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Radiology Image: A 3-month-old male

A 3-month-old male

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Patient data
  • Age: 3 months
  • Gender: Male
  • Medical history: None
  • Initial presentation: ALTE incident, CPR performed
  • Examination: None

CT-scan of the head

CT-scan of the head

CT-scan of the head

CT-scan of the head

Question about CT-scan of the head.

S. Spijkers & M. Maas

Checklist (trauma) head CT scan

Soft tissue windows: Start inferiorly and work up to the vertex.

  1. 4th ventricle: is it shifted? Compressed? Blood visible?
  2. Cerebellum: a bleed or infarct?
  3. Brainstem cisterns obliterated? Check the quadrigeminal and ambient cisterns.
  4. Check lateral ventricles for blood (especially in occipital horns), size (especially temporal horns), and mass effect.
  5. Extra-axial blood: extradural haematoma is lens-shaped, does not cross sutures; subdural haematoma crosses sutures; subarachnoid haematoma channels into sulci and fissures; measure maximum thickness of clot in millimetres; check circle of Willis, Sylvian fissure for subarachnoid haematoma.
  6. Look for intraparenchymal haematomas and contusions, especially frontal and temporal tips, inferior frontal lobes and under any fractures (measure clot thickness in millimetres).
  7. Measure midline shift in millimetres at level of septum pellucidum.
  8. Check top cuts for effacement of sulci, often a subtle sign of mass effect.

 

Bone windows:

  1. Check five sets of sinuses (ethomoid, sphenoid, frontal, mastoid, maxillary) for fracture or opacification; the maxillary sinuses may only be partially seen on standard head cuts.
  2. Look for fracture of orbital apex, petrous temporal bone or convexities (if depressed, is it more than a table’s width? Measure the depression in millimetres).
  3. Check for intracranial or intraorbital air; this is much easier to see on bone windows than soft tissue windows.

Checklist MRI (Lumbar spine)

  1. Alignment: look at the normal lordosis, look at the posterior marginal line. Any vertebrae out of line?
  2. Vertebra: Quality of the marrow signal.
  3. Conus: Position and caliber of the conus. Terminates at L1/L2
  4. Cauda equina: Stenosis of the central spinal canal, compression of the cauda equina
  5. Discs: bulge wider that it is deep, or deeper than it is wide, evaluate all the discs
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For spinal injuries the TLICS or Thoracolumbar Injury Classification and Severity Scale is a widely accepted method to identify and score the injury based on morphology, integrity of the PLC (posterior ligamentous complex) and neurological status. Each subgroup can receive a score of 1-4 respectively 0-3 for both the PLC and neurological status. This score than indicates the severity of the injury. A common interpretation is that a score of less than four requires no surgery, a score of precisely four may requires surgery (which may be the surgeons choice) and a score above four always requires surgery.

The answers of question two are the four subdivisions of morphology. Further scoring in PLC and neurological status is not included in this exercise.

The scoring for our case is as follows. The unstable burst fracture with PLC damage of L3 is scored five points. The ventral compression fracture of T11 is scored one point, as there is no PLC damage present. No neurological abnormalities were present at the time of the examination and thus, as the fracture with the highest amount of point is choses, this patient was scored 5 points, which implies need for surgery.

CT-scan of the head

CT-scan of the head

CT-scan of the head

CT-scan of the head

  1. M.  Hofer, CT teaching manual. Stuttgart: Thieme, 2007.
  2. J.  Norton, Surgery. New York, NY: Springer, 2008.
  3. Announcement: An NIH Consensus Development Conference on Infantile Apnea and Home Monitoring’, Pediatr Res, vol. 20, no. 6, pp. 515-515, 1986.
  4. Nvk.nl, ‘Apparent Life Threatening Event (ALTE) > Nederlandse vereniging voor Kindergeneeskunde’, 2015. [Online]. Available here [Accessed: 10- Oct- 2015].
  5. F. Gaillard, ‘Diffuse axonal injury | Radiology Reference Article | Radiopaedia.org’,Radiopaedia.org, 2015. [Online]. Available here [Accessed: 11- Oct- 2015].
  6. D. Smith and D. Meaney, ‘Axonal Damage in Traumatic Brain Injury’, The Neuroscientist, vol. 6, no. 6, pp. 483-495, 2000.
  7. Emedicine.medscape.com, ‘Diffuse Axonal Injury Imaging: Overview, Radiography, Computed Tomography’, 2015. [Online]. Available here [Accessed: 11- Oct- 2015].

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