Neuroradiology Head Trauma

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    History
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit http://www.neurosurgeonindia.org/
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  • After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”

    Other recent MS patients who have had Autologous Stem Cell Transplantation (ASCT), or stem cell therapy have posted videos and comments on YouTube. www.youtube.com/watch?v=jFQr2eqm3Cg.

    Dr. Avneesh Gupte, the Neurosurgeon at Noble Hospital performing the procedure has been encouraged by results in Cerebral Palsy patients as well. “We are fortunate to be able to offer the treatment because not every hospital is able to perform these types of transplants. You must have the specialized medical equipment and specially trained doctors and nurses”. With regard to MS patients, “We are cautious, but nevertheless excited by what patients are telling us. Suffice to say that the few patients who have had the therapy through us are noticing recovery of neuro deficits beyond what the venous angioplasty only should account for”.

    Dr. Unmesh of Noble continues: “These are early days and certainly all evidence that the combination of liberation and stem cell therapies working together at this point is anecdotal. However I am not aware of other medical facilities in the world that offer the synthesis of both to MS patients on an approved basis and it is indeed a rare opportunity for MS patients to take advantage of a treatment that is quite possibly unique in the world”.

    Autologous stem cell transplantation is a procedure by which blood-forming stem cells are removed, and later injected back into the patient. All stem cells are taken from the patient themselves and cultured for later injection. In the case of a bone marrow transplant, the HSC are typically removed from the Pelvis through a large needle that can reach into the bone. The technique is referred to as a bone marrow harvest and is performed under a general anesthesia. The incidence of patients experiencing rejection is rare due to the donor and recipient being the same individual.This remains the only approved method of the SCT therapy.
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  • Great Presentation and very informative . Thank you
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  • Slide #8 Epidural Hematoma Case A 32 y/o man presented to the ER after slipping on ice in his driveway. The patient fell backwards and hit his head on the ground. The patient got up and returned to his house and told his wife what had happened. After about 20 minutes of sitting the patient began complaining of a headache. Approximately one hour after the fall the patient became disoriented and obtunded. The patient's wife immediately called an ambulance, which brought him in to the ER. On arrival the patient was obtunded to the point that he could not answer or respond to questions. The CT on the left was taken shortly after arrival. Diagnosis: Epidural Hematoma On CT, epidural hematomas appear as well-defined, high attenuation lenticular or biconvex extra-axial collections. Associated mass effect with sulcal effacement and midline shift is frequently present. Overlying linear skull fractures can often be visualized on bone windows. If an epidural hematoma appears heterogeneous, containing irregular areas of lower attenuation, this can indicate active extravasation of fresh unclotted blood, requiring immediate surgical attention. Alternatively, areas of low attenuation can represent serum extruded from the clot.
  • Slide #9 CT of the head obtained without intravenous contrast enhancement shows a biconvex high-attenuation epidural hematoma adjacent to the right frontal lobe ( arrows ). The lesion extends superiorly to the level of the body of the lateral ventricle ( arrow )
  • Slide #10 and inferiorly to the roof of the right orbit (arrow). Mild mass effect is exerted on the subjacent brain parenchyma. A fracture is visible extending through the right side of frontal bone (arrow)
  • Slide #11 to the roof of the right orbit (arrow) with associated extracranial soft tissue swelling (arrow).
  • Slide #16 Subdural Hematoma Case: A 26 yo female presents to her family practice physician complaining of a headache that has persisted for over one month and sporadic blurry vision that has worsened over the last week. The headache is only slightly relieved with Ibuprofen and is worse when doing strenuous activity. The blurry vision comes and goes and can last minutes to hours when it is present. The neurologic and physical exams are normal except for some slight papilledema. The patient was then sent for a CT exam, the results of which are shown here. Diagnosis: Subdural Hematoma
  • Slide #17 Axial CT images of the brain show a large isodense right-sided subdural hematoma ( short arrows ) extending from the high convexities to the low frontal lobe. It is producing extensive right to left midline shift with subfalcine ( arrow )
  • Slide #18 and right uncal (arrow) herniation. There is trapping of the ventricles and left temporal horn with acute ependymal cerebrospinal fluid seepage, predominantly in the left periatrial and occipital regions (long arrow).
  • Slide #19 Subdural Hematoma
  • Neuroradiology Head Trauma

    1. 1. Neuroradiology Traumatic Hemorrhage By: Luke Aldo, MSIV LECOM Erie, Pennsylvania
    2. 2. Layers of the Meninges
    3. 3. Epidural Hematoma <ul><li>Accumulation of blood in the potential space between dura mater and bone </li></ul><ul><li>EDH is considered to be the most serious complication of head injury, requiring immediate diagnosis and surgical intervention (mortality rate associated with epidural hematoma has been estimated to be 5-50%) </li></ul>
    4. 4. Pathophysiology <ul><li>Usually results from a brief linear contact force to the calvaria that causes separation of the periosteal dura from bone and disruption of interposed vessels due to shearing stress </li></ul><ul><li>Skull fractures occur in 85-95% of adult cases </li></ul><ul><li>Extension of the hematoma usually is limited by suture lines owing to the tight attachment of the dura at these locations. </li></ul><ul><li>The temporoparietal region and the middle meningeal artery are involved most commonly (66%) </li></ul>
    5. 5. Frequency <ul><li>Epidural hematoma complicates 2% of cases of head trauma (approximately 40,000 cases per year) </li></ul><ul><li>Alcohol and other forms of intoxication have been associated with a higher incidence of epidural hematoma </li></ul><ul><li>Sex </li></ul><ul><ul><li>more frequent in men, with a male-to-female ratio of 4:1 </li></ul></ul><ul><li>Age </li></ul><ul><ul><li>rare in individuals younger than 2 years </li></ul></ul><ul><ul><li>rare in individuals older than 60 years because the dura is tightly adherent to the calvaria </li></ul></ul>
    6. 6. History <ul><li>Head trauma </li></ul><ul><li>Lucid interval between the initial loss of consciousness at the time of impact and a delayed decline in mental status (10-33% of cases) </li></ul><ul><li>Headache </li></ul><ul><li>Nausea/vomiting </li></ul><ul><li>Seizures </li></ul><ul><li>Focal neurological deficits (eg, visual field cuts, aphasia, weakness, numbness) </li></ul>
    7. 7. Diagnostic Imaging <ul><li>Noncontrast CT scanning of the head (imaging study of choice for intracranial EDH) not only visualizes skull fractures, but also directly images an epidural hematoma </li></ul><ul><li>It appears as a hyperdense biconvex or lenticular-shaped mass situated between the brain and the skull, though regions of hypodensity may be seen with serum or fresh blood </li></ul><ul><li>MRI also demonstrates the evolution of an epidural hematoma, though this imaging modality may not be appropriate for patients in unstable condition </li></ul>
    8. 12. Subdural Hematoma <ul><li>Rapidly clotting blood collection below the inner layer of the dura but external to the brain and arachnoid membrane </li></ul><ul><li>Typically, low-pressure venous bleeding of bridging veins (between the cortex and venous sinuses) dissects the arachnoid away from the dura and layers out along the cerebral convexity </li></ul><ul><li>It conforms to the shape of the brain and the cranial vault, exhibiting concave inner margins and convex outer margins (crescent shape) </li></ul><ul><li>Frequency is related directly to the incidence of blunt head trauma </li></ul><ul><li>It’s the most common type of intracranial mass lesion, occurring in about a third of those with severe head injuries </li></ul>
    9. 13. Mortality/Age <ul><li>Mortality </li></ul><ul><ul><li>Simple SDH (no parenchymal injury) is associated with a mortality rate of about 20% </li></ul></ul><ul><ul><li>Complicated SDH (parenchymal injury) is associated with a mortality rate of about 50% </li></ul></ul><ul><li>Age </li></ul><ul><ul><li>It’s associated with age factors related to the risk of blunt head trauma </li></ul></ul><ul><ul><li>More common in people older than 60 years (bridging veins are more easily damaged/falls are more common) </li></ul></ul><ul><ul><li>Bilateral SDHs are more common in infants since adhesions existing in the subdural space are absent at birth </li></ul></ul><ul><ul><li>Interhemispheric SDHs are often associate with child abuse </li></ul></ul>
    10. 14. History <ul><li>Usually involves moderately severe to severe blunt head trauma </li></ul><ul><li>Acute deceleration injury from a fall or motor vehicle accident, but rarely associated with skull fracture </li></ul><ul><li>Generally loss of consciousness </li></ul><ul><li>Any degree or type of coagulopathy should heighten suspicion of SDH </li></ul><ul><li>Commonly seen in alcoholics because they’re prone to thrombocytopenia, prolonged bleeding times, and blunt head trauma </li></ul><ul><li>Patients on anticoagulants can develop SDH with minimal trauma and warrant a lowered threshold for obtaining a head CT scan </li></ul>
    11. 15. Diagnostic Imaging <ul><li>MRI is superior for demonstrating the size of an acute SDH and its effect on the brain, however noncontrast head CT is the primary means of making a diagnosis and suffice for immediate management purposes </li></ul><ul><li>Noncontrast head CT scan (imaging study of choice for acute SDH) </li></ul><ul><ul><li>The SDH appears as a hyperdense (white) crescentic mass along the inner table of the skull, most commonly over the cerebral convexity in the parietal region. The second most common area is above the tentorium cerebelli </li></ul></ul><ul><li>Contrast-enhanced CT or MRI is widely recommended for imaging 48-72 hours after head injury because the lesion becomes isodense in the subacute phase </li></ul><ul><li>In the chronic phase, the lesion becomes hypodense and is easy to appreciate on a noncontrast head CT scan </li></ul>
    12. 20. Summary <ul><li>Epidural Hematoma </li></ul><ul><ul><li>Potential space between the dura in the inner table of the skull </li></ul></ul><ul><ul><li>Can’t cross sutures </li></ul></ul><ul><ul><li>Skull fractures in temporoparietal region </li></ul></ul><ul><ul><li>Middle meningeal artery </li></ul></ul><ul><ul><li>Lenticular or biconvex shape </li></ul></ul><ul><ul><li>Lucid interval </li></ul></ul><ul><ul><li>Common in alcoholics </li></ul></ul><ul><ul><li>Medical emergency </li></ul></ul><ul><ul><li>CT without contrast </li></ul></ul><ul><ul><li>Evacuate via burr holes </li></ul></ul><ul><li>Subdural Hematoma </li></ul><ul><ul><li>Between the dura mater and the arachnoid mater </li></ul></ul><ul><ul><li>Can cross sutures </li></ul></ul><ul><ul><li>Cortical bridging veins </li></ul></ul><ul><ul><li>Crescent shape </li></ul></ul><ul><ul><li>Loss of consciousness </li></ul></ul><ul><ul><li>Common in elderly </li></ul></ul><ul><ul><li>Common in alcoholics </li></ul></ul><ul><ul><li>Medical emergency </li></ul></ul><ul><ul><li>CT without contrast </li></ul></ul><ul><ul><li>Evacuate via burr holes </li></ul></ul>
    13. 21. Bibliography <ul><li>Abramson, Nina, MD. Subdural Hematoma. Brigham Radiology: 1994 Nov. </li></ul><ul><li>Azmoun, Leyla, MD. Epidural Hematoma. Brigham Radiology: 1995 Nov. </li></ul><ul><li>Liebeskine, David, MD. Epidural Hematoma. Emedicine.com: 2006 Apr; 1-10. </li></ul><ul><li>Scaletta, Tom, MD. Subdural Hematoma. Emedicine.com: 2006 May; 1-10. </li></ul>

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