 and
6.
abnormality. A total of 1 1 9 patients CT examination or one that did not
minimal
pressed
tion.
in tables
Injuries
Normal or minimal (41 .6%) had a normal show
focal abnormality; (2) and (3) extracerebral in terms of mortality
Eighteen patients (6.3%) had a relatively large homogeneous well defined mass of blood density (fig. 4) demonstrated by CT. These were identified as hematomas and distinguished from hemorrhagic contusions. The masses were usually frontal or temporal, and in one-third there was intraventricular
patients
adult
and
with
75%
acute
were
clinically
subdural
grade
hematomas,
3 or 4. Of the
31%
died.
CT
IN ACUTE
HEAD
TABLE CT Findings
TRAUMA
29
3
According
to Clinical Clinical
Grade
Grade
T tel N
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Finding
of Patients
Patients
1
2
3
42
38
23
6
1 19
41.6
8
21
17
46
16.1
8
8
2.8
4
Examined
Nonfocal:
Normal
or minimal
General cerebral Diffuse shearing white matter
abnormality* swelling injury of cerebral
.
Focal abnormality: Intracerebral: Hemorrhagic contusion Intracerebral hematoma Focal cerebral swelling
-
Minimal
Pediatric
.
.
.
11 2 4
11 5 6
33 9 2
61 18 12
21.3 6.3 4.2
2 2
7 2
8 5
19 5
36 14
12.6 4.9
patient may have more than one finding. subarachnoid hemorrhage, depressed fracture,
or limited
TABLE Acute
,
6 2
Extracerebral: Acute subdural hematoma Epidural hematoma Note-A
.
pneumocephalus.
4
TABLE
Head Injury Patients According Clinical Grade and Mortality
to Admission
Mortality
Related
6 to CT Findings
#{149}#{149}y1#{149}#{149}#{149}#{149} Trauma
Patients
% of
Admission
in
.
No. Patients
.
Finding
Pattants
I
Nonfocal: Normal or minimal abnormality General cerebral swelling Diffuse
144
8
100
5.6
shearing
TABLE Head Injury Clinical Admission Cr i I Grade
43 35 26 38 142
Total
to Admission
and Mortality % of Ad I Patients
No. Patients
1 2 3 4
According
No. Deaths
Patients in Clinical
rhagic and
solely
to the
contusion
0 2 0 18 20
100
underlying
epidural
hematoma,
contributed swelling
to the
to the mass
.
.
45% with associated
19
36 (child) 10(adult)
0
6 50
of cerebral
contusion
mass lesion,
8
50
61
26*
18 12
33 0
36 14
31 7
19% without.
Dying(%)
30.3 24.6 18.3 26.8
0 5.7 0 47.4 14.0
Neurologic deficits persisted in one-third of the suvors. Epidural hematoma. Fourteen patients (4.9%) had epidural hematomas. In 13, the collections were biconvex, peripheral, and demarcated by either sutures or the edge of the stripped dura (fig. 6). In 57%, the mass effect was due
.
Intracerebral hematoma Focal cerebral swelling Extracerebral: Acute subdural hematoma Epidural hematoma
5
Patients Grade
injury
.
white matter Focal abnormality: Intracerebral: Hemorrhagic
Acute Adult
Mortality
(%)
Dying(%)
Total
Related to
whereas
mass effect
effect in 14%.
hemor-
in 29%, Adults
constituted 64% of this group, and 79% were grade 3 or 4. One patient died (7%) and two have persistent neurologic deficit (14%).
Other Skull
Findings
Radiography
Skull radiography was performed on 76% of patients with acute head injuries. Films were normal in 31% of the children and in 33% of the adults with significant intracranial abnormality demonstrated by CT. Skull films were positive for fracture in 32% of children and 23% of adults in whom there was no significant intracranial abnormality on CT. Skull fractures were associated with significant intracranial lesions demonstrable by CT in 69% of children and in 67% of adults (table 7). Arteriography
Angiographic procedures were performed on 16 adults and three children as part of the initial diagnostic evaluation. Of the 19 studies, 13 were performed at hospitals without CT equipment prior to transfer of the patient. Of the 19 arteriographic procedures, 58% were performed during the first quarter of the study.
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30
ZIMMERMAN
in 6-year-old female struck by car A, Day of injury. Compression of lateral ventricles bilaterally. Subarachnoid hemorrhage is present in interhemispheric fissure (arrows). B. 36 days after injury. Lateral ventrides are top normal in size. Patient is clInically normal. and
ET
AL.
Fig.
4. -Intracerebral
Fig. 1 . -General cerebral swelling rendered immediately comatose.
year-old with right hematoma of lateral horn. B, focal left enlargement
hematoma
with
intraventricular
extension
in 35-
male who fell while drunk and was admitted in stuporous state hemiparesis. A, Day of injury. Large left frontal intracerebral within white matter, with extension into frontal horn (arrows) ventricle. Blood is present in third ventricle and opposite frontal 173 days after injury and surgical evacuation of hematoma. Note frontal encephalomalacia (arrowheads) and left frontal horn (arrows). Patient has right-side weakness 1 year after injury.
Fig. 2.-Diffuse shearing injury of cerebral white matter in 4-year-old female in coma after automobile injury. Day of injury. Hemorrhage eccentrically on left side of corpus callosum. Bilateral cerebral swelling is present. Patient died.
Fig. 3.-Hemorrhagic contusion in 22-year-old male with moderate disturbance of consciousness and left-side weakness after severe beating. MultipIe right frontal and temporal skull fractures were present. Day of injury. Extensive right frontal and temporal areas of hemorrhagic contusion (arrows). Patient is neurologically normal 5 months after injury.
Fig. 5.-Acute subdural coma, with pain response left subdural hematoma
hematoma in 36-year-old male admitted in only. after fall. A, Day of injury. Small acute (arrows) with disproportionate mass effect (compression left lateral ventricle). B, 83 days after injury. Bilateral atrophic ventricular enlargement. Patient has marked recent memory loss and spastic hemiparesis.
hematomas, rhagic
four
negative
the
the 286 patients with acute clinical criteria for arteriography
clinical with
grades focal
injuries, [16].
2B, 3B, 4B (disturbance
neurologic
findings),
and
120 They
satisfied fell into
of consciousness 4A (coma
with
pain
response only, without focal neurologic findings). In the pre-CT era, all of these patients would have undergone arteriography. In 13 cases (68%), the CT scans and arteriograms demonstrated the same abnormality (five acute subdural
one
but
information.
had
been
was
made
rhagic
on
by CT information
patients,
inasmuch
farction
was
epidural
and
graphic sion
(two
contusions,
one
was as
(26%),
whereas
cerebral
gave
to
CT
carotid CT
one better
the diagnosis examination but two
injury).
superior
hemor-
and
hematomas, shearing
a traumatic
demonstrated of the
the
five
the
two
hematoma, CT scan
cases arteriographic
In
missed
hematomas,
epidural
examination),
quality
Of
intracerebral
contusions,
hemor-
The in
angio-
one
artery
merely
of
showed
hemisphere.
Ventriculography One
adult
patient
ary to herniation
with
from
a brain
cerebral
stem
hematoma
swelling
and
19
occlu-
second-
hemorrhagic
in-
CT
IN
ACUTE
HEAD
31
TRAUMA
ium
and
cranial
base
skull radiography, unless depressed,
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by blood
obvious
at autopsy,
and
often
on
were usually not identified by CT separated, or secondarily suggested
in the
sinuses
or mastoid
air cells.
Discussion Clinical
Findings
and
CT
The patients with acute nonpenetrating cerebral injury can be prognostically subdivided on the basis of clinical findings into three categories: (1) those with cerebral and (or) bodily injury incompatible with survival: (2) those in a persistent vegetative state: and (3) those who recover Fig. 6. -Acute epidural hematoma in 52-year-old male who suffered right temperoparietal skull fracture after falling. Neurologic examination was normal and patient was wide awake at time of CT examination. A, Day of injury. Large right temperoparietal epidural hematoma with compression and shift of right lateral ventricle. B, Day after injury (and evacuation of epidural hematoma). Scan is normal and patient was normal clinically.
carbia)
Incidence
of Skull
CT Finding and Patienf Group
appear
identical disruption. absence
lesion
Fractures
Fractures
the
by revealing when
already
labile
In the
first
Adult
77
23
disruption
69
they either succumb to the hospital. The
67
impact,
Note-Data
based
on 218 of 286 patients
(76%)
contusion was studied by emergency ventriculography. The ventriculographic findings confirmed the CT demonstration of brain stem enlargement.
of the
and
severe wherein
with into
are
Craniotomy was performed on nine children and 24 adults; 13 epidural, 14 acute subdural, and six intracerebral hematomas were evacuated. All patients with epidural, 83% of those with intracerebral, and 64% of those with acute subdural hematomas who underwent surgery survived. Numerous other patients had elevation of depressed skull fractures, insertion of subarachnoid bolts or intraventricular cannulas for intracranial presand
closure
of scalp
lacerations.
had
vehicular by a
typical
There was excellent correlation between all gross lesions identified on the CT scan (intraand extracerebral hematomas, hemorrhagic contusions, swelling) and the neuropathologic findings. A portion of the small, very superficial, and usually minimally hemorrhagic contusions of the outer cortex was not identified by CT. Review of the CT examinations in these patients demonstrated that these contusions could often not be appreciated even in retrospect. Linear fractures of the calvar-
to secondary In this
more
invasive
procedures,
with
The of
can
so severe
little
clinical
group
results
with
most
significant
white injury.
the
injury
type of
of injury
high
lesion
injury was a small (fig. 2). It is significant
4,
in persistent
this time
the
severe with
biomechanical
at the
speed revealed
hemorrhage because
shearing
of
alter
the cerebral category of
which
patients
of
to
apparent the patients
injury of clinical
that
after admission at the time
do
force
manifestation
surgery, effect on
biomechanical
system
sustained
All eight
or
patient.
patients
degree
type
because
injury
in it is which
occurs in this region [18]. Seven of the eight patients in this series passed through a persistent vegetative state. Half of the patients died and the survivors showed poor recovery.
Autopsy
diswith
severe
in management
injury fell into deaths occurred.
a severe
collision.
with
due
the clinically this series,
In
who
CT in this type corpus callosum
the
initial
a major role parenchy-
reversible.
of the
shearing the second
state.
still
nervous
to severe
sustained
of
attention
patients
vegetative
those
CT plays significant
prior to or shortly damage is sustained
medical
of moderate
for
central
biomechanical 93% of the
Patients matter fall
to
helpful
are
outcome. CT demonstrates biomechanical injury.
These Surgery
monitoring,
are
condition
32
31
the
often cannot groups. Patients
ventriculography, could have a deleterious
category
68
.pIt
During
changes
they
as angiography, in themselves
Pediatric Positive:
sure
and
at a time
such which
[17].
forms of mechanical injury and superimposed injury (due to hypoxia, hypoperfusion, hyper-
of injury, CT may be very it may obviate the need
Fracture
time
examination in these
clinically
Negative:
Pediatric
of
forms of biomechanical by demonstrating the injury
7
a period
period, neurologic between patients
nonfatal secondary
mal TABLE
within
acute tinguish
Recognition
immediately The
after
pediatric
patients
(fig. 1) represent different course adults) small swelling
with focal
of trauma
with
CT
pattern
of
prognosis bilateral
general
cerebral
children
lesions.
cerebral
is
most
likely
injury
swelling
patients patients
associated
swelling Acute
this
possible.
a distinct group. These and outcome from the
hemorrhagic in
the makes
general due
to
have (mostly
a
with cerebral
secondary
The most widely accepted explanation of the swelling is that a primary change in the cerebrovascular resistance occurs (due to traumatic stimulus, hypercarinjury.
32
ZIMMERMAN
bia and/or hypotension), resulting in increased cerebral blood flow, intraparenchymal vasodilatation increased cerebral blood volume, and reduced cerebral compliance. This produces bilateral cerebral swelling which may lead to edema, or on its own may produce sufficient mass effect to result in herniation and death. The most common pathologic finding in children who die from acute head injury [19] is diffuse cerebral swelling with obliteration of cerebrospinal fluid spaces and with venous congestion of the cortex. Statistical comparison cannot be made between our series and studies performed before CT because no prior diagnostic method was capable of demonstrating cerebral swelling as definitively as CT. The low mortality (6%) and the low morbidity (3%) for cerebral swelling in the present series, notwithstanding the high frequency of swelling in the pediatric population (24%), indicates that cerebral swelling need no longer be the most frequent autopsy finding following acute pediatric head trauma. Early detection by CT and early control of secondary injury are the two major factors contributing to a favorable recovery (fig. 1). All epidural hematomas, a number of large intracerebral hematomas, and large subdural hematomas are lifethreatening focal mass lesions often amenable to surgical correction. Prior to CT, radiologic evaluation of head trauma was directed toward detection of these mass lesions. By circumventing the delays and risks encountered with arteriography, CT permits more rapid and accurate identification of these lesions. Also, the general condition of the entire brain can be assessed. The patient can be taken from the CT scanner to the neurosurgical operating room, and definitive surgery can be performed. Nowhere is this more clearly demonstrated than in the case of the acute epidural hematoma, where the primary threat to life is due to the hematoma itself (fig. 6). In case of an epidural hematoma that is not associated with parenchymal injury [1], the patient may be temporarily asymptomatic while the extracerebral life-threatening mass expands. Prompt surgical evacuation of the epidural hematomas in our series resulted in a 100% postoperative survival. The low mortality rate in this series (table 6) lies well within the 10% figure advanced by Hooper [20] as the ideal goal of early diagnosis and treatment. Jameison and Yelland [21] reported a mortality of 15.6% for epidural hematomas in the pre-CT era. The surgical mortality in our series for acute subdural hematomas was 36%. The mortality for the nonoperated acute subdural hematomas was 27%, which compares favorably with the 63%-68% mortality reported prior to CT [22, 23]. To a certain degree, this also reflects the greater degree of accuracy of CT in identifying less symptomatic small acute subdural hematomas that might otherwise have gone undetected clinically or by other diagnostic studies. It is the parenchymal injury that accounts for the mass effect being disproportionately large compared to the size of the subdural hematoma,
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,
when
the
hematoma,
subdural
surgical
is small
(fig.
evacuation
5). In the
seems
small
to
be
subdural
unneces-
ET AL. sary, and treatment should be directed at the medical management of the parenchymal injury and its mass effect [15]. The underlying parenchymal damage accounts for the frequent late finding of atrophic ventricular enlargement (fig. 5). Intracerebral hematomas (fig. 4) can usually be differentiated from hemorrhagic contusions (fig. 3) by CT. The surgical mortality in this series for intracerebral hematomas was only 13%, which compares favorably with the pre-CT mortality figure of 25.4% reported by Jameison and Yelland [21]. Hemorrhagic contusion is the most frequent focal acute parenchymal abnormality identified by CT (21%) in head trauma patients. Its significance during the acute period lies in its association with other mass lesions and in its contribution to the mass effect, as edema develops during the first few days after injury [11].
Its
permanent psychologic Economic
ultimate
significance
neurologic aberration. Aspects
is
that
dysfunction,
focal
it
may
produce
seizures,
and
CT
The variables in the analysis of cost factors in the management of acute head injury are considerable, especially with inflation in the cost of hospital care and the changing methods of management of acute head trauma (many prompted by the information now available from CT). An attempt at a retrospective study of cost factors for pre-CT trauma patients was undertaken (10 years, 1964-1973), but an accurate comparison to the data corresponding to the period following the advent of CT (1974) could not be made. One current method of analysis of CT costs [24] uses the concept of the cost per positive diagnostic study. On the basis of a charge of $225 per CT examination and a CT positive incidence rate in this study of 48.4%, the cost per positive CT examination was $464.85. This can be compared to the per positive cost rate when the indications for an examination are symptoms such as headache, with a yield of 0.8% positive studies [24]. What this method of analysis does not indicate is the value
of negative
or minimally
abnormal
CT examination
in the grade 4 comatose trauma patient, wherein the clinical evaluation is not capable either of diagnosis or prognosis but CT is decisive. Cost can also be analyzed in terms of dollars saved because of elimination of other diagnostic methods. In this study, clinical symptomatology would have warranted emergency arteriography in a minimum of 120 patients had CT not been available. This does not include patients with clinical grades 2A and 3A, whose neurologic status deteriorated over several days after injury. These patients would also have undergone arteriography. The prevailing cost for a carotid arteriogram is around $415. The cost of arteriography for all 120 patients would have been $49,800. The 19 arteriograms performed cost $7,885. In 13 studies, arteriography was performed at other hospitals primarily because they lacked CT facilities. In 101 of 107 patients evaluated at the Hospital of the University of Pennsylvania, arteriography was felt to be unnecessary after CT. In these 101
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CT
IN ACUTE
patients, the difference between the cost of the CT examination and arteriography (101 x $190) amounted to a saving of $19,190. Analysis of the 19 cases where both carotid arteriography and CT were performed revealed that the same primary diagnosis was reached in 63%; CT was more accurate than arteriography in 26%, and provided less information than arteriography in 5% (one case). Skull radiographs were performed in 76% of the acute head injury population. Prior to CT, 100% of the hospitalized head trauma patients would have had skull radiography as the first radiologic procedure. The mcidence with which skull radiography is performed on patients has progressively decreased during the course of this study. Presently, skull examinations are performed when the patient’s condition is sufficiently stabilized, frequently days after injury, and then for the evaluation of facial injury, depressed calvarial fracture, or fracture of the cranial base associated with cerebrospinal fluid oto- or rhinorrhea. A certain proportion of the present skull radiographic examinations are done because of the referring physician’s adherence to traditional ways of evaluating trauma patients. The results in our series indicate that CT is the procedure of choice in the initial evaluation of cerebral parenchymal injury, and that skull radiography should be reserved for the indications mentioned above. Skull radiographic costs are about $50 per examination. The savings on the 68 patients not examined in this series is 68 x $50, or $3,400. Prior to CT, patients with significant head injury associated with focal mass effect and midline shift (demonstrated by arteriography or ventriculography) have undergone craniotomy, surgical exploration, and decompression in many trauma centers [25]. Of the 85 patients with significant head injury and CT evidence of focal mass effect and midline shift, 79 survived long enough to be considered for surgery. As a consequence of the CT findings (hemorrhagic contusion, focal swelling, small acute subdural hematoma, small intracerebral hematoma), surgery was avoided in 46 of the 79 patients (58%) who were then managed medically. The approximate neurosurgical fee for craniotomy with exploration (excluding operating room and anesthesia) is $1 300. This represents a savings in this series of 46 x $1 300, or $50,400. Ambrose et al. [3] reported a 94% reduction in the number of craniotomies for acute head injury since using CT.
HEAD
to the results of neurosurgical series before CT, show a significant improvement in mortality rate for intracerebral, subdural, and epidural hematomas. There has been a progressive decrease in the use of arteriography, skull radiography, and in surgical intervention. REFERENCES AD, Victor M: Craniocerebral trauma, in Principles New York, McGraw-Hill, 1977, pp 562-585 2. de Villasante JM, Taveras JM: Computerized tomography 1.
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3.
Ambrose
Am J Roentgenol
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ment 4.
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puted
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AB:
LaRoque
JH:
in the manage-
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D: EMI 1 :847-848,
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GS,
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DG,
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of
OW:
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hemato-
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Dolinskas
C,
B: Computed
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II, Piepgras the
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12. Kobrine Al, Timmins E, Aajjoub AK, Rizzoli HV, Davis DO: Demonstration of massive traumatic brain swelling within 20 minutes after injury. J Neurosurg 46:256-258, 1977 13. Zimmerman RA, Bilaniuk LT, Bruce D, Dolinskas C, Obrist W,
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KuhI
cerebral
swelling.
D:
Dolinskas
Computed
AA,
C,
arachnoid pediatric
Zimmerman
Bilaniuk
bleeding on cranial head trauma patients.
pediatric
LT:
computed
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Radiology A sign
of
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tomograms
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of
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Dolinskas
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Cranial
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Gennarelli
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from
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Zimmerman
AA,
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Radiology. 19.
injury. Crit
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Nervous 18.
with
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of post-traumatic
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By accurately differentiating the various forms of gross neuropathologic lesions resulting from trauma to the brain, CT leads to prompt and more effective treatment. Frequently the prognosis can be implied from the CT findings. Patients with CT findings consistent with shearing injury invariably have a poor prognosis. However, the pediatric patient with general cerebral swelling has a good prognosis when the entity is recognized and treated early. The results in this series, when compared
head
1976
bral
Conclusions
33
TRAUMA
1973, pp 753-830
Gennarelli
T:
of the cerebral
Strich SJ: Cerebral trauma, in Greenfield’s ogy, edited by Blackwood W, Corsellis JAM, ett Arnold, 1976, pp 327-360
20. Hooper
A: Observations
47:71-87,
1959
on extradural
Computed
white
to-
matter.
Neuropathol-
London,
hematoma.
BrJ
EverSurg
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34
ZIMMERMAN
21. Jameison KG, Yelland JDN: Traumatic intracerebral hematoma. Report of 63 surgically treated cases. J Neurosurg 37:528-532, 1972 22. Jameison KG, Yelland JDN: Surgically treated traumatic subdural hematomas. J Neurosurg 37 : 1 37-1 49, 1972 23. Talalla A, Morin MA: Acute traumatic subdural hematoma: a review of one hundred consecutive cases. J Trauma 11 :771-776,
1971
ET AL. 24.
Knous WA, Davis cost effectiveness university
hospital.
of the American
DO, Young of cranial Paper
Society
5, Gulati computed
presented
at
of Neuroradiology,
A: Utilization tomography
the annual New
and at a
meeting Orleans,
February 1978 25. Miller JD, Becker DP, Ward JD, Sullivan HG, Adams Aosner MJ: Significance of intracranial hypertension severe head injury. J Neurosurg 47 : 503-51 6, 1977
WE, in
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This article has been cited by: 1. Ray Bradford, Arabinda K. Choudhary, Mark S. Dias. 2013. Serial neuroimaging in infants with abusive head trauma: timing abusive injuries. Journal of Neurosurgery: Pediatrics 12:2, 110-119. [CrossRef] 2. Andy S. Jagoda, Stephen V. Cantrill, Robert L. Wears, Alex Valadka, E.John Gallagher, Steven H. Gottesfeld, Michael P. Pietrzak, Jason Bolden, John J. Bruns, Robert Zimmerman. 2002. Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Annals of Emergency Medicine 40:2, 231-249. [CrossRef] 3. M. Zumkeller, R. Behrmann, H. E. Heissler. 1996. CT-Kriterien und Überlebensrate bei Patienten mit akutem Subduralhämatom. European Surgery 28:5, 308-312. [CrossRef] 4. I. Semih Keskil, M. Kemali Baykaner, Necdet �eviker, Memduh Kaymaz. 1995. Assessment of mortality associated with mild head injury in the pediatric age group. Child's Nervous System 11:8, 467-473. [CrossRef] 5. J. Windolf, R. Inglis, A. Pannike, U. Inglis, U. Gerlach, S. Gottschalk, J. Kieseleczuk, M. Krieger, H. Langwara, M. Schnabel, M. Siemsen, V. Studtmann, O. Trentz, Ch. Wendler, A. Zabel, Th. Zimmermann. 1992. Röntgenuntersuchungen des Schädels bei Kopfverletzungen—eine Multicenterstudie. Unfallchirurgie 18:1, 10-18. [CrossRef] 6. Stuart J. Masters, Philip M. McClean, Joseph S. Arcarese, Reynold F. Brown, John A. Campbell, Howard A. Freed, George H. Hess, Julian T. Hoff, Arthur Kobrine, Dennis F. Koziol, Joseph A. Marasco, David F. Merten, Harry Metcalf, James L. Morrison, Jay A. Rachlin, John W. Shaver, John R. Thornbury. 1987. Skull X-Ray Examinations after Head Trauma. New England Journal of Medicine 316:2, 84-91. [CrossRef] 7. John C. M. Brust, P. C. Taylor Dickinson, Edward B. Healton. 1981. Failure of CT Sharing in a Large Municipal Hospital. New England Journal of Medicine 304:23, 1388-1393. [CrossRef]
