Radiology of the Head and C-Spine

1. HEAD AND CERVICAL SPINE
- Emergency Radiologic Approach -
Ranieri Falcão Aguiar
Radiology Fellow
Radiology Department
Sir Charles Gairdner Hospital
11-12-2014

2. HEAD

3. HEAD - INITIAL STUDIES
Fundamentals of Diagnostic Radiology, 3rd ed.

4. What to look for?
• Fractures
• Hemorrhage
• Epidural hematoma
• Subdural hematoma
• Subarachnoid
• Intraventricular
• Intracerebral hematoma
• Cortical contusions
• Diffuse axonal injury
• Stroke
Fundamentals of Diagnostic Radiology, 3rd ed.

5. Head ct - approach
1. Midline
2. Symmetry
3. Basal cisterns
4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.

6. Head ct - approach
1. Midline
2. Symmetry
Fundamentals of Diagnostic Radiology, 3rd ed.

7. Head ct - approach
1. Midline
2. Symmetry
3. Basal cisterns
Fundamentals of Diagnostic Radiology, 3rd ed.

8. Head ct - approach
1. Midline
2. Symmetry
3. Basal cisterns
Fundamentals of Diagnostic Radiology, 3rd ed.

9. Head ct - approach
1. Midline
2. Symmetry
3. Basal cisterns
4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.

10. Head ct - approach
1. Midline
2. Symmetry
3. Basal cisterns
4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.

11. Head ct - approach
1. Midline
2. Symmetry
3. Basal cisterns
4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.

12. Head ct - approach
1. Midline
2. Symmetry
3. Basal cisterns
4. Ventricles
Fundamentals of Diagnostic Radiology, 3rd ed.

13. Head ct - approach
1. Midline
2. Symmetry
3. Basal cisterns
4. Ventricles
EMERGENCY CT CHECKLIST
1.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?
Fundamentals of Diagnostic Radiology, 3rd ed.

14. fractures
Fundamentals of Diagnostic Radiology, 3rd ed.

15. fractures
Fundamentals of Diagnostic Radiology, 3rd ed.

16. Epidural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.

17. Subdural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.

18. Subdural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.

19. Subdural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.

20. Subdural hematomas
Fundamentals of Diagnostic Radiology, 3rd ed.

21. Subarachnoid hemorrhage
Fundamentals of Diagnostic Radiology, 3rd ed.

22. Diffuse axonal injury
Fundamentals of Diagnostic Radiology, 3rd ed.

23. Cortical contusions
Fundamentals of Diagnostic Radiology, 3rd ed.

24. 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.

25. CERVICAL SPINE

26. Cervical spine - RADIOGRAPHS
STANDARD VIEWS
•Lateral
•Antero-posterior
•Open mouth

27. CERVICAL SPINE - ANATOMY
• SPECIFIC ANATOMY
• C1
• C2
• SUBAXIAL
SPECIFIC FRACTURES

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

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

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

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

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

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

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

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

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

37. X-ray adequacy
Fundamentals of Diagnostic Radiology, 3rd ed.

38. alignment
Fundamentals of Diagnostic Radiology, 3rd ed.

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

40. alignment

41. ALIGNMENT

42. ROTATED

43. measures
 > 3 mm  highly suggestive of transverse ligament rupture = instability!
 5 mm in children
Fundamentals of Diagnostic Radiology, 3rd ed.

44. measures
ABOVE C4 < 1/3rd OF VERTEBRAL BODY
BELOW C4 < 1 VERTEBRAL BODY
*NOT SENSITIVE
Fundamentals of Diagnostic Radiology, 3rd ed.

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

46. A B
JEFFERSON’S FRACTURE
A + B > 6,9 mm indicates transverse ligament tear = instability!
A-Z of Emergency Radiology, 1st ed. 2004

47. HANGMAN’S FRACTURE
A-Z of Emergency Radiology, 1st ed. 2004

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

50. SHOULD I WORRY ABOUT VERTEBRAL
ARTERIES?
• 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)
1. Vertebral Artery Injury Associated With Blunt Cervical Spine Trauma. Spine. 2013
Jul;38(16):1352–61.

51. 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.

52. C-spine
TO SUM UP
1.3 STANDARD VIEWS
2.XRAY QUALITY
3.ALIGNMENT  3 LINES AND C1 LATERAL MASSES
4.FOLLOW BONE CORTICES
5.DISTANCES
• ATLANTO-DENS INTERVAL
• PRE VERTEBRAL SOFT TISSUE
6.CT
7.MRI  LIGAMENTOUS OR MEDULLARY INJURIES

53. THANK YOU!