CT scanning

CT scanning has revolutionized the management of the head-injured patient. It has virtually replaced skull radiography because it provides images of the brain and other soft tissues. CT scanners have become widespread in the developed world and allow for rapid low-cost non-invasive imaging. A CT scanner is now considered essential in the optimal care of patients with brain injuries.

Fractures of the skull and skull base can be readily diagnosed. When skull base fractures are noted, cerebrospinal fluid leaks may be anticipated and injury to the facial nerve should be sought. Depressed skull fractures and those that are exposed due to a scalp laceration require surgical repair. Extracranial hematomas, both epidural and subdural, are readily identified on CT. If they are associated with a shift in midline of approximately 5 mm or more, surgical intervention is generally required. Parenchymal injuries such as contusions and intracerebral hematomas are also diagnosed by CT scan. Contusions often evolve in a delayed fashion, sometimes with associated clinical deterioration hours or even days after the initial injury.

Sequential follow-up studies are recommended after the initial CT scan, particularly when the patient's condition deteriorates. With continued improvement in emergency systems, many patients reach trauma centers within 1 h of the injury. Therefore the initial CT scan may not show the maximum pathology. Consequently, some neurosurgeons advocate routine scanning of patients with moderate and severe head injury 4 to 8 h after presentation in order to identify expanding hematomas and contusions. Other features to look for on a cranial CT scan include evidence of brain swelling such as the compression or absence of the basal cisterns, a shift in the midline, or herniation.

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