Imaging of Traumatic Brain Injury

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Imaging of Traumatic Brain Injury

• Paul Broadbent, M.D.

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Overview

• Traumatic brain injury has multiple mechanisms
  and varied presentations
• Imaging plays an important role in evaluating the
  full spectrum of these patients
• New imaging techniques provide additional insight
  into the diagnosis and treatment of these
  patients

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Mild Traumatic Brain Injury

• 1.2 million Americans are evaluated in EDs
  annually for concussion or mild TBI
• ¼ of all patients with TBI have symptoms that
  persist beyond 1 year (320,000 per year)

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TBI Defined

• Traumatic brain injury occurs when a sudden
  trauma causes damage to the brain
• Person may or may not experience a loss of
  consciousness at the time of injury.
• Symptoms of mild TBI include headache,
  confusion, lightheadedness, dizziness, blurred
  vision, ringing in the ears, fatigue, change in
  sleep patterns, mood changes

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TBI Symptoms Continued

• Behavioral changes, trouble with memory,
  concentration, attention or thinking.
• Patients with moderate or severe TBI may
  experience the above symptoms as well as nausea,
  seizures, weakness, numbness, confusion,
  restlessness or agitation.
• source NINDS

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Imaging Tools Old School to Cutting Edge

• Plain Radiographs
• Computed Tomography (CT)
• MRI with standard anatomic sequences
• Gradient Echo (Blood sensitive) MRI
• Diffusion Tensor Imaging
• Spectroscopy
• fMRI
• Perfusion Imaging
• Quantitative techniques

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Skull Radiographs
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Skull Radiographs

• Limited information such as depressed or
  displaced fractures and sinus opacity
• Does not predict presence or degree of brain
  injury
• Generally not a part of the modern evaluation of
  head injury

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Computed Tomography
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Head CT

• Advantages for TBI include availability, short
  scan times, detailed anatomic information -
  including evaluation of facial and temporal bone
  fractures
• Less sensitive for small parenchyma bleeds such
  as those seen with DAI

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Anatomic Patterns of Traumatic Brain injury

• Blood epidural, subdural, parenchyma,
  ventricular, and subarachnoid
• Direct injury to brain frontal lobe and
  anterior temporal lobe
• Sheering injury deformation of brain causing
  diffuse axonal injury

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45 y.o. with remote TBI
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GE 3T MRI Scanner
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45 y.o. with headaches and remote head injury
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Traumatic Contusion Location

• Occur in characteristic locations where brain is
  adjacent to bony protuberance or dural fold
• Nearly 50 involve temporal lobes
• 33 involve frontal lobe surfaces such as gyrus
  rectus as noted in index case
• 25 parasagital
• Multiple bilateral lesions in 90
• source Osborn et al Diagnsotic Imaging - Brain

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TBI DAI, Contusion and subdural Hemorrhage
Taber et al. J Neuropsychiatry Clin Neurosci
18141-145, May 2006
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Combat Related Blast Injury
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59 y.o. female with TBI X2 Recent and Remote
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T2 and Gradient Echo
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MR Spectroscopy
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Multivoxel Spectroscopy
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42 y.o. male passenger in MVC
Scheid et al AJNR June/July 2003
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39 y.o. female who fell from a horseGCS14
Scheid et al AJNR June/July 2003
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27 y.o. Male Remote TBI
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3T MRIAll Roads Lead To Disconnection
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MR Imaging Detection of Cerebral Microbleeds
Effect of SWI, Thickness and Field Strength
Namdigram et al
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SWI at 3T
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Words the cool kids use

• Notion noh-shuhn noun. An opinion, view,
  or belief. Conception or idea.
• Wonk wongk noun. A person who studies a
  subject or issue in an excessively assiduous and
  thorough manner a policy wonk.
• Anisotropy Not isotropic. Having properties
  that differ according to direction of
  measurement.

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Cool Words Defined

• Fractional anisotropy Directionality of water
  molecules with values between 0 (perfectly
  isotropic diffusion) and 1 (the hypothetical case
  of an infinite cylinder)

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Cool words continued

• Brownian motion the random movement of
  microscopic particles caused by collisions with
  molecules of medium.

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Diffusion
Jellison et al AJNR 25356-359, March 2004
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40 y.o. male 7 days after TBI demonstrates DAI
Traumatic Brain Injury Diffusion-Weighted MR
Imaging findings AJNR 201636 1641 Liu et al
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9 patients with DAI
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Color coded FA with ROI from control study
participant
Yuan et al AJNR Nov-Dec 2007
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Diffusion Tensor Color Map
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Fiber Tracking at 3T
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Fiber Tracts at 3T
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15 y.o. female ejected from car with normal GOS
at 12 months
Holshouser et al AJNR May 2005
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Frequency Distribution of Blood Flow
Abnormalities in Focal Patients
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Frequency Distribution of Blood Flow
Abnormalities in Diffuse Patients
SPECT Imaging in Head Injury Interpreted with
Statistical Parametric Mapping Stamatakis et al
Journal of Nuc Med Vol 43 2002
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33 y.o. male after Sports InjuryGCS 15 on
Admission
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Tennis Anyone?

• In there study Detecting Awareness in the
  Vegetative State Owens et al. used fMRI to
  demonstrate preserved conscious awareness in a
  vegetative state.
• When asked to imagine playing tennis the patient
  activated cortical areas in a manner
  indistinguishable from normal volunteers

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Conclusion

• TBI is a broad spectrum entity with varied
  mechanisms and presentations
• Imaging plays an important role in the diagnosis
  and treatment of these patients from the mild to
  severely injured
• Imaging techniques are evolving rapidly and
  moving far beyond the evaluation for gross blood
  or skull fracture
• Evaluation is greatly effected by knowing what to
  look for and having these powerful imaging tools
  available

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Thank You For Your AttentionDrive Safely!
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Gradient Echo Imaging
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AVM with prior Hemorhage
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