Evaluation of Craniocerebral Trauma Using

EVALUATION OF CRANIOCEREBRAL TRAUMA USING

COMPUTED TOMOGRAPHY

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS OF DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS
( in block letters) / DR. DEEPAK THOMAS. J.
DEPT OF RADIODIAGNOSIS
A.I.M.S, B.G.NAGARA. NAGAMANGALA TALUK, MANDYA DISTRICT, KARNATAKA
2 / NAME OF THE INSTITUTION / ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES, B.G.NAGARA.
3 / COURSE OF STUDY AND SUBJECT / M.D. RADIODIAGNOSIS
4 / DATE OF ADMISSION TO COURSE / 13TH MAY 2009
5 / TITLE OF THE TOPIC / EVALUATION OF CRANIOCEREBRAL TRAUMA USING COMPUTED TOMOGRAPHY.
6 / BRIEF RESUME OF INTENEDED WORK
6.1 NEED FOR THE STUDY
6.2 REVIEW OF LITERATURE
6.3 OBJECTIVES OF THE STUDY / APPENDIX I
7 / MATERIALS AND METHODS / APPENDIX II
7.1 SOURCE OF DATA: DEPARTMENT OF RADIODIAGNOSIS
SRI ADICHUNCUNAGIRI INSTITUTE
OF MEDICAL SCIENCES.
7.2 DOES THE STUDY REQUIRE ANY
INVESTIGATIONS OR INTERVENTIONS YES
TO BE CONDUCTED ON PATIENTS OR OTHER APPENDIX IIB
ANIMALS, IF SO PLEASE DESCRIBE BRIEFLY
7.3HAS ETHICAL CLEARANCE BEEN
OBTAINED FORM YOUR INSTITUTION IN CASE OF 7.2 / YES
APPENDIX IIC
8 / LIST OF REFERENCES / APPENDIX III
9 / SIGNATURE OF CANDIDATE
10 / REMARKS OF THE GUIDE
11 / NAME & DESIGNATION OF
(IN BLOCK LETTERS)
11.1 GUIDE / DR. BALAKRISHNA.B.V.M.B.B.S , M.D.
PROFESSOR AND HOD
DEPARTMENT OF RADIODIAGNOSIS
SRI ADICHUNCHUNAGIRI
INSTITUTE OF MEDICAL SCIENCES.
11.2 SIGNATURE
11.3 CO-GUIDE (IF ANY)
NAME :
SIGNATURE :
11.4 REMARKS
11.5 HEAD OF DEPARTMENT / DR BALAKRISHNA.B.VM.B.B.S , M.D
PROFESSOR AND H.O.D
DEPARTMENT OF RADIODIAGNOSIS
SRI ADICHUNCHUNAGIRI
INSTITUTE OF MEDICAL SCIENCES.
11.6 SIGNATURE
12.1 REMARKS OF CHAIRMAN AND PRINCIPAL / DR M.E.MOHAN MBBS.MD.
PRINCIPAL
SRI ADICHUNCHANAGIRI
INSTITUTE OF MEDICAL SCIENCES
B.G.NAGARA.MANDYA
12.2 SIGNATURE

APPENDIX-I

6.0 BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY

The human brain is of incredible complexity in design and function , but very vulnerable to injury. Head trauma can have transient symptoms, or lead to chronic signs and symptoms. The medical management of acute head trauma can be quite complicated and expensive. As more medical and surgical therapies for head trauma are available the role of neuroimaging has become more important.1

Today it is clearly recognized that trauma can be identified, evaluated and often prevented. Previously, the mainstay of diagnosis of intracranial traumaticlesions was at best clinical evaluation, plain roentgenograms of skull and cerebral angiography. An accurate diagnosis cannot be made on the basis of physical examination alone except on rare occasion. In addition a detailed examination cannot be performed when patient’s condition is rapidly deteriorating. Plain roentgenograms and angiography suffer from lack of sensitivity and specificity.Angiography in addition is hazardous invasive procedure on a patient already having a potential brain damage.

The primary goal in treating a patient with craniocerebral trauma due to any

cause is to prevent the patients life and remaining neurological function. The

optimal management of these patients depends on early and correct diagnosis and

therefore neuroimaging has a vital role. The advent of CT has been a major

breakthrough in meeting these vital requirements.

CT is the single most informative diagnostic modality in evaluation of a patient with head injury. It can demonstrate significant primary traumatic injuries including extradural, subdural, intracerebral, subarachnoid and intraventricular haemorrhages, skull fractures, cerebral oedema, contusions and cerebral herniations.The present day scanners due to refined technology can further help in diagnosing diffuse axonal injuries which were never thought before. Contribution of CT is crucial to complete injury assessment and forms the basis of patient management.2

Prompt recognition of treatable injuries is critical to reduce mortality and CTof the head is the cornerstone for rapid diagnosis.3 Follow up assessment using the CT is frequently necessary to detect progression and stability of lesions and evidence of delayed complications and sequalae of cerebral injury which can

determine whether surgical interventions are necessary.

CT is currently the procedure of choice than MRI because it is faster and more readily available and it is more easily accommodates emergency equipmentand can easily enable the detection of blood during the acute phase. Inability to acquire bone details and cost factors further makes MRI inferior to CT in the evaluation of craniocerbral trauma.

CT is quick, cost effective, non invasive method to assess time and extent of cerebral injury and is an essential aid to triage patients to observation, medical or surgical management. It has also made the neuroradiologist an essential member of the trauma care unit.

This study attempts to assess the utility of CT in the diagnosis, management and prognosis of patients with cerebral trauma.

APPENDIX-IB

6.2 REVIEW OF LITERATURE

The problem of head trauma is very old, imaging of the injuries or their

effects was not contemplated till late 19th century, specially 1895 when William

Conrad Roentgen, Professor of Physics and Acting Rector of the University of

Wurzburg discovered X Rays – the imaging modality. He received the first Nobel

Prize in Physics in 1901 for that discovery.

Vander Naalt J, Hew J.M. et al in 1999 agreed that CT was the most frequently used imaging technique in patients with acute head injury in which it provides accurate detection of parenchymal and subrarachnoid haemorrhages. MRI on the other hand is more sensitive in detection of smaller lesions / non –haemorrhagic contusions 4.

Nagy K.K, Joseph K.T. Krosner S.M. et al stated in 1999 that CT was useful in the management of patients with minimal head injury and leads to change in treatment of small but significant number of patients.

The use of portable CT has been useful in dealing with severe head injuries where minutes truly count in determining outcome and survival. Trauma patient is admitted directly to CT scanner, resuscitated on CT bed, monitored and scanned immediately on admission.

In the operation theatre portable CT is useful in early detection of delayed intracranial haemorrhages that may occur because of release of tamponade that occurs after operative evacuation. Normally this bleeding is not recognized till

several hours later unless neurological deficits are manifested.

The use of portable CT has potential advantages over frameless stereotacticnavigation devices; precise registration of patient’s position to predetermined landmarks is not required with real time CT guidance and undetected patientmovement causing inaccurate positioning registration is not a problem. 5

Mittl R.L. Grossman.R.I. Hiechle.J.F in 1994 said that MR changes consistent with DAI in 30% of mildly head injured patients with absence of CT abnormality thereby explaining for the persisting symptoms.6

Kido D.K., Cox C. et al in 1992 showed clear cut correlation of Glasgow coma score and Glasgow coma outcome score after head injury with CT lesion size regardless whether lesion was intra or extra axial, lesion was more than 4100 cu.mm had two fold higher risk and poor outcome than those with abnormal scans.

Jaykumar P.N., Sastry Kolluri V.R. et al in 1991 concluded that progressworsened in presence of

• Advanced age
• Hematoma > 4cm in linear dimension.
• GCS less than or equal to 8
• Severe degree of midline shift and obliteration of basal cisterns.7

The radiological signs in patients with diffuse axonal injury were illustrated in an article by Levi L.,Guiburd J.N. et al in 1990. They said that differentialacceleration parts of brain on impact can produce shearing forces at grey matter junction, in the brain stem or corpus callosum. Axons and small vessels tear to produce picture of diffuse axonal injury. Diagnosis was based on visualization of small, non expansive hemorrhagic lesion at corticomedullary junction at nuclear medullary junction, corpus callosum or cerebellum and small intraventricular bleeds with generalized oedema.

In 1990 Massaro F. Lacotte M. Faccani G. et al in their study on operated cases of acute SDH put forth that the extent of primary brain injury as indicated byadmission CT and GCS are the most important prognostic factors for predictive patient outcome.

Studies indicating predictive usefulness of CT in traumatic brain injurieswere published, few of which are illustrated below. Levi L. Guiburd J.N.et al in the same article in 1990 pointed out the poor prognosis associated with deeper lesions of DAI. They using , the GCS and CT findings classified brain injury into severe ( GCS<9 ), moderate ( GCS9-12 ) and minor ( GCS13-15 ) 8

In a comparative study of CT and MRI Zimmerman et al in 1988 classified head injury patients into three groups according to duration of examination from time of injury – Acute ( 1 to 3 days ), Subacute ( 15 to 20 days ) and Chronic ( one month to three years ).9

Francis Lee, Louis K.Wagner et al stated in 1987 that patients with upper facial fractures were at the greatest risk for closed head injury than those with mandibular and midfacial regions combined or isolated 10.

Ann Christine Duhaime et al in 1987 published an article on the shaken baby syndrome. They said that vigorous shaking appears unlikely to result in severehead injury. The whiplash shaken baby syndrome as described by Caffey

according to them is probably a misnomer, as the angular acceleration that can be

achieved with shaking a child appears to be well below that required to produce

serious brain injury. 11

It was realized that the CT appearance of EDH and SDH can mimic each other, as was proved during the operative intervention to drain their collections and by autopsy.Since the differentiation between the two did not have much prognostic significancecommon term “Extra axial collection” was labelled to them. Dough Reed et al in May 1986 and Braun J et al in 1987 in AJNR insisted on the usage of the term extra axial collections rather than classifying them into SDH and ESH.12

Markwalder T.M. in 1981 reviewed the cause and factors promoting formation and increase in the size of chronic SDH. He stated that rebleeding from capillaries in themembrane was a more likely cause of increase in the size of chronic SDH than the osmotic gradient theory. He said that chronic SDH were more common in elderly patients with minor craniocerebral trauma due to absence of tamponade effect of contusion and oedema, which occurs in major trauma and by presence of cerebral atrophy.13

Barmier and Dubowitz in the same year described a new sign to detect extraaxialmass lesion with density same as adjacent brain parenchyma. Normally grey matter ofboth hemisphere is of equal thickness and therefore the grey-white matter interface of each hemisphere is equidistant from inner table of skull. A small isodense SDH will cause apparent thickening of grey matter due to mechanical displacement of grey white matter interface.14

In 1981, Smith and Batnitzsky stated that anaemia can give an isodense appearance to an acute SDH, thereby causing discrepancy between the age and density of SDH.15

APPENDIX-IC

6.3 AIMS AND OBJECTIVES OF THE STUDY

1. To study with aid to CT, the different traumatic lesions in trauma to the head
2. To correlate between skull fractures and intracranial lesions.
3. To establish that CT has significant role in management of patients with head injury.
4. To assess prognostic significance of CT in the outcome of patients of head injury.

APPENDIX-II

7. MATERIAL AND METHODS

APPENDIX-IIA

7.1 SOURCE OF DATA

The data for the study intended to be carried in patients with head injury,

referred to Department of Radio-diagnosis , SriAdichunchanagiriHospital and Research Centre, B.G Nagara, Nagamangala Taluk, Mandya District.

APPENDIX-IIB

7.2 METHODS OF COLLECTION OF DATA

My intended study is a prospective study to be carried on 100 patients

with craniocerebral trauma referred to the Department of Radio diagnosis,

SriAdichunchanagiriHospital and Research centre for a period of 24 months

Patient selection will be based on the following criteria.

I .INCLUSION CRITERIA OF STUDY GROUP

• Adults from the age of 18 years onwards

• Patients with a history of road traffic accident, fall or assault are included in the study

II. EXCLUSION CRITERIA OF STUDY GROUP

• Paediatric cases

• Penetrating injuries

• Patients with history of previous cerebrovascular accidents

• Patients with previous bleeding disorders.

• Known diabetic and hypertensive patients receiving anticoagulant therapy.

EQUIPMENT

Patients will be scanned using Single Slice Spiral: GE CT/e machine

• This is a fifth generation CT scanner.
• Matrix slice is 512
• Gantry tilt +/- 20 degree
• Slice thickness is10mm, 5mm, 3mm,
• K.V- 80 to 130.
• MAS -50 to 300

A complete clinical history of the patients taken, which included, age sex,

type of injury, principal presenting complaints. The type of trauma further

classified to beinto Road traffic accidents, Falls, Assaults, industrial accidents and

miscellaneous. Thisfollowed by general physical examination and detailed

examination of the central nervous system.

After initial resuscitation, severity of the cranio-cerebral trauma to be

graded withthe help of “Glasgow Coma Scale” (GCS) as follows.

Grades Scores

Normal 15

Mild head injury 13-14

Moderate head injury 9-12

Severe head injury < 8

CT Technique:

The patients to be examined for CT scan should be immobilized and kept in

supine position. The Gantry tilt given in the range of ± 0-20 degrees, so as to

parallel the scan plane to the orbito-meatal line.

Contiguous axial sections of slice thickness in the range of 10mm, 5mm

and 3mm, were taken respectively.

APPENDIX-IIC

7.3Does the study require any investigations or interventions to be conducted on patients and other animals? If so describe briefly

Yes , all the patients have to undergo CT evaluation of the head. No other investigations or interventions will be conducted on patients.

7.4 Has ethical clearance been obtained from your institution in Case of 7.3

Yes, Ethicalclearance has been obtained from research and dissertation

committee / ethical committee of the institution for this study.

APPENDIX-IIC

PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL

SECTION A
a / TITLE OF THE STUDY / EVALUATION OF CRANIOCEREBRAL TRAUMA USING COMPUTED TOMOGRAPHY
b / PRINCIPLE INVESTIGATOR ( NAME AND DESIGNATION ) / DR.DEEPAK THOMAS.J.
POST GRADUATE STUDENT IN DEPT OF RADIODIAGNOSIS
A.I.M.S ., B.G.NAGAR,MANDYA
c / CO-INVESTIGATOR
(NAME AND DESIGNATION) / DR.BALAKRISHNA.B.V.
M.B.B.S , M.D
PROFESSOR & HOD
DEPARTMENT OF RADIODIAGNOSIS
SRI ADICHUNCHUNAGIRI
INSTITUTE OF MEDICAL SCIENCES,B.G. NAGARA-571 448
d / NAME OF COLLABORATING DEPARTMENT /INSTITUTIONS / NO
e / WHETHER PERMISSION HAS BEEN OBTAINED FROM THE HEADS OF COLLABORATING DEPARTMENT & INSTITUTION / NA
SECTION – B
SUMMARY OF THE PROJECT / APPENDIX I
SECTION – C
OBJECTIVES OF THE STUDY
SECTION – D
METHODOLOGY / APPENDIX II
A / WHERE THE PROPOSED STUDY WILL BE UNDERTAKEN / DEPARTMENT OF RADIODIAGNOSIS
S.A.H & R.C.,B.G.NAGARA
B. / DURATION OF THE PROJECT / 24 MONTHS FROM NOV 2009
C / NATURE OF THE SUBJECT:
DOES OF THE STUDY INVOLVE ADULT PATIENTS?
DOES THE STUDY INVOLVE CHILDREN?
DOES THE STUDY INVOLVE NORMAL VOLUNTEERS?
DOES THE STUDY INVOLVE PSYCHIATRIC PATIENTS?
DOES THE STUDY INVOLVE PREGNANT WOMEN? / YES
NO
NO
NO
NO
D / IF THE STUDY INVOLVES HEALTH VOLUNTEERS
I. WILL THEY BE INSTITUTE STUDENTS?
II. WILL THEY BE INSTITUTE EMPLOYEES?
III WILL THEY BE PAID?
IV IF THEY ARE TO BE PAID, HOW MUCH
PER SESSION? / NO
NO
NO
NO
E / IS THE STUDY A PART OF MULTI CENTRAL TRIAL? / NO
F / IF YES, WHO IS THE COORDINATOR?
(NAME AND DESIGNATION)
HAS THE TRIAL BEEN APPROVED BY THE ETHICS, COMMITTEE OF THE OTHER CENTERS?
IF THE STUDY INVOLVES THE USE OF DRUGS PLEASE INDICATE WHETHER.
I. THE DRUG IS MARKETED IN INDIA FOR
THE INDICATION IN WHICH IT WILL BE
USED IN THE STUDY.
II, THE DRUG IS MARKETED IN INDIA BUT
NOT FOR THE INDICATION IN WHICH IT
WILL BE USED IN THE STUDY
III. THE DRUG IS ONLY USED FOR
EXPERIMENTAL USE IN HUMANS.
IV. CLEARANCE OF THE DRUG CONTROLLER
OF INDIA HAS BEEN OBTAINED FOR :

• USE OF THE DRUG IN HEALTHY

VOLUNTEERS
USE OF THE DRUG IN-PATIENTS FOR
A NEW INDICATION.
PHASE ONE AND TWO CLINCIAL TRIALS

• EXPERIMENTAL USE IN –PATIENTS

AND HEALTHY VOLUNTEERS. / NA
-
-
NA
NA
NA
NA
NA
G / HOW DO YOU PROPOSE TO OBTAIN THE DRUG TO BE USED IN THE STUDY?
-4 GIFT FROM A DRUG COMPANY
-5 HOSPITAL SUPPLIES
-6 PATIENTS WILL BE ASKED TO PURCHASE
-7 OTHER SOURCE (EXPLAIN) / NA
H / FUNDING (IF ANY) FOR THE PROJECT PLEASE STATE
-8 NONE
-9 AMOUNT
-10 SOURCE
-11 TO WHOM PAYABLE / NO
I / DOES ANY AGENCY HAVE A VESTED INTEREST IN THE OUT COME OF THE
PROJECT? / NO
J / WILL DATA RELATING TO SUBJECT/CONTROLS BE STORED IN A COMPUTER? / YES
K / WILL THE DATA ANALYSIS BE DONE BY
-12 THE RESEARCHER?
-13 THE FUNDING AGENT / YES
NO
L / WILL TECHNICAL /NURSING HELP BE REQUIRED FROM THE STAFF OF HOSPITAL.
IF YES, WILL IT INTERFERE WITH THEIR DUTIES?
WILL YOU RECRUIT OTHER STAFF FOR THE DURATION OF THE STUDY?
IF YES GIVE DETAILS OF

1. DESIGNATION
2. QUALIFICATION
3. NUMBER
4. DURATION OF EMPLOYMENT

/ NO
NO
NO
NA
NA
NA
NA
M / WILL INFORMED CONSENT BE TAKEN? IF YES
WILL IT BE WRITTEN INFORMED CONSENT:
WILL IT BE ORAL CONSENT?
WILL IT BE TAKEN FROM THE SUBJECT THEMSELVES?
WILL IT BE FROM THE LEGAL GUARDIAN? IF NO, GIVE REASON : / YES , CONSENT WILL BE
TAKEN FROM THE PATIENT
N / DESCRIBE DESIGN, METHODOLOGY AND TECHNIQUES / APPENDIX II

ETHICAL CLEARANCE HAS BEEN ACCORDED

CHAIRMAN,

DATE: P.G.TRAINING-CUM RESEARCH COMMITTEE,

A.I.M.S., B.G.NAGARA

APPENDIX-III

LIST OF REFERENCES:

1. Ko DY Clinical evaluation of patients with head trauma. Clin N Am 2002 : 12 (2) : 165 – 174.

1. Riegor J, Linesenmaier U, Pfeifer M. Radiological diagnosis in acute craniocerebral trauma. Radiologe 2002: 42(7) : 547 – 55.

1. Udsteun GJ, Claar JM. Imaging of acute head injury in the adult. Seminar in Ultrasound CT MR, 2001 ; 22(2): 135 – 147.

1. Van der Naalt J, Hew JM, van Zomeran H, Sluter WJ, Minderhoud JM. CT and MRI in mild to moderate head injury : Early and late imaging related to outcome. Ann Neurol 1999 : 46(1) : 70 – 78.

1. Butler WE, Piaggio CM, Niklason L, Gonzalez RG, Cosgrove GR, et al. A mobile computed tomographic scanner with intraoperative and intensive care unit applications. Neurosurgery 1998: 42(6): 1304 – 1310.

1. Mittl RL, Grossman RL, Hiehle JF, Hurst RW, Kauder DR, Gennarelli TA et al. Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings. AJNR Am J Neuroradol 1994; 15(8) : 1583 – 1589.

1. Jaykumar PN, Sastry kolluri VR, Basavakumar DG, Subbakrishna DK, Arya BY, Das BS et al. Prognosis in countercoup intracranial hematomas. A clinical and radiological study of 63 patients. Acta Neurochir (wien) 1991: 108(1-2):30 – 33.

1. Levi L, Guilburd JN, Lemberger A, Soustiel JF, Feinsod M. Diffuse Axonal injury: Analysis of 100 patients with radiological signs.Neurosurgery 1990: 27(3) : 429 – 432.

1. Zimmerman RA, Bilanuik LT, Hackney DB, Goldberg Hl, Grossman RI. Head injury: Early results of comparing CT and high field MR.Am J Neuroradiology 1986: 147(6) : 1215 – 1222.

1. Lee KF, Wagner LK, Lee YE, Suh JH, Lee SR. The impact absorbing effects of facial fractures in closed head injuries : An analysis of 210 patients. J Neurosurg 1987: 66(4): 542 -547.

1. Duhaime AC, Gennarelli TA, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome : A clinical , pathological and biochemical study. J Neurosurg 1987: 66(3) : 409 – 415.

1. Reed D, Robertson WD, Graeb DA, Lapointe JS, Nugent RA, Woodhurst WB. Acute subdural hematomas : A trypical CT findings. AJNR Am J Neuroradial 1986: 7(3) : 417 – 421.

1. Markwalder TM. Chronic subdural haematomas : A review J Neurossurg 1981 : 54 (5): 637 – 645.

1. Barmier E, Dubowitz B. Gray white matter interface displacement: A new sign in the CT diagnosis of subtle subdural hematomas. Clin Radiolol 1981: 32(4): 393 – 396.

1. Smith WP, Batnitzsky S, Rengachary SS. Acute isodense subdural haematomas : A problem in anaemic patients. AJNR Am J Roentgenol 1981: 136(3) : 543 – 546.