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Hello and welcome to Noon Conference, hosted by Modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr. Benjamin Strong

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for a case-based lecture entitled Intracranial Trauma ct

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Dr. Strong completed residencies in both internal medicine

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and radiology, and completed a fellowship in body M-S-K-M-R.

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He worked as an emergency physician for three years,

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private practice radiologist for two years,

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an academic radiologist for two years.

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He's worked in various capacities for virtual radiologic

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for the past 21 years

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and holds licenses to practice in all 50 US states.

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At the end of the lecture, please join him in a q

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and a session where he will address questions you may have

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on today's topic.

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Please remember to use that q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we're ready to begin today's lecture,

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Dr. Strong, please take it from here.

1:05

Thanks very much, Ashley.

1:06

Uh, thanks to everyone at modality

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for the invitation to speak.

1:10

It's a real pleasure to be here.

1:13

So we'll be doing intracranial hemorrhage today.

1:17

Uh, I find this an entertaining picture

1:20

because in my residency I had conceived that this is

1:24

how I really wanted to view CT scans.

1:27

It only took about three hours for me to parse and skew

1:32

and stack, uh, every image here on this normal ct.

1:36

And, uh, obviously it never took off.

1:40

So we'll be doing the left hand column here on

1:43

intracranial hemorrhage.

1:45

And I will tell you my cases come from a variety of sources.

1:50

About a third are cases I read myself

1:53

about a third have come to me

1:55

through the medical malpractice

1:57

and QA processes at virtual radiologic,

2:01

and about a third have come from my colleagues.

2:04

So I'll try and call those out when relevant.

2:08

We'll start with a pretty apparent case

2:10

of epidural hemorrhage.

2:13

So this one, the, a few points to make about epidurals,

2:17

they're, of course, when this large, they're relatively easy

2:20

to spot a lens shaped hyperdense lesion,

2:24

often in the middle cranial fossa.

2:27

But I never fully appreciated until later in my career

2:31

how often these, uh, will dissect down into the floor

2:35

of the middle cranial fossa.

2:37

And that will have a few findings, uh, that are specific to

2:40

that, that we'll call out here in a second.

2:43

So, higher up, you can see that large

2:46

epidural there in the lateral aspect,

2:48

in the middle cranial fossa.

2:50

And the important point here is

2:52

that there is uncle herniation very early,

2:56

but that's what happens.

2:57

That medial temporal lobe will shift medially,

3:01

distort the five pointed star of the SRA cell cistern,

3:06

and will ultimately, uh, drop over the anterior portion

3:11

of the tentorium, which you can see happening right here.

3:15

So that's the very important finding here.

3:18

When we go up another level, you'll see again that uncle

3:22

displacement, but here is the finding I was talking about,

3:26

about lesions in the floor of the middle cranial fossa.

3:30

They will often elevate

3:31

and distort the temporal horn

3:34

of the lateral ventricle on that side.

3:37

And this will happen as well

3:39

with lateral middle cranial fossa lesions.

3:43

But it's particularly note notable in lesions in the floor

3:47

of the middle cranial fossa.

3:49

And that was pointed out to me many years ago by one

3:52

of my attendings, and it has been

3:55

the first finding I have identified in many cases

3:59

of smaller epidural hemorrhage.

4:07

Our first movie of the day often runs a little

4:11

jittery, so here we go.

4:14

So I really relate to this case in a lot of ways.

4:19

Uh, first of all, when I was in emergency physician,

4:22

this was my worst fear

4:25

because I had trained in internal medicine

4:27

and I was not particularly procedurally adept.

4:31

I was a pretty good diagnostician,

4:33

but I truly did live in fear

4:36

of having a kid come in.

4:38

Uh, this was a teenager, a 14-year-old,

4:41

and that makes it all the worse, right?

4:43

I always lived in fear of a young kid coming in

4:47

with the classic talk and die presentation.

4:50

That's what they always called this in er,

4:53

the patient usually passes out from the initial impact

4:57

and then awakens and is relatively lucid

5:01

and then deteriorates quite rapidly, so thus the

5:05

to and die patient.

5:07

So that often will require emergent decompression

5:10

with a drill through the squamous

5:12

portion of the petris bone.

5:14

And that was something I had never performed.

5:17

So I lived in constant fear of this happening to me.

5:20

And so I remember this was in the middle of North Dakota,

5:25

Minot, North Dakota was where this came in from,

5:28

and I had to call it into the ER doctor

5:31

and describe essentially

5:33

to this poor guy my worst nightmare.

5:35

And I always remember, I I said,

5:37

this is a very large epidural.

5:39

There is pending uncle herniation

5:41

and it needs to be decompressed right away.

5:44

And we started to hang up and he came back on the phone

5:46

and said, you said epidural, right?

5:50

And I, as I hung up, I thought, Ugh,

5:52

he's living my worst nightmare.

5:54

Uh, so the other thing I relate to about this case is

5:58

that this was a 14-year-old who was playing baseball,

6:02

and he was hit with a line drive.

6:04

Now that seems straightforward enough,

6:06

but if you think about where this blow landed,

6:09

it was on the side of his head,

6:10

which means he played little league baseball much like I

6:14

did, and that he was looking anywhere

6:16

but at the actual action on the field.

6:21

So here is that patient's non-displaced skull fracture,

6:26

which affected, of course, the middle meningeal artery,

6:29

and they can be extremely subtle.

6:34

I, all right, our next one is actually a twofer

6:39

or a bogo.

6:40

Buy one, get one, uh, with two epidural collections.

6:44

And it's a great one because it shows the difference, uh,

6:48

between a venous epidural and an arterial epidural.

6:52

So the venous epidurals will typically span a dural

6:57

venous sinus, and they occur most typically in the frontal

7:01

region, in the posterior fossa across the transverse sinus.

7:06

And here in the temporal pole, this is related to tearing

7:11

of the sphen parietal sinus

7:13

and is a, uh, probably the third most common location

7:17

for a venous epidural.

7:19

These don't always have to be surgically addressed,

7:22

and in fact, many times they're not.

7:25

They're simply observed.

7:27

But it, it is important to note that that's a,

7:29

that's a tricky spot to identify these.

7:32

And so it's, uh,

7:33

someplace you should always have on your search pattern.

7:37

But we are lucky here in that, uh, the,

7:40

this patient also has an arterial epidural,

7:44

and you can see the classic lens shaped hyperdense

7:47

collection, respecting skull sutures.

7:50

There as is the, uh, typical appearance

7:53

of an arterial epidural note.

7:55

Also, the heterogeneity.

7:58

Not all epidurals are going to be homogeneously hyperdense.

8:03

And in fact, contrary to your intuition,

8:06

when you see a swirling heterogeneous epidural,

8:11

it often is hyperacute rather than one that is, uh, older

8:15

and resolving and forming clot.

8:18

So there's a bit of a swirl going on in here as clot forms.

8:21

And so you will note sometimes in the hyperacute epidurals,

8:26

there'll be markedly heterogeneous.

8:31

So here is that patient sini.

8:34

There's the temporal pole, venous epidural,

8:39

and then the arterial epidural in a classic location.

8:44

And this patient had a much more visible skull fracture

8:49

that extends superiorly here,

8:57

that one quite a bit more obvious than the preceding,

9:01

which was really only visible on one cut.

9:08

All right, this is another venous epidural,

9:11

and it is associated with contusions of the frontal lobes.

9:15

The inferior frontal lobes are particularly vulnerable to

9:19

contusion, uh, partly

9:21

because of the added mobility in the frontal lobes compared

9:25

to other regions of the brain, and also

9:27

because of, of their location adjacent

9:30

to the planum sphenoid alley.

9:31

That horizontal plate of bone

9:33

that separates your orbits from the, uh, floor

9:37

of the anterior cranial cranial fossa.

9:40

So that's a relatively rough surface,

9:42

and the mobility of the frontal lobes allows them

9:45

to get beaten up by that roughened surface.

9:48

So you can see here a mix of cortical

9:51

and white matter hypodensity as is common in contusions.

9:57

And here is the lens shaped venous epidural.

10:01

And note, the venous epidurals will span sutures,

10:05

this one spanning the, uh, early closing atopic suture.

10:10

But because of the arrangement of Doral reflections,

10:13

the venous epidurals can span, uh, sutures of the skull,

10:18

unlike the epidurals which typically respect them.

10:23

So here are those frontal lobe contusions

10:27

and that venous epidural extending right up to the apex.

10:31

So this one is also associated

10:36

with a skull fracture.

10:38

An important point to make about skull fractures is

10:42

to make certain that, uh, you identify the passage

10:46

of a fracture through any sinus.

10:49

And so you can see this one goes through the frontal sinus,

10:53

and that technically qualifies as an open fracture

10:57

and should be, uh, surgically debrided

11:00

and prophylaxed with antibiotics.

11:02

Note also, uh, when we ascend to the uppermost element of,

11:07

uh, portion of this fracture,

11:09

it's actually entering the sagittal suture and spreading it.

11:13

So we have a dias static

11:15

suture there, right there at the top.

11:17

You can see how it's widened anteriorly.

11:30

All right, so that is a venous epidural

11:33

in the frontal region.

11:37

And this one I have set up

11:39

for the residents to guess themselves.

11:41

But, uh, this one goes across the transverse sinus.

11:45

So you can see little dots

11:46

of gas there in the transverse sinus suggesting

11:49

it has been violated.

11:51

And when we go to the cine, you can see epidural hemorrhage.

11:56

That would be, again, a venous epidural hemorrhage extending

12:00

superiorly, fortunately for this patient,

12:02

superiorly from the transverse sinus.

12:06

And of course there's a little hemorrhagic contusion there

12:10

in the posterior temporal or inferior parietal lobe.

12:16

So this patient was simply observed,

12:18

and I remember the neurosurgeon said, well, if it had gone

12:22

inferiorly and were compressing on the, uh,

12:27

cerebellar hemisphere,

12:28

he'd have felt very differently about it

12:29

and had a much lower threshold for surgery.

12:34

But they ultimately ended up just observing this patient.

12:37

And there you can see the skull fracture that led to this

12:41

traversing again, that transverse sinus.

12:53

All right, moving on to other types of hemorrhage.

12:56

This is a subdural hemorrhage.

12:58

You can see that crescent of extra axial density there.

13:03

And, uh, our head of the QA committee always likes

13:08

to say that subdurals

13:10

and subarachnoid, they're very hard to sort out

13:13

and they often are present together.

13:18

And so when she reports these, you know,

13:20

she always tells me 25% of them are clearly subdural,

13:23

25% are clearly subarachnoid,

13:27

but there is a middle ground

13:29

where you really can't sort them out very well.

13:32

And you can see these little of density

13:35

running up the sulky there in the right frontal region.

13:39

So this is a nice example of probably mixed subdural

13:43

and subarachnoid hemorrhage.

13:45

So a large number of these, uh, I will just report

13:48

as mixed subdural, mixed, uh, subdural arachnoid.

13:55

So the real reason I have this, uh, case in here though

13:59

is this gas at the skull base.

14:02

That is something to really tune on

14:04

and make sure you note in any given case.

14:07

Now, of course, you may have penetrating trauma

14:09

with an overlying laceration,

14:11

in which case all bets are off.

14:13

And the significance of this skull base gas may be,

14:17

uh, questionable.

14:19

However, you really wanna spot this

14:22

because it can be a very important indicator of a skull base

14:26

or mastoid fracture.

14:28

And that is the case here.

14:30

I was always taught in residency to define, uh,

14:34

temporal bone fractures as longitudinal or transverse.

14:38

And then of course, as soon as you learn a system like that,

14:41

along comes a perfectly oblique fracture

14:44

that doesn't fit into either classification.

14:48

Uh, I saw a lecture some years ago where the presenter said,

14:52

what really matters is involvement of the middle ear cavity

14:55

and otic capsule.

14:57

Those are the things that will cause either conductive

15:00

or sensor neural hearing loss.

15:02

And so those are really the things

15:04

to concentrate on in reporting temporal bone fractures.

15:08

So I had adopted that and fortunately so

15:11

because this again, kind of defies classification

15:15

as either a longitudinal or transverse fracture,

15:18

and you can see that it is entering the middle ear cavity.

15:22

So this has an important finding, which is

15:26

incu dissociation.

15:29

The ice cream has fallen off the cone.

15:32

If you look on this normal side, you can see a little dot

15:35

of, of, um, malus

15:39

and sitting on the incus right here.

15:43

And that's the normal situation.

15:44

And over here you can see the two are clearly separated,

15:49

meaning you've got inchy or dislocation.

15:53

So there is that skull base gas that calls your attention

15:56

to the fact that a temporal bone

15:59

or mastoid fracture must be present.

16:03

And

16:10

I've even got a blow up right there, gets a little pixely,

16:14

but does make it clear.

16:20

All right, I included this one just

16:22

because it's about every manifestation

16:25

of subdural hemorrhage that can be seen.

16:27

And in the case of an infant, of course,

16:30

this basically is pathognomonic for abusive trauma.

16:35

I'm very pleased to have seen the lexicon has changed.

16:38

I was raised to call this non-accidental trauma.

16:41

I don't see any reason to euphemized, uh,

16:43

what's going on here.

16:44

And so now it typically is referred to as abusive trauma.

16:48

And I, that's one of the few changes in terminology

16:51

that I've been very pleased to see.

16:54

So the tentorium can be hyperdense,

16:57

and when you've got a small bilateral tentorial

17:00

hemorrhage, that can be difficult.

17:02

But here we're saved by the asymmetry,

17:05

and you can pretty confidently I think, say that that is

17:09

tentorial hemorrhage.

17:10

And of course, tentorial hemorrhage is always going

17:13

to be subdural in location.

17:16

So a little higher up, you can appreciate

17:18

that there is too much density, not just

17:20

that one hyperdense dot,

17:22

which is most likely more acute hemorrhage in the setting of

17:26

previous resolving subdural hemorrhage.

17:29

But you can also see in the CSF all surrounding the frontal

17:33

lobes that there is too much density

17:35

that should be CSF density.

17:37

It should affect, essentially match the density of the,

17:41

uh, ventricles.

17:42

And clearly it is too dense.

17:44

So this is evidence of a previous subdural

17:47

with a new acute hemorrhage superimposed on that.

17:51

So the more astute of you may have already noticed

17:54

that there is also cytotoxic edema,

17:57

quite extensive cytotoxic edema, in fact involving both the,

18:02

uh, temporal and occipital lobes as well

18:04

as the frontal lobes.

18:06

So you can see this on both sides

18:08

and in all of these locations.

18:10

So the really, the only normal brain is kind

18:13

of in the middle cerebral distribution here.

18:17

And this is the classic appearance of strangling, right?

18:21

It, uh, spares the posterior fossa

18:24

and just mainly hits the anterior circulation,

18:27

the carotid circulation,

18:28

because of course, the carotids are the vessels

18:31

that get compressed when a patient is strangled.

18:34

So you can see here again,

18:35

there is a classic subdural location next to the foul.

18:39

That parol same density is always subdural,

18:42

just like tentorial density is always subdural.

18:46

And you can again, appreciate the extent

18:48

of the cytotoxic edema

18:50

and the infarcted brain, which is pretty much all

18:54

of the brain tissue you see here.

18:56

And then lastly, more parols hemorrhage here at the vertex.

19:02

So this patient has subdural hemorrhage almost

19:05

everywhere you can have.

19:06

It was a very sad case,

19:13

I'm afraid we, uh, got onto that one a little too late.

19:19

So again, appreciate that cytotoxic edema,

19:22

you really can't see gray, white differentiation

19:25

throughout most of the brain.

19:27

And again, note the sparing of the posterior fossa.

19:30

Again, classic for carotid compression.

19:41

And there again, we're appreciating the increased density

19:44

of the CSF suggesting a remote

19:48

prior subdural.

19:55

All right, actually kind of a similar case,

19:57

but this one in an adult,

19:58

this will just round out all the locations

20:01

of subdural hemorrhage.

20:02

This one is clival, so that's another location

20:06

that when you see extra axial hemorrhage,

20:08

you can just say this is by virtue of its anatomic location.

20:12

Subdural, again, we have an asymmetric density

20:16

of the tentorium,

20:19

an extra axial collection with a little bit

20:22

of midline shift.

20:24

And then lastly, relatively subtle,

20:27

but still clearly present Parolin hemorrhage right

20:30

there, superiorly.

20:52

All right, well now

20:55

this is the dreaded iso dense subdural.

20:58

This is the one we all live in fear of.

21:01

I was taught early in my career that you should always look

21:04

for these tendrils of white matter extending all the way out

21:08

to the inner table.

21:10

Of course, they don't anatomically,

21:12

but on a ct they certainly appear to.

21:15

And so you wanna make sure that the brain, uh,

21:19

is running all the way out to that inner table.

21:21

And if you look in this right frontal region, you can see

21:24

that they don't quite make it.

21:26

There is fortunately some leftward midline shift

21:30

to help you out here,

21:32

but that is as iso dense as a subdural can get.

21:36

So there's that midline shift,

21:40

but a very challenging call to make.

21:44

You can see there's a crescent there of distance between,

21:49

uh, the normal white matter

21:51

that you should see extending all the

21:53

way to the inner table.

21:58

So an iso dense subdural, we've got one more of those,

22:01

not quite as dramatic,

22:04

but just to tune your eye, there is a similar finding in,

22:08

in fact, the same location, an iso dense subdural.

22:12

And again, you can just see the slightest bit

22:14

of mass effect, midline shift,

22:17

and a little compression of that right lateral ventricle.

22:36

All right, well, this one is a very complex case,

22:40

and actually it took me a long time to figure out exactly

22:44

what was going on in the region of the brainstem here.

22:48

But ultimately I was able to discern, uh,

22:51

that this is uncle herniation here.

22:54

This is the onca, uh, pooching over the anterior tentorium

22:59

right in this region, right on the right aspect

23:02

of the super cell cistern.

23:04

So what it's causing is displacement

23:06

of the brainstem, which is over here.

23:09

And when you initially look at this,

23:11

this density looks like it's in the interocular faucet,

23:14

but in fact it's not.

23:15

This is peres cephalic, as is this.

23:19

So here is our large subdural,

23:23

and these are both peres cephalic hemorrhage.

23:28

Then we have, of course,

23:29

a little hemorrhage in the dilated ventricle here.

23:32

And of course, the right lateral ventricle is efface.

23:37

So that's not actually the reason I have this case

23:40

in my collection.

23:42

The reason is that it has a beautiful depiction

23:45

of a sub false herniation.

23:48

So look at the position of the lateral ventricles here.

23:51

You can see they're all the way into the left side,

23:55

and there has been herniation

23:57

of the medial frontal gyrus under the falk.

24:00

And what happens in this case

24:02

is it will pinch the anterior cerebral artery

24:06

and cause an infarct in that region.

24:09

So you can see the hypodensity

24:11

of the herniated right frontal lobe de uh,

24:16

denoting an infarct.

24:17

And here you can even see that some

24:19

of the right frontal lobe

24:20

that has not herniated is still affected by the occlusion

24:24

of the anterior cerebral artery.

24:27

So it's actually all ischemic there.

24:32

And here we see the similar phenomenon

24:34

with both the herniated

24:36

and the, uh, still in place, medial right frontal lobe,

24:40

all showing evidence of infarct.

24:45

So that is a sub falses scene herniation.

24:52

And again, you can just appreciate that

24:54

that is uncle herniation with displacement of the brainstem.

25:13

All right, so that was a sub falses herniation.

25:19

Here we have another subdural,

25:21

and this one is, the last one was a bit heterogeneous

25:25

and suggested a stuttering or re-bleeding hemorrhage.

25:30

And this one is even more.

25:31

So this looks like it might have been multiple

25:34

repetitive subdurals layering out.

25:37

When you see this kind of laminated appearance

25:39

of the extra axial fluid, uh, that suggests, uh,

25:43

repeated hemorrhages over time.

25:45

And that is a common scenario with subdurals.

25:48

Oftentimes these are aging patients with atrophic brains

25:52

who suffer falls and then have gait instability

25:55

because of the, uh, hemorrhage that accumulates,

25:59

and then that sets them up for additional falls.

26:02

So it is a common manifestation of subdurals in

26:06

that particular patient demographic

26:07

that you'll see this kind of, uh, repetitive bleeding.

26:12

So this is, there is that bleeding.

26:15

Of course, this is another case of uncle Herniation,

26:19

and it has a few really important points to make, especially

26:23

the fact that the temporal horn

26:26

of the lateral ventricle is dilated here.

26:29

And what's happening is as

26:31

that onus herniates over the tentorium,

26:34

right in this anterior tentorial region, it will pinch

26:39

the lateral ventricle

26:40

and that will allow the herniated portion

26:43

of the temporal horn to dilate up.

26:46

And that is a phenomenon known as a trapped horn.

26:50

Attending jokes are about as bad as dad jokes,

26:54

but I always remember one of my attendings, he,

26:57

he couldn't see a trapped horn without saying

27:00

beep beep beep.

27:03

So I find myself compelled to repeat it.

27:07

So the other neat finding here is that in this case,

27:10

the brainstem is not as displaced as it was on

27:14

that previous uncle herniation.

27:15

Certainly there is some compression here,

27:18

but in this case, we've got an a similar density to

27:22

what we saw last time.

27:23

But this one is actually in the substance, the mentum

27:27

of the midbrain, and that is a classic

27:31

duray hemorrhage that occurs due to infarction

27:35

of the brainstem, usually associated with herniations,

27:39

I believe the classic duray hemorrhages associated

27:42

with foramen magnum herniation.

27:44

But in this case, this displaced onus is clearly causing a

27:48

vascular compromise there.

27:50

So this brainstem was in fact ischemic and hemorrhagic.

27:54

So you don't often see duray hemorrhages on ct, uh,

27:59

as the patient rarely survives long enough to be imaged.

28:05

So very nice example of uncle herniation though, uh, again

28:09

with a trapped horn.

28:28

All right, uh, this one is in here just to remind everyone

28:32

to look here every time.

28:34

This is an interocular fossa subarachnoid hemorrhage.

28:38

That location always is subarachnoid,

28:41

and this is visible really only on two cuts.

28:45

So it's a very subtle finding.

28:47

But you know, I, I do wanna point out

28:51

that this is still very important.

28:54

I view the tiny intracranial hemorrhage much like I do the

28:58

small pulmonary embolism in that no one is going

29:02

to address the effects of this tiny hemorrhage, right?

29:05

No one needs to go evacuate this, uh,

29:09

or, uh, in the case of a pe, right?

29:12

No one needs to thrombo lys a tiny pe.

29:15

But both are important in that they serve as indicators

29:20

of either in the case of intracranial hemorrhage,

29:23

a severe intracranial injury,

29:25

or in the case of a pulmonary embolism, it's a harbinger

29:29

of the large, uh, pulmonary embolism that is to come, right?

29:34

So both serve as important indicators when

29:37

the finding itself is small and seemingly inconsequential

29:41

and may not need to be specifically addressed.

29:45

Uh, still it's important to spot these

29:47

because seeing intracranial hemorrhage in a trauma patient

29:51

puts them on an entirely different prognostic

29:54

trajectory, right?

29:55

The assumption can be

29:57

that there could very well be hidden intracranial

30:00

in injury here.

30:02

And when you look statistically, the patients

30:05

that even have these small intracranial hemorrhages, uh,

30:09

actually do not do as well as patients

30:11

that have truly normal CT scans on presentation.

30:19

So again, just visible on a couple cuts,

30:23

and this also brings up an important principle in radiology,

30:27

uh, uh, in, in my capacity as chief medical officer,

30:31

I attend and have attended, uh, quality assurance meetings

30:35

for a variety of the facilities we cover over the years.

30:39

And I used to routinely attend the quality assurance, uh,

30:43

meetings at this particular facility.

30:45

And I remember this one was in fact missed

30:48

and they showed it at the QA meeting.

30:50

And I, uh, always remember one

30:52

of the radiologists at the table said, well,

30:54

how am I supposed to see that?

30:58

And, uh, fortunately I didn't have to answer,

31:01

actually a neuroradiologist sitting next to me did.

31:03

And he said exactly what I would've said.

31:06

He said, you look there every time.

31:10

And that is the essence of radiology.

31:12

You know those places that you're blind

31:15

to in your search pattern and you actually expedite them.

31:19

You put them at the top of your search pattern

31:21

and make sure you never miss it.

31:23

So when I actually say the words,

31:26

there is no intracranial hemorrhage.

31:28

My eye goes to that pre pontine

31:30

and peres cephalic region, then to the interocular fossa,

31:34

and then to the dependent portions of the occipital horns,

31:38

because I know that's

31:39

where intracranial hemorrhage will collect

31:42

and where I may not see it.

31:49

Alright, another case of subarachnoid hemorrhage,

31:52

this one intraventricular

31:54

and a very helpful hint given to me by, uh,

31:58

the same attending as from our first case.

32:01

He was, uh, particularly tuned apparently

32:03

to the temporal horns,

32:05

but he pointed out to me that the architecture

32:08

of the white matter in the temporal region makes it, uh,

32:12

a little less resistant to the expansion

32:15

of the temporal horns than the other regions surrounding

32:19

the lateral ventricles.

32:20

Uh, add to that, the effect of gravity,

32:24

and you get, basically the temporal horns are

32:28

the first place that you will see dilation

32:31

of the ventricular system in early hydrocephalus.

32:34

So if you're ever wondering, oh,

32:36

these ventricles are really on the fence,

32:38

I don't know if I'm quite looking at hydrocephalus, go down

32:42

to the temporal lobes, look at those temporal horns

32:45

and see if they're prominent in a young brain.

32:48

They may not even be visible normally, right?

32:51

So if you can see them

32:52

and they appear to be at all prominent, then what you are

32:55

probably looking at is in fact hydrocephalus.

32:59

So here we have density in the fourth ventricle,

33:02

and here are those dilated temporal horns going right

33:05

out to the onus.

33:06

And that's extremely helpful.

33:07

Again, a young brain, you really shouldn't see them

33:10

that prominent.

33:12

Uh, and so that helps you to, to identify the fact

33:15

that you are looking at hydrocephalus here.

33:18

So here we can see additional intraventricular hemorrhage in

33:22

the third ventricle and lateral ventricles.

33:24

And a similar case actually resulted in a question from a

33:28

colleague who said, why doesn't

33:30

that hemorrhage fill the ventricles completely?

33:33

You would think that it would fill

33:35

and expand those ventricles

33:37

until the pressure mounting in the ventricles would stem

33:41

or stach the flow of blood into the ventricles.

33:45

Well, that probably did happen,

33:47

and you will see this phenomenon

33:48

that you'll have in intracranial

33:50

or intraventricular hemorrhage that will stop,

33:54

the clot will form,

33:56

but it will cause a chemical appendicitis

34:00

and potentially even occlude the foramina of Monroe or Luka.

34:05

And what then happens is dilation of those ventricles around

34:09

and already formed intraventricular clot.

34:13

And I think you can see that here,

34:14

that the clot does not completely fill the ventricles,

34:18

and yet the clot is in a vaguely ventricular form shape.

34:23

And that was present in the fourth ventricles as well.

34:25

And you can see the, uh, temporal horns here,

34:28

even in at this level, are a little prominent, again,

34:32

denoting the presence of hydrocephalus.

34:36

So there we have circled those temporal horns.

34:38

And again, you can see that fourth ventricular clot is

34:41

smaller than the fourth ventricle

34:43

that has dilated up around it.

34:46

Little bit of SoCal subarachnoid hemorrhage is, uh,

34:50

present there as well, probably in the right frontal region.

34:57

So a nice case demonstrating that phenomenon

35:00

of intraventricular hemorrhage with subsequent development

35:04

of hydrocephalus.

35:21

Alright, uh, some hemorrhagic contusions.

35:24

We've seen contusions of the frontal lobes,

35:27

which is a very common location.

35:29

Uh, we've seen the venous epidural at the temporal pole.

35:33

Certainly the temporal poles are also at risk for, for

35:37

cerebral contusions, but yet another place

35:40

to look every time is in the temporal lobes immediately

35:45

above the petre ridges, just like I was describing

35:48

with the frontal lobes

35:49

and the planum sphenoid alley,

35:51

the inferior temporal lobe sits right on that petre ridge,

35:55

and it's a rough surface that can really beat that portion

35:58

of the brain up.

36:00

And this one, I actually, this is from my residency days.

36:05

I actually managed to save this case

36:07

because it was so humiliating.

36:09

I was a second year resident

36:11

and I was sitting with a fourth year resident,

36:13

and we had this case up on the alternator.

36:16

It was back in the days when we were hanging films

36:20

and we were looking at this case and it just finished.

36:23

And the attending walked in, uh, same attending actually.

36:27

And he said, what'd you guys think of this?

36:29

And I said, I think it was normal.

36:32

And, uh, the attending turned to the fourth year

36:35

and said, what did you think of this?

36:37

And the fourth year said, I thought it was normal.

36:40

And our attending said, you guys are terrible.

36:44

And pointed out the fact

36:45

that there was a hemorrhagic contusion, not only

36:49

of the left temporal, but also of the right temporal.

36:52

It's much more subtle on the right temporal,

36:54

but there is just a hint of cortical hypodensity

36:58

with those stifled hyper densities, denoting hemorrhage.

37:02

Uh, that's the classic salt

37:03

and pepper appearance of a hemorrhagic contusion.

37:07

Uh, this became part absolutely part of my search pattern.

37:12

And I will tell you a helpful hint as well

37:14

that a different attending gave me back in training.

37:17

I asked him what's the best way to assess proper placement

37:22

of the brain in the gantry?

37:25

And he said, the petras ridges go by the petre ridges.

37:29

And so that developed into my head CT search pattern

37:33

that I go to those petre ridges, I find them, I make sure

37:37

that they are symmetric,

37:38

and thus I am assured

37:40

that the patient is appropriately placed within the gantry.

37:43

And then I click my scroll wheel up one

37:47

and look at the immediately adjacent

37:50

inferior temporal lobes sitting right

37:52

above the petre ridges.

37:54

And I do that every time.

37:56

And it's mainly

37:57

because of this case, you can see a little white matter, uh,

38:01

vasogenic edema extending superiorly from

38:04

that more injured left side.

38:12

So those are hemorrhagic contusions.

38:17

All right, uh, moving on to sheer injury,

38:20

which is not always amenable to diagnosis by ct.

38:24

Of course, sheer injury can happen without hemorrhage.

38:28

That's actually fairly rare.

38:30

Most DAI

38:32

or diffuse axonal injury will leave

38:35

a tiny dot of hemorrhage.

38:36

It's just often not enough to see on CT scan.

38:40

I will tell you, I've been seeing a lot of

38:43

CTE patients imaged with Mr.

38:47

Specifically the swan sequence.

38:49

And the swan sequence has such exquisite sensitivity

38:53

for paramagnetic artifact

38:55

that I have concluded just about every a axonal shear will

39:00

drop a tiny microscopic dot of hemorrhage

39:03

that will be visible on swan,

39:06

but again, on the ct, there has

39:08

to be a fairly significant amount of hemorrhage for you

39:10

to be able to spot it.

39:12

So this is a very fortunate case that's almost perfect.

39:17

I say almost because, uh,

39:19

Adam's triad is the off touted constellation

39:24

of findings that you will see in sheer injury.

39:26

And Adam's triad was brainstem hemorrhage,

39:32

septum lucidum, or corpus callosum hemorrhage,

39:35

and then subcortical white matter hemorrhage,

39:37

usually frontal.

39:40

I have determined over my 30 years in radiology

39:43

that atom's triad never happens.

39:46

I'm sure there's one out there somewhere.

39:48

In fact, I did finally just get a good case

39:51

of brainstem hemorrhage related to sheer injury,

39:54

but it didn't have all the other locations.

39:57

So I don't rely on brainstem hemorrhage to be present.

40:01

I think it's relatively infrequent in diffuse axonal injury.

40:05

But I have noticed

40:07

that medial temporal hemorrhage is actually quite common.

40:11

So I've decided to, uh,

40:13

to call this strongs triad rather than atoms triad.

40:17

And I'm swapping out the brainstem for

40:20

that medial temporal region.

40:22

So here is that little dot of hemorrhage

40:24

that you can see in the medial temporal region.

40:28

And as we go higher, this in the septum lucidum, again,

40:32

it can sometimes be in the corpus callosum.

40:35

Most of the time I'll see it just under the corpus callosum.

40:38

In the septum lucidum.

40:41

And then even higher up you can see that

40:45

sub cortical frontal white matter.

40:48

Again, the frontal lobes are a little more mobile.

40:51

And so, uh, this is the most common location that you'll see

40:55

that that's a very nice case of sheer injury.

41:00

It's not Adam's triad, but it is Strong's triad.

41:05

Sorry, we'll get that to run

41:15

septum lucidum, and then subcortical white

41:19

matter of all of these.

41:23

I really consider the septum lucidum

41:26

to be the most reliable.

41:28

It's most consistently present in cases of sheer injury,

41:32

and I consider it the most specific as well.

41:35

Um, because once you see it,

41:36

you can be pretty certain there's been a, a sheer injury

41:40

and that most likely other portions

41:42

of the brain are affected.

41:44

So generally speaking, uh, Mr will give you the full extent

41:48

of the injury.

41:50

Flare will show the torn, uh, axons, uh, axonal,

41:55

fales, uh, to great advantage.

41:57

And swan will be, of course, very sensitive for hemorrhage.

42:06

All right, well, that is our run through

42:08

of intracranial hemorrhage.

42:10

I have plenty more to share,

42:12

but I thought I would pause at this point

42:15

and, uh, see if we have any questions

42:18

that have been submitted.

42:21

Dr. Strong, thank you so much for that case review.

42:24

We have a ton of questions that have been submitted.

42:26

Oh, great. Um, do you wanna open up that q and a box?

42:30

Are, are you able to find it or I can

42:32

Start. I had my chat

42:33

open.

42:34

Yeah, if you can find

42:37

the little question mark in the quote bubble.

42:41

There we go. Awesome. Got it. Terrific.

42:46

I'm sorry to hit you all with that glare.

42:48

I've got a very large monitor in the center here

42:50

that creates a, a floodlight effect, a

42:53

Sunburst.

42:56

Alright, Uh, can we use lens shape

43:01

to diagnose epidural hematoma all the time?

43:04

A hundred percent of time? If not, what is the exception?

43:07

I definitely do go by the lens shape.

43:10

Uh, if you're, if it's in a location

43:12

where you assume it's an arterial epidural, uh,

43:17

you also wanna see it respecting sutures as we discussed.

43:20

But I think that is the main finding to go on.

43:24

And as I discussed earlier, uh,

43:26

you really can't always separate out subdural hemorrhage

43:30

from subarachnoid hemorrhage.

43:32

Uh, but I don't just throw them all in the trash can

43:36

of extra axial hemorrhage.

43:38

I specifically read those as mixed subdural subarachnoid

43:42

because to call something an epidural puts it on a whole

43:45

other level of treatment and urgency.

43:48

And so I think it's very important

43:50

to point out when you think there is an epidural hemorrhage.

43:53

And I do base that on the lens shape.

43:56

And in the case of arterial epidurals, the respecting

44:00

of the, uh, skull sutures.

44:04

Uh, let's see. Can we differentiate venous

44:06

and arterial e epidural hemorrhages solely based on imaging

44:09

and how location, location, location is my answer to

44:13

that if it spans a dural venous sinus.

44:16

And again, the three classic locations that I,

44:19

if I see a lens shaped collection, I'm going to call

44:23

that a venous epidural, are spanning

44:26

that atopic suture in the frontal region, uh,

44:29

the temporal pole, the tearing of the sphen parietal sinus,

44:33

and spanning the lambdoid suture

44:35

and transverse sinus posteriorly.

44:38

If it's anywhere else, um, I'm probably going to hedge

44:42

and not specifically call it venous.

44:44

It's really going

44:45

to be based entirely on its location within the skull.

44:51

Uh, oh,

44:55

just a question on indication

44:57

for performing the CT scan minor versus severe head trauma.

45:00

Uh, everybody gets a CT scan now.

45:04

I'm, uh, I'm jealous of them all

45:06

because I did not have a CT scanner when I was an ER doctor,

45:09

and so, uh, had to do everything on a clinical exam.

45:14

And so, uh, I'm jealous of the, uh,

45:19

propagate ordering of cts that is, uh, possible now

45:22

for ER physicians,

45:24

but I don't think people are very hung up on the indications

45:27

for CT scans.

45:28

Even minor traumas will get scanned.

45:32

And, uh, unfortunately there are occasionally surprises

45:35

that just encourage, uh, that kind of, uh,

45:39

imaging abuse in the ERs.

45:41

I don't know that it's really abuse.

45:43

Uh, you know, when I was an ER doctor, I would get

45:46

particularly incensed about people telling me I had, uh,

45:50

ordered too many scans in the preceding month, uh,

45:53

or too many tests I should say,

45:54

because I didn't get to order CT scans.

45:57

Uh, but that is the common attitude

46:01

of emergency physicians is you're coming

46:03

to me saying order fewer tests, order fewer scans,

46:07

but when there is a problem,

46:09

if a patient develops unsuspected complications from an

46:13

undiagnosed intracranial hemorrhage, uh,

46:16

you'll be nowhere to be found.

46:17

I will be left hanging as the final decision maker.

46:21

And so I definitely respect that argument from the er, uh,

46:26

from our er brethren.

46:28

And I would say as further extension of that, you know,

46:31

in radiology today,

46:33

we have such terrible capacity demand mismatch.

46:36

Everybody is just drowned.

46:38

And so, uh, nobody is doing much

46:41

to increase the capacity of radiology.

46:43

There has been no large scale expansion

46:46

of radiology training slots, uh,

46:49

a reduction in the requirements

46:51

for foreign medical graduates to get credentialed in the us.

46:54

Those sorts of things I would think would be the larger

46:57

scale efforts at addressing capacity demand imbalance.

47:01

And I really don't see anyone doing that.

47:04

So since we're not increasing the capacity side of

47:06

that equation, people always are looking at the imaging

47:10

side, the demand side of that equation

47:12

and saying, can we limit demand?

47:15

And I can tell you that is an issue

47:17

that's raised on a regular decade long cycle

47:20

and has been throughout my career.

47:23

It will never come to pass.

47:24

In fact, it's getting worse partly

47:27

because of the phenomenon I just described, right?

47:29

That our er brethren are the ones responsible

47:33

and accountable for the decisions they're making.

47:37

And so it's unfair to limit their ability to order tests.

47:40

But on top of that, we have

47:42

so many mid-level providers in ERs and urgent cares,

47:46

and the statistics are all quite clear on

47:49

that they are much more inclined to order imaging studies.

47:52

So rather than, uh, getting a handle on it, trying

47:55

to limit the demand

47:57

and the amount of imaging that's ordered,

47:59

I see things going in the wrong direction.

48:02

Uh, it, it is increasing and will continue to increase.

48:11

All right. Um,

48:16

are there any intracranial hemorrhagic lesions?

48:20

If yes, what type?

48:21

Uh, certainly underlying lesions are a

48:24

consideration in traumas.

48:25

They're going to be less so,

48:27

but certainly you have, uh, any number

48:30

of things that can hemorrhage.

48:31

You can have he hemorrhagic metastases

48:34

as in the case of melanoma.

48:36

That's kind of the classic, uh, GBMs can, of course,

48:40

hemorrhage that, uh,

48:41

is the classic pathology finding on GBMs is they have a

48:45

tendency towards hemorrhage and necrosis.

48:48

And of course, uh, probably the most important

48:51

of them is an A VM.

48:53

So you can definitely get spontaneous subarachnoid

48:56

hemorrhage from AVMs.

48:58

In fact, that is right up there with bar aneurysm in terms

49:02

of the frequency with which underlying lesions cause a

49:06

traumatic subarachnoid hemorrhage.

49:07

So that is a, a good point that you should always be wary,

49:12

uh, that there could be an underlying lesion in

49:14

intracranial hemorrhage.

49:15

But in the setting of trauma, it's, uh, it's not

49:19

as big a consideration,

49:24

uh, what is considered an urgent situation

49:27

with either subdural hemorrhage or subarachnoid hemorrhage.

49:31

I, I would tell you shift is the most important thing

49:34

that you can impart to your clinical brethren.

49:38

If you see any evidence of midline shift

49:40

or impending herniation be that foraminal onal

49:45

or sub falses scene, those are real indications

49:48

that urgent intervention is going to be required.

49:54

So, uh, also,

49:55

what is the recommended management based on the CT findings,

49:59

neurosurgical intervention, observation,

50:01

repeat scan, et cetera.

50:03

Uh, those really tend to be based on the size

50:07

and the amount of shift

50:08

or pending herniation that you're noting.

50:11

So I think my answer for that one, uh,

50:13

is basically the same, that if you see shift, uh,

50:17

it is very likely that they're going

50:19

to be intervening in a surgical fashion rather than simply

50:22

observing,

50:29

Uh, what technique was used, non-contrast,

50:33

contrast enhanced bone window 3D reconstruction, et cetera.

50:37

I would tell you that's a, that's a very good question.

50:40

Um, I have a whole collection of strokes,

50:44

and I found it entertaining

50:45

that I looked back one time a resident said to me, uh,

50:48

were any of those on stroke window?

50:50

Stroke window was not readily available in, uh, in my days

50:54

of printed CT scans.

50:56

And so we learned

50:57

to get along without them incredibly enough.

51:00

Now I look back and think, that's ridiculous.

51:03

Of course, if you have that tool available to you,

51:05

you should be availing yourself of it.

51:08

So, uh, that leads me though to my answer on hemorrhage,

51:11

which is make sure you have

51:15

multiplanar reformats.

51:17

We actually had to fight quite a battle

51:20

with our sending facilities.

51:22

Most of them agreed, uh,

51:25

after a short discussion to begin sending both coronal

51:28

and sagittal reformatted images straight from the modality,

51:33

uh, which gives you the best resolution, of course, right?

51:36

But we had a few holdouts, uh, mostly, you know,

51:40

the tenured radiologists that say,

51:42

axials have been just fine for me for all these years,

51:47

and we're not going to change our protocols for you.

51:49

And it really, uh, came down to serious headbutting

51:52

where we, uh, had to produce articles

51:55

and make a, a very, uh, concerted argument to

52:01

require coronal

52:02

and sagittal imaging on all non-contrast head cts.

52:06

So in terms of protocol and, uh,

52:09

and all of that, the standard non-contrast head CT is

52:12

undoubtedly the best initial assessment

52:15

of the brain in the er.

52:17

Uh, but I think it's very important that you have

52:20

NPRs in all cases and review them in all cases.

52:24

And the ones that are my favorites,

52:26

especially in looking at intracranial hemorrhage,

52:29

are the coronal images.

52:30

The vertex, especially venous epidurals of the vertex

52:34

that span the superior sagittal sinus.

52:36

They can be very difficult to spot on axial imaging.

52:41

And so I highly recommend that you not only perform, um,

52:46

multiplanar reformats on all your head cts,

52:49

but that you, uh, particularly tune on

52:51

that vertex region on the coronal images.

52:54

I think those are the most valuable.

52:57

And yes, there are difficulties in, uh,

53:01

getting reformats some of the older scanner scanners

53:04

because of gantry tilt.

53:06

Uh, you, you really were restricted in your ability

53:08

to create those NPRs,

53:10

but that is mostly gone, uh, has mostly gone

53:13

by the wayside at this point.

53:15

And most scanners are capable of overcoming that gantry tilt

53:19

and still giving you quality.

53:21

NPRs, uh,

53:25

can a venous epidural hematoma be resorbed at a 24

53:28

hour follow up?

53:30

Uh, certainly anything is possible

53:32

and these are low pressure bleeds.

53:34

And if it's small enough, I, I would say

53:37

that is probably possible.

53:39

I would expect you'll see a little residual 24 hours is a

53:42

pretty quick time period for resorption

53:45

of extra axial hemorrhage.

53:47

But it's very possible

53:49

that a venous epidural won't stay along, uh,

53:51

won't stay around very long.

53:58

Uh, do you do CTA cow if the brain is

54:03

questionable for subarachnoid

54:04

or negative to look for aneurysm?

54:06

Absolutely. The case, uh,

54:08

that's usually going to be the next step.

54:10

If you identify subarachnoid hemorrhage

54:12

and can't see a specific aneurysm on a non-contrast scan,

54:16

which is typically the case, uh,

54:18

the next step will be a CTA.

54:20

So yeah, I think that, uh, that is a reasonable,

54:24

uh, progression of events.

54:28

All right, we're through the questions.

54:30

I actually, uh, will share one last great case with you.

54:34

I always come prepared.

54:36

Uh, the first lecture I gave to a large group,

54:39

I came in 10 minutes early

54:41

and said, would anyone like to see those cases again?

54:46

So, uh, I know now to come prepared

54:48

and I do have a favorite case that I'll share with everyone

54:54

as our parting one.

54:57

So this is actually not an intracranial hemorrhage

54:59

and for that I apologize.

55:02

So we're not any longer on our established theme,

55:07

uh, but this is, uh, quite the case.

55:10

So this is actually a great demonstration

55:14

of the vulnerability of a fused spine

55:20

to fracture.

55:21

And I can tell you I do a lot of work in medical malpractice

55:25

and this has bubbled up as

55:28

not the most common cause of medical malpractice cases,

55:33

but a second tier.

55:35

So I'll impart those twos, I won't hold the secret.

55:39

Uh, the three most common missed findings that will convert

55:44

to a medical malpractice case are aortic dissection,

55:48

spinal epidural abscess

55:51

and superior mesenteric artery occlusion, acute

55:56

superior mesenteric artery occlusion.

55:58

Those three together amount to 40%

56:03

of the pathologies that lead to medical malpractice cases.

56:07

Now at vRad, we are predominantly emergent.

56:11

So there is uh, some skew in the patient population there,

56:15

but that is uh, uh, worth noting, right?

56:17

Those are the three big ones.

56:20

My next tier of missed findings that can lead

56:24

to a medical malpractice are spinal

56:27

fracture in ankylosing spondylitis

56:31

and missed intracranial aneurysm on

56:34

non-contrast CT scan.

56:36

As I said, it's not the greatest uh, study for that,

56:40

but you can on occasion actually see an unruptured

56:45

aneurysm with no associated subarachnoid hemorrhage.

56:47

And we've seen a few cases of that

56:49

where it could be called on a non-contrast scan isn't.

56:53

And then of course the patient may very well at

56:55

that point be presenting with a minimal sentinel bleed

57:00

and they come in a week or two later with the real thing.

57:03

So, uh, this is a case of ankylosing spondylitis fracture.

57:08

And the particular thing about ankylosing spondylitis with

57:11

that fusion of the spine, these patients have a tendency

57:15

or an inflexible spine that is more vulnerable to fracture

57:19

and the particular fracture that they're vulnerable

57:22

to is one at the cervical thoracic junction.

57:26

Because when a patient who is not known

57:28

to have ankylosing spondylitis is intubated,

57:32

it will snap the neck, right, typically at C seven T one.

57:36

So this is a finding that suggests

57:39

that's what happened here.

57:40

This patient has an endotracheal tube,

57:42

but they have a defect in the anterior cervical region from

57:46

a cricothyrotomy, which is done

57:49

for emergent airway management.

57:51

And that's what always happens when the neck fractures due

57:54

to ankylosing spondylitis during intubation, they will have

57:58

to emergently manage with a cricothyrotomy

58:01

and then as you can see later,

58:03

place an endotracheal tube once the spine

58:06

has been stabilized.

58:07

So here is that spine

58:09

and the amazing thing about this is on the axial images,

58:13

it will look like an irregular disc space.

58:16

It's a very hard thing to spot

58:17

and this one may be a little lower in the thoracic spine

58:20

than is typical for an intubation fracture.

58:23

Uh, but we know that that was in fact the case.

58:26

When we look at this uh, cine images on this, you'll see

58:29

that all of the disc spaces are gone,

58:31

the spine is completely fused

58:33

and there's only this one irregular axial lucency

58:38

through the upper thoracic spine that mimics the appearance

58:41

of a disc space but isn't in addition, uh, this was kind

58:45

of a procedural flail.

58:46

You can see there's a chest tube outside

58:49

of the chest cavity here.

58:51

And what I'm pointing to here is fusion of the cost

58:55

of transverse joint.

58:57

When you're wondering is this spinal fusion due

59:00

to ankylosing spondylitis look into locations, the cost

59:04

of transverse joints will fuse.

59:05

That is specific for ankylosing spondylitis.

59:09

It is not very sensitive.

59:12

The other place to look, here's the extra thoracic gas in

59:15

that chest tube placement.

59:17

The other place to look in ankylosing spondylitis.

59:20

Again, there's cost of transverse, very nice fusion there

59:25

and we've got some uh, spinal canal gas due to that fracture

59:29

and a misplaced left chest tube as well.

59:32

So the other place to look, uh, when you are trying

59:35

to confirm a diagnosis of ankylosing spondylitis is the

59:39

SI joints, they will fuse completely

59:42

SI joint fusion is both sensitive

59:44

and if bilateral, also pretty specific

59:47

for ankylosing spondylitis.

59:49

Uh, an old attending of mine said one time,

59:51

when you're thinking ankylosing spondylitis go

59:54

to the SI joints, if they are not fused,

59:57

then whatever you're looking at in the spine is not

60:00

ankylosing spondylitis.

60:02

And that has held up for me over the decades.

60:04

So very worthwhile advice there.

60:07

All right, here we are on the lung windows just best showing

60:09

that that gas introduced

60:12

by the failed chest tube placement was able

60:14

to enter the spinal canal through that fracture.

60:17

So we'll look at the nies here.

60:23

So there is that transverse lucency through the upper spine.

60:28

Note the cost of transverse fusion

60:30

and note the absence of disc spaces.

60:33

I switch back and forth between the window settings

60:36

for fuller appreciation, but see that fused spine

60:40

and the fused SI joints.

60:45

So this poor patient actually had a head injury

60:47

and that's why he was intubated.

60:49

So everything you see below the le, the level

60:52

of the skull base was actually done to him

60:55

by the emergency room staff.

61:00

Alright, just a fun case to finish out with.

61:03

But I'd like to thank everyone for attending.

61:06

Thank you for all your questions

61:08

and I hope to see you again in a similar venue.

61:12

Dr. Strong, thank you so much for

61:13

that awesome case review.

61:14

And for the bonus case, that might be the first time

61:16

someone's shown a bonus case, even got a bonus case.

61:20

Thank you so much. And yes, thank you for everyone else

61:22

for participating and asking such great questions.

61:25

You can access a recording of today's noon conference

61:27

and all of our previous ones by creating a free account.

61:30

And we will also email out a link to the replay later today.

61:34

Be sure to join us next week, Thursday,

61:36

October 23rd at 12:00 PM Eastern,

61:38

where Dr. Francis Ding will deliver a lecture entitled

61:42

My Myelopathy, excuse me,

61:43

from Spinal Cord Signal to Diagnosis.

61:46

You can register for that@modality.com.

61:48

Follow us on social media

61:49

for updates on future noon conferences.

61:52

Thanks again for learning with us and have a great day.