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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Pediatric trauma
Prof. Pia C Sundgren MD, PhD
Department of Diagnostic Radiology, Clinical Sciences, Lund University, Sweden
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
1. Primary brain injuries
occur at the time of the accident and are direct result of the
impact
- extra-axial
- intra-axial
2. Secondary brain injuries
is casued by systemic factors such as:
- increased intracanial pressure - edema
- brain herniation - compression of intracranial
blood vessels
- hypotension - hypoxia
Classification
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
1. Primary brain injuries - extra-axial
epidural hematoma (EPI)
subdural hematoma (SDH)
subarchnoid hemorrhage (SAH)
intraventricular hematoma (IVH)
Classification
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
1. Primary brain injuries – intra-axial
diffuse axonal injury (DAI)
cortical contusions
subcortical lesions
intracerebral hematoma (ICH)
brainstem lesions
Classification
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
2. Secondary brain injuries
brain edema
obstuction of the CSF
herniation
ischemia
secondary hemorrhage
pneumocephalus
CSF leakage
Classification
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
encephalomalcia, porencephaly
axonal injury
diabetes insipidus
”growing fracture”
liquorhoe
cranial nerve injuries
hydrocephalus
carotid-cavernous fistulae
Sequelae
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
sensible for bleeding MPR reconstruction
sensible for fracture possiblity for 3D reconstractions
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Skull fractures
result from direct impact to the calvarium
important because of their association with
intracranial injury
the incidence ranges from 2 to 20%
the parietal > occipital > frontal > temporal bones
linear fractures are most common, followed by
depressed and basilar fractures
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Impression / depressed fracture
A classic fracture in children
- ping-pong injury
- soft calverium
- surgery might be needed
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Impression / depressed fracture
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
linear fracture with damage to the underlying dura
close to sutures
diastas >3-4 mm: growing fracture
children < 3 yrs- strapped meningier
- pulsative liquore
Growing fracture
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
meningier and brain tissue
brain tissue that became gliotic porencephalic cyst
growing
fracture
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
90% associated with skull fracture at coup site
cause
90% arterial (middle meningeal artery)
10% venous (sinuses) especially children < 2 years
localization
epidural space
95% unilat.
90-96% supratentorial
complication
re-bleed
growing rapidly
Epidural hematoma (EDH)
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
• biconvex
• hyperdense
• cross dural folds (falx, tentorium)
• do not cross sutures
• shift of the midline structures
• associated with contusions
or brain edema
Epidural hematoma (EDH)
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
CT
lucid interval 1-2 days in 50% of the
cases
20% not visible on the first CT!!!
MR
• the signal pattern is related
to age of the bleed
• the displaced dura can be
seen on T2-w images
• effacement of the dural
sinuses - MRA
Imaging - Epidural hematoma
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
- grow more rapid than in
adults (due to plasticity of
the infants brain)
24h primaEpidural hematoma (EDH)
- epidural hematoma can cross sutures
if associated fracture with diastases
of the suture and rift of the dura
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
cause
tearing of the bridging veins
tearing of larger veins
localization
subdural space on the contre-coup side
cross suture lines but is limited by falx and tentorium
issues
symptoms may be delayed in children
(due to large CSF spaces)
re-bleeding common
SDH of different age - ? child abuse
Subdural hematoma (SDH)
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
cause
combination of edema and increased hypertension
reduced vascular resistance and autoregulation
1/5 of all severe cranial trauma
children > adults
development 24 - 48 hours
high mortality
Diffuse cerebral edema
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
brain swelling max 24-72h
any insult leading to release neurotransmitters and
neuropeptides
a secondary cascade of vascular leakiness
obstruction arterial inflow - ischemia
Acta Neuropathol (2011) 122:519–542Courtesy Dr M Argyropoulou
Encephalopathy
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Encephalopathy
J Neuroradiol (2007) 34:109–114
Patterns
primary irreversible
contusion point of brain impact
diffuse axonal injury
secondary potentially reversible
diffuse supratentorial brain swelling
infarction of parasagittal watershed areas in cerebrum &
cerebellum
venous ínfarction - parieto-occipital
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
CT not sensitive at initial stage
MRI very sensitive
3 - 7 days post trauma
maximal edema and cell necrosis
MR imaging
multiple, small focal lesions
5-15 mm oval, ellipsoid, parallel to white matter tracts
T2 = hyperintense
SWI or GRE T2*
Diffuse axonal injury (DAI)
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Ashwal et al, Dev Neurosci 2006; 28:309-26
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
premature (v 36)
after sectio due to
risk for asphyxia
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
T1 DWISWI
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
- all sports and recreation-related concussion in U.S.
1.6-3.8 million/year
- concussion is COMMON in youth sports: 8.9% of
high school athletes
- 47% of all reported sports concussions occur
during high school football
Sports-Related TBI
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
football: 64
ice hockey: 54
lacrosse: 40
soccer: 19
wrestling: 22
.
soccer: 33
lacrosse: 31
field hockey: 22
basketball: 19
Rates per per 100,000 athletic exposures
Male
Female
Boys Girls
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Sharp DJ, Scott G, Leech R. Nat Rev Neurol 2014;10:156-66.
Traumatic Brain Injury
Structure and Function
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
De
lta
FA
RWEcp
Corpus Callosum
Courtesy Dr Christoffer Whitelow, Wake Forest, USA
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
• IFOF and ILF
• Terminals
Tract Terminal Regions
Delta F
A
IFOF ILF
RWEcp
Delta F
A
RWEcp
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
microbleed
MRI finding Boxing
(N=98)
Non-boxing
(161)
OR 95% CI P-
value
Microhemorrhage
3(3%) 0 - 0.053
Diffuse axonal
injuries
26(27%) 0 - 0.000
Cavum septum
pellucidum (CSP)
58
(59%)
92 (57%) 1.08 0.63-
1.87
0.800
Dilated
perivascular
space (DPVS)
61
(62%)
52 (32) 3.46 1.97-6.05 0.000
Posttraumatic
cysts
2 (2) 0 - 0.142
Association of abnormal finding in MRI brain and thai boxing
Higher statistically significant in young boxer
Higher prevalence, but no statistically significant
Higher statistically significant in young boxer
Prof. Jiraporn Laothamatas, Mahidol University, Bangkok, Thailand
The 1st Bangkok International Pediatrics Update (BIPU 2017)
AIMC.mahidol.ac.th & med.mahidol.ac.th
IQ of Child Boxers vs Normal Control
IQ 90-110 Can complete Diploma or Bachelor degree
IQ 80-90 Can complete High School
p = 0.87
p = 0.89
Exposed Duration (Year)
Beauchamp,et al 2012
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Increased MD over 2 years follow up p<0.00001 (N=113): further gliosis and neuronal damage
Decreased FA over 2 years follow up p<0.00001 (N=113):
further damage of the brain connectivity due to axon and myeline damage
The 1st Bangkok International Pediatrics Update (BIPU 2017)
Prof. Jiraporn Laothamatas, Mahidol University, Bangkok, Thailand
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Decreased MD p<0.00001 (N=113) 2-5 years boxing experience group cytotoxic edema and acute demyelinating process
Increased R2* p>0.00001 (N=113) Further increased iron accumulation of old blood product
Prof. Jiraporn Laothamatas, Mahidol University, Bangkok, Thailand
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
boxing in pediatrics has definitely caused structural
brain damage in both gross and microstructural brain
functional brain damage such as decreased memory
tasks with only better motor skill
these damages increase in severity with numbers of
years of boxing
result from neuropsychological test has shown
significantly decreased overall IQ with longer years of
boxing. AIMC.mahidol.ac.th & med.mahidol.ac.th
Summary
The 1st Bangkok International Pediatrics Update (BIPU 2017)
Prof. Jiraporn Laothamatas, Mahidol University, Bangkok, Thailand
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
normal developmental anatomy that may mimic
trauma:
• ossification tip of dens (completes 3-6y)
incomplete ossification of tip of dens mimics increased
distance between C2 and occiput
Pediatric spine - normal variants/findings
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
normal developmental anatomy that may mimic
trauma:
• secondary ossification centers
- unfused ring apophyses
(normal physis are smooth with subchondral sclerotic lines)
Lustrin ES, et al. Radiographics 2003; 23: 539-560
Pediatric spine - normal variants/findings
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Pediatric spine - normal variants/findings
Synchondroses (symmetrical, expected location)
Courtesy Prof T Huisman
Jones TM, et al. J Am Acad Orthop Surg 2011;19:600-611
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
wedged vertebral
bodiesossification congenital non-union
Pediatric spine - normal variants/findings
non calcified
apophysis
The distance between
atlas and dens:
child < 4.5 mm
adult 3 mm
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Brachial plexus birth palsy : 1 per 1000 live births
Risk factors:
• macrosomia
• prolonged labor
• breech delivery
• previous deliveries with brachial plexus birth palsy
Injuries at birth
Brachial plexus palsy occurs
when traction forces are applied
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
upper plexus C5 and C6
lower plexus C7 and C8
± T1
Plexus anatomy
• pure upper trunk: C5 , C6
• upper plexus C5, C6, C7: Erb’s palsy 80%
• lower plexus C7, C8: Klumpke’s palsy
(very rare)• total plexus: 20% (from C5 to T1)
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
upper brachial plexus injury
infant is unable to:
- abduct the arm from the shoulder
- rotate the arm externally from the shoulder
- supinate the forearm
This results in the classic 'waiter's tip' appearance
Erb´s palsy
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
imbalance of the intrinsic and extrinsic muscles
- intrinsic muscles must be paralyzed - claw deformity
- long extensor muscles hyperextend the MCP joint
- long flexor muscles flex the PIP and DIP joints
CAVE: injuries of the sympathetic
branch to the stellate ganglion
= Horner’s syndrome
Klumpke´s palsy
lower brachial plexus palsy
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
- intramedullary edema in the acute phase
- myelomalacia in the chronic phase
- hypointense lesions on GRE T2-w* - hemorrhage
MRI of the spine and additional findings
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
in the absence of neurological improvement at
4 to 6 months
microsurgical nerve reconstruction
postoperative improvement in muscular tone:
- pure upper trunk 80%
- Erb’s palsy 75%
- complete palsy 45%
Treatment
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
injury to the spinal column and spinal cord is the
major cause of disability, affecting predominately
young healthy individuals
spinal cord injuries are rare in infants
and children (1-2% of all pediatric trauma victims)
the type of injuries is slightly different in the
pediatric population compared to adults
Accidental spine and spinal cord injury
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Cause < 3 years2 1-20 years1 overall
Motor vehicle 66% 44% 47.7%
Fall 15% 14% 20.8%
Pedestrian 11%
Bicycle 6%
Violence 14.6%
Sports 16% 14.2%
Causes for accidental injuries
1Kokoska E et al. Characteristics of pediatric… J. Ped. Surg. 2001:36;100-105 (408 cases (+))2Polk-Williams A et al. Cervical spine injury…. J. Ped. Surg. 2008:43;1718-1721 (1523 cases (+))
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Spinal trauma and spinal cord injury
< 8 years of age 50% in C1-C2 (-C3) region
incidence of dislocations
incidence of cord injuries
> 8 years of age shift towards C5 and below
- C-spine fractures
mortality rates 17% (overall), higher in small
children
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Imaging of children with spine trauma
If low velocity trauma or minor fall:
no pain at motion
no tenderness
no neurological deficits
NO imaging
or plain films
If high velocity trauma or trauma with
tenderness
reduced motion
pain at motion
or suspected head injury (multitrauma)
CT
Neurological symptoms MRI
NEXUS Low-Risk Criteria, CanadianC-spine rule, NICE guidelines 2016Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
increased flexibility of the cervical spine due to:
incomplete ossifications of the vertebral bodies
ligament laxity
incomplete development of the spinous process
increased head-to-torso ratio
week cervical musculature
cervical spine injuries at higher levels
Causes for higher cervical injuries in children
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
• uncinate processes small <10y
• junction between vertebral body and end plates is cartilaginous ~> risk for injury (Salter-Harris I)
• more horizontal orientation of cervical facets
greater range of physiologic flexion/extension
• shallow occipital condyles
VanderHave et al J Am Acad Orthop Surg 2011;19:319-327
Causes for higher cervical injuries in children
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Typical spine injuries in children
• odontoid fracture, subluxation
• cranio-cervical dislocation or disassociation
• Chance fracture (“seatbelt injury” especially in
the thoracic spine)
• SWICORA
always look for ligamentous injury
NOTE: always look for more
(common with multiple injuries)
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Odontoid fracture
rapid deceleration with flexion (MVC
often through synchondrosis of
C2 at the odontoid base
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Complex of occipital-atlanto-axial dislocation
occipital condyle is small, almost horizontal
and lacks inherent stability
severe hyperextension w/wo distraction
- rupture transverse lig. of the dens -
• anterior translation (hypereflextion)
• posterior translation (hyperextension)
• longitudinal
incomplete – subluxation
complete – dislocation/disassociation
atlanto-occipital condyle distance > 5mm
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Consider the complex when:
- distance odontoid process and the basion >
12 mm
- occipital condyles and atlas > 5mm
- Wackenheim line does not touch the tip of the
odontoid process
- joint widening on CT and joint fluid on MRI
Complex of atlanto-occpital dislocation
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Atlanto-occiptal dislocation
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Asymmetrical dislocation
CT underestimates the degree of soft tissue
injury
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
vertebral bodies change shape on follow up !!
developing skeleton
Asymmetrical dislocation
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Craniocervical distraction injury
CT sag CT sag CT cor
CT upon admission
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
MRI upon admission
T1 sag T2 corT2 sag
Craniocervical distraction injury
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Craniocervical distraction injury
MRI 6 days later
T1 sag T2 corT2 sag
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Chance fracture
- failure of the interspinous ligaments at flexion
- anterior axial loading
- often at the thoracolumbar region
- burst fracture of the vertebral body
- widening of spinous processes
in adolescent spine:
- fracture line through the physeal plate
(never through disc)
in adult spine:
- fracture line through the intervertebral disc/
vertebral body
Courtesy Dr J Schneider, Basel
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Spinal cord injury without radiographic abnormality
- SCIWORA -
specific to children and extremely rare in adults
incidence: 19-34% of all spinal cord injuries in children
more common in younger children < 8 years of age
can have delayed onset of clinical symptoms and
signs up to 4 days after initial injury
recurrent SCIWORA several days to weeks after
initial event (17%)
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
• immature and elastic pediatric spine
• vulnerable to external forces
• allows for significant inter-segmental movement
• transient disc protrusion
compression and stretching of the spinal cord
cord injury
Spinal cord injury without radiographic abnormality
- SCIWORA -
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
The elasticity of neonatal bony spine is eight
times that of the cord
Biomechanics in children
5
cm
6/7
mm
Leventhal H. J. Pediatr 56:447 1969
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
SCIWORA
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
SCIWORA
4 month later
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
3 year old in MVA
SCIWORA
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
T2-wSTIRT1-w
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
lack of visualization does not imply root avulsion
pseudomeningoceles are NOT pathognomonic of
root avulsions
intact roots have been shown in the presence of
pseudomeningoceles
pseudomeningocele AND absent nerve rootlets
best predictor of root avulsions
Plexus injury
visualization of the nerve rootlets strongly suggests
a preserved root
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
pre-ganglionic:
nerve root avulsion
post-ganglionic:
conduction deficits
Spectrum of injuries
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Plexus injury- nerve root avulsion
methemoglobin
Day 4
Day 14
pseudomeningocele
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
- evaluation of ventral and dorsal nerve roots
- detection of intradural nerve defects
CT-myelography
equal or better than standard myelography and
MR imaging, especially at the C5 and C6 levels
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
- usually filled with contrast media
- appear as lateral outpouching of the thecal sac
- may lie within the spinal canal
- or extend through the neural foramina
Pseudomeningoceles
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Summary
traumatic brain injuries in children are unusualbut can be quit severe and with permanent damage
CT initial imaging modality, be liberal with MRI(include SWI)
- severity- predict outcome
multiple SDH of different age – child abuse???
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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp
Summary
• important to have good knowledge about- pediatric spine anatomy- variants
• good quality images
• restrictive with CT in small children (radiation)
• liberal with MRI
• high incidence of dislocations and cord injury (<10 yrs)
• important to have good knowledge about- pediatric spine anatomy- variants
• good quality images
• restrictive with CT in small children (radiation)due three sets of plain X-rays
• liberal with MRI
• high incidence of dislocations and cord injury (<10 yrs)
Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 AntwerpPC Sundgren, Spine Infect… ASSR’ 12
Thank you