International Journal of Advanced and Integrated Medical Sciences

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Role of Computerized Tomography as Prime ImagingModality in the Evaluation of Traumatic Brain Injury
  IJAIMS
ORIGINAL ARTICLE
Role of Computerized Tomography as Prime ImagingModality in the Evaluation of Traumatic Brain Injury
1Parveen Hans, 2Atul Mehrotra, 3Pramod Kumar, 4Mohit Agarwal, 5Lalit Kumar, 6Pradeep Parakh, 7Sagar Tyagi
1,7Junior Resident, 2,3Associate Professor, 4Assistant Professor5Professor, 6Professor and Head
1-7Department of Radiodiagnosis, Rohilkhand MedicalCollege & Hospital, Bareilly, Uttar Pradesh, India
Corresponding Author:
Parveen Hans, Junior ResidentDepartment of Radiodiagnosis, Rohilkhand Medical College &Hospital, Bareilly, Uttar Pradesh, India,
e-mail: drparveenhans@gmail.com
10.5005/jp-journals-10050-10067
 
ABSTRACT
Introduction: Trauma is the most common worldwide cause ofdeath and disability in young adults. Neurotrauma is one of themost frequent indications for emergent neuroimaging becauseimaging plays such a key role in patient triage and management.
Aims and objectives: (1) To assess the role of computedtomography (CT) in patients with traumatic head injury. (2) Tolocalize trauma to a particular extraaxial and intraaxial compartmentand to delineate various spectrum of hemorrhagesthat occur in craniocerebral trauma with the aid of CT. (3) Toevaluate the value of early CT imaging with patient prognosis.
Materials and methods: This is a prospective study carriedout in 100 patients with traumatic brain injury, referred to theDepartment of Radiodiagnosis, Rohilkhand Medical College& Hospital, Bareilly, Uttar Pradesh, India, for CT scan during aperiod of 1 year. The patients were scanned using GE BrightSpeed 16-Slice multidetector CT.
Conclusion: Computed tomography is the single-most informativediagnostic modality in the evaluation of a patient with ahead injury and should be considered the first imaging of choicein acute head injury as it forms the cornerstone for rapid andeffective diagnosis.
Keywords: Computed tomography, Extradural hemorrhage,Glasgow coma scale score, Head trauma, Intracranial hemorrhage,Subarachnoid hemorrhage, Subdural hemorrhage.
How to cite this article: Hans P, Mehrotra A, Kumar P,Agarwal M, Kumar L, Parakh P, Tyagi S. Role of ComputerizedTomography as Prime Imaging Modality in the Evaluation ofTraumatic Brain Injury. Int J Adv Integ Med Sci 2017;2(1):17-23.
Source of Support: Nil
Conflicts of Interest: None
 
 

INTRODUCTION

Trauma is the most common worldwide cause of deathand disability in young adults. Neurotrauma is responsiblefor the vast majority of these cases and is a worldwidepublic health problem that carries enormous personal,societal, and financial impact.

 
Traumatic brain injury (TBI) causes a spectrum of braininjuries ranging from transient physiological dysfunction,manifested by short periods of confusion and amnesia tosevere immediate irreversible neuronal damage and death.

Of all head-injured patients, approximately 10%sustain fatal brain injury, and an additional 5 to 10% haveserious permanent neurologic deficits, while 20 to 40% ofTBI survivors have moderate disability.1

Trauma is one of the most frequent indications foremergent neuroimaging because imaging plays such akey role in patient triage and management.

Computed tomography (CT) is the single-most informativediagnostic modality in the evaluation of a patientwith head injury. Besides facilitating rapid implementation,it can demonstrate significant primary traumaticinjuries including extradural hemorrhage (EDH), subduralhemorrhage (SDH), intracerebral hematomas,subarachnoid hemorrhage (SAH), and intraventricularhemorrhage (IVH), skull fractures, cerebral edema, contusions,and cerebral herniations. Contribution of CT iscrucial to complete injury assessment and forms the basisof patient management.2

Computed tomography is widely available, rapid,permits close monitoring of unstable patients, compatiblewith respirators and other mechanical support devices, andcan be used in patients with unknown medical history. It isvery sensitive in detecting acute hematomas and depressedfractures that require emergency surgery. However, CTis less sensitive in detecting white matter injuries andposterior fossa lesions due to beam hardening artifacts,from the surrounding bones. Moreover, CT aids in surgicalplanning, prognosticating outcome, and recovery time.

This study highlights the role of CT in early diagnosis,thus aiding a better prognosis in patients with traumatichead injury.

AIMS AND OBJECTIVES

The aims and objectives of the study are:
  1. To assess the role of computed tomography (CT) inpatients with traumatic head injury.
  2. To localize trauma to a particular extraaxial and intraaxialcompartment and to delineate various spectrumof hemorrhages that occur in craniocerebral traumawith the aid of CT.
  3. To evaluate the value of early CT imaging with patientprognosis.

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Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Graph 1: Sex-wise and age-wise distribution in craniocerebral injury

MATERIALS AND METHODS

This is a prospective study carried out in 100 patientswith TBI, referred to the Department of Radiodiagnosis,Rohilkhand Medical College & Hospital, Bareilly, UttarPradesh, India, for CT scan during a period of 1 year fromJanuary 2015 to December 2015.

Patients of any age and sex admitted in Rohilkhandhospital with TBI that has occurred within 24 hoursand having Glasgow coma scale (GCS) score < 15 wereincluded in the study. Patients with GCS score - 15, withno positive CT findings, and with cranial trauma thatoccurred during childbirth were excluded from the study.

A complete clinical history of the patients wasnoted, which included age, sex, type of injury, principalpresenting complaints. The type of trauma was furtherclassified into road traffic accidents (RTA), falls, assaults,and miscellaneous. Follow-up of patients during theirhospital stay was performed.

The patients were scanned using GE Bright Speed16-Slice multidetector CT.

Computed Tomography Protocol

The patients were examined with CT scanner in thesupine position. The Gantry tilt was in the range of ±0 to20°, so as to parallel the scan plane to the orbitomeatal line.

Bone algorithms and wide window settings werestudied to visualize the various craniocerebral changes.

Technical Factors

Matrix size - 512, slice thickness - 5 mm, Kilo voltage - 80to 120, and Milli ampere second - 50 to 270.

Statistical Methods

Rates, ratios, and percentages of different findings on CTand outcome will be computed, compiled, and studied

 
Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Graph 2: Incidence of different modes of injury

RESULTS

A total of 100 patients with TBI with positive findings onCT scan were included in the present study.

Male population dominated the study, with 66% ofpatients being male and 34% being female.

The peak incidence of head injury was found in theage group of 21 to 30 years, i.e., 36%. Incidence in otherage groups was 19% in age group of 31 to 40, 15% in 11 to20, 12% in 41 to 50, 10% in 0 to 10, 6% in 51 to 60, and 2%patients aged above 60 years (Graph 1). In our study, RTAwas found to be the commonest mode of head injury withan incidence of 69%, followed by other modes of injury,such as falls with an incidence of 27%, assaults 3%, and miscellaneous1%. But in children (0-15 years age group), fallwas found to be the commonest mode of head injury, withan incidence of 83.33% followed by RTA - 16.6% (Graph 2).

According to the study, cases with moderate headinjury with GCS score of 9 to 12 were the commonest,accounting for 37% of all cases, followed by cases withmild head injury with GCS score of 13 to 14 accountingfor 33% cases, and with severe head injury were leastcommon accounting for 30% (Graph 3).

Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Graph 3: Grading of head injury based on GCS score

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Role of CT as Prime Imaging Modality in Evaluation of Traumatic Brain Injury

Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Figs 1A and B: Axial bone window: (A) Volume rendering; and (B) depressed fracture of right parietal bone


Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Fig. 2: Fracture of right orbital roof involving the frontal sinuswith hemosinus and pneumocephalus

In the present study, calvarial bone fracture was seenin 76 patients; out of these commonest type of fractureswere linear fractures accounting for 50 (65.8%) cases, followedby depressed fracture 14 (18.4%) (Figs 1A and B)and skull base fractures (Fig. 2) accounting for 12 (15.8%)cases.In the present study, contusions (Fig. 3) were thecommonest intracranial lesion noted in 47 patients(47%) and soft tissue swelling/injury (80%) and fractures(76%) were the commonest of all lesions. Otherlesions which were seen on CT scan are cerebral edema44%, SAH 34% subdural hematoma 22%, extraduralhematoma 20%, intracerebralhematoma 9%, and IVH6%, midline shift 15%, and pneumocephalus 14%(Graph 4).

As described in the literature, in our study also EDHis usually associated with fracture of overlying bone(Figs 4A and B). Out of 20 patients with EDH, 17 patientshad an overlying associated fracture.

Poor outcome was noted in patients with a GCS scoreof < 8. Patients with GCS score of < 8 had a mortality of30%, followed by 8.1% in patients with GCS of 9 to 12,and no mortality was found in patients with 13 to 14 GCSscore (Graph 5).

 
Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Fig. 3: Hemorrhagic contusions with surrounding edema in right frontal lobe

Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Graph 4: Incidence of various lesions as observed on CT scan

χ 2 = 14.23 and p < 0.001, which shows that the relationshipis highly significant and GCS score is a goodindicator of outcome.

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Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Figs 4A and B: Hyperdense, lentiform-shaped EDH in left frontal region (A) with overlyingfrontal bone fracture (B)


Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Graph 5: Outcome based on the GCS score

According to the present study, SDH (41.6%) (Figs 5A, Band 6) was the most common extraaxial bleed noted inpatients who expired, followed by SAH of 33.3%; EDHwith 16% was the least common hemorrhage noted inthese patients.

 
Diffuse cerebral edema, midline shift, intraparenchymalbleed (Fig 6), and IVH are indicators of poorprognosis. Increased incidence of contusions was alsonoted in patients who expired.

In patients with EDH, timely diagnosis and promptsurgical decompression surgery improve prognosis withreduction in mortality rate from 10 to 0%. Significantreduction in mortality is also noted in surgically managedpatients of intraparenchymal bleed from 55 to 25%.Therefore, timely diagnosis and early surgical managementsignificantly improves outcome.

DISCUSSION

Males were found to be more predominant than femalesin the present study.

Incidence reported in other studies were Zimmermanet al3 79%, Saboori et al4 78.2%, and Holmes et al5 65%.This male preponderance can be attributed to theincreased outdoor activity and travel by males.

In the present study, patients in the age group of 21to 30 years formed the bulk of the study. Khan et al6 alsomentioned in their study that peak incidence of TBIs wasbetween 15 and 35 years age group, and Saboori et al4reported a mean age of 29 years for patients of head injury.Study by Ogunseyinde et al7 also stated that head injurywas common in patients younger than 35 years.


Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Figs 5A and B: Noncontrast CT axial: (A) Reformatted coronal; and (B) image showing acute SDH in rightfrontoparietal region and SAH in left parietotemporal region

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Role of CT as Prime Imaging Modality in Evaluation of Traumatic Brain Injury

Role of Computerized Tomography as Prime Imaging Modality in the Evaluation of Traumatic Brain Injury
Fig. 6: Noncontrast CT axial image showing large acute SDH in rightfrontal region and intraparenchymal hematoma with surroundingedema in bilateral frontal lobe

By these studies, it is noted that head injury is seencommonly in socially and economically productive agegroup of the population, and hence has an impact on thefinancial aspect of the family.

Road traffic accidents were found to be the commonestmode of injury in the present study accounting for 69%.Zimmerman et al3 also reported RTA as the major cause,albeit in a lesser population (39%). Gururaj8 in his studyreported vehicular accidents as the major mode of headinjury with an incidence of 60% and Ziya Ahmad andKarmakar9 reported 85.9%. This increased incidence dueto RTA can be attributed to the increased vehicular movementbecause of rapid urbanization, economic growth,and lifestyle changes.

In younger patients (< 15 years), fall was found to bethe most common mode of injury (83.33%), followed byRTAs (16.66%), which is consistent with other previousstudies.

Linear fractures were found to be the commonesttype of fracture with an incidence of 65.8%, followed bydepressed fractures accounting for 18.4%, and skull basefracture 15.8%. Study by Lloyd et al10 showed an incidenceof linear fractures of 84% and that of depressed fracturesto be 9%. Goyal et al11 also stated that linear fracture (77%)is the most common followed by depressed fracture (13%).

In the present study, patients classified as moderatehead injury with a GCS score of 9 to 12 formed the bulk ofthe study accounting for 37%, followed by 33% of patientswith mild head injury with GCS score of 13 to 14, and30% of patients with severe head injury with GCS scoreof < 8. This increase in incidence of moderate and severehead injury seen is probably due to exclusion of patientswith normal CT findings in the present study conducted.

 
Contusion was found to be the commonest intracraniallesion detected on CT accounting for 47% inthe present study. Dublin et al12 also reported similarobservation (40%).

Subdural hematoma was found in 22% cases in thepresent study. Incidence reported in other studies wereOgunseyinde et al7 (28.7%) and Gupta et al13 (19%).

Intraparenchymal bleed accounted for 9% of lesionsin the present study, whereas higher incidence of 26.3%was noted in the study conducted by Ogunseyinde et al.7

Intraventricular hemorrhage was the least commonlesion noted with an incidence of 6% in the presentstudy. LeRoux et al14 in their studies had stated thatIVH is noted in 1 to 5% of all patients with head injury.Gupta et al13 reported incidence of 10.7%. TraumaticIVH is thus relatively uncommon and usually reflectssevere injury.

Extradural hematoma was found to be associatedwith an overlying fracture in 85% of cases in the presentstudy. Igun15 reported 100% association of EDH with anoverlying fracture. A blow to the calvarium resulting infracture of the adjacent bone causes displacement of duraaway from the inner table of skull, resulting in damageto underlying vessel, thus causing extradural hematoma.

The commonest hemorrhage found in patients whoexpired was subdural hematoma and intraparenchymalhemorrhage with an incidence of 41% each. This can beattributed to the more severe impact of trauma to causethe hemorrhage and also the significant midline shiftnoted in these patients leading to a grave prognosis.Cooper16 in his study stated that mortality due to subduralhematoma was between 35 and 50%, and SDH isalso associated with worse outcome because it is generallycaused by high velocity injuries resulting in moreprimary brain injury. Midline shift, if present, carriespoor prognosis and found in 75% patients who expired.

In addition, EDH was seen in 16% of patients whoexpired. Bricolo and Pasut17 and Smith and Miller18 intheir studies stated that mortality with EDH is approximately5%. Since EDH is usually associated with lowvelocity injury, it results in little primary injury to brainand causes poor outcome only if the expanding hematomais allowed to compress the brain. Increased associationof EDH with mortality is found in our study becauseof other associated intra- or extraaxial lesions.

In the present study, poor outcome was noted witha GCS score of < 8 with a mortality of 30%, followed by8.1% in patients with GCS of 9 to 12, and no mortalitywas found in patients with 13 to 14 GCS score. Study conductedby Stuart et al19 reported an incidence of 34.50%mortality with a GCS score of < 8.

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p-value is calculated using chi-square test and foundto be < 0.001, which shows that the relationship is highlysignificant and GCS score is a good indicator of outcome.This increased mortality in a patient with a reducedGCS score is due to more severe primary brain insultassociated.

Operative decompression was carried out in sixpatients with extradural hematoma and four patientswith intraparenchymal hematoma. All operatedpatients had good prognosis except in one patient withintraparenchymal hematoma who expired. Traumaticextradural hematoma is a neurosurgical emergency andtimely surgical intervention for significant extraduralhematoma is gold standard as stated by Cheung et al20in their study. According to Bullock et al,21 patients whohad EDH with thickness >15 mm, midline shift >5 mmshould be surgically managed regardless of GCS score,and craniotomy provides a more complete evacuationof hematoma.

Khaled et al22 also found in their study that surgicalintervention in EDH is associated with the best prognosis.Out of many factors affecting the outcome, the mostimportant one is the duration of time between accidentand surgery; mortality can be close to 0% if this timeinterval can be minimized.

Chowdhury et al23 stated that EDH is one of the mostrewarding neurosurgical emergencies. It must be diagnosedin the early period of the trauma and evacuatedearly to prevent potential mortality and morbidity.

Therefore, early diagnosis is very crucial in patientprognosis.

CONCLUSION

Head injury is a major neurological cause of death anddisability in young and middle-aged patients, withRTAs being the most common cause in adults and fallin children.

Neuroimaging technique provides vital diagnostic,prognostic, and pathophysiological information in themanagement of brain injury. Radiological imagingmodalities help in the assessment of intracranialhemorrhage, fractures, and other structural lesions.Apart from the correct diagnosis, the time to establisha diagnosis is very crucial for successful managementand favorable outcome in patients with TBI.

Computed tomography is widely available, relativelyinexpensive, highly sensitive, and safe imaging modalityand provides the ability to rapidly evaluate patientswith acute head injuries. Contribution of CT is crucial tocomplete injury assessment and forms the basis of patientmanagement.

In addition, CT aids in surgical planning, prognosticatingoutcome, and recovery time. It can demonstratesignificant primary traumatic injuries including extradural,subdural, intracerebral hematomas, SAH, andIVHs, skull fractures, cerebral edema, contusions, andcerebral herniations.

 
Moreover, CT is one of the most comprehensive diagnosticmodality for early and accurate diagnosis, thusaiding a better prognosis in patients with head injury.

Thus, it is justifiable to conclude that CT is the singlemostinformative diagnostic modality in the evaluationof a patient with a head injury and should be consideredthe first imaging of choice in acute head injury as it formsthe cornerstone for rapid and effective diagnosis.

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