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Cranial nuclear magnetic resonance imaging in head trauma.

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prolonged ictal confusion in later life [3], often is seen
for the first time in late adulthood. Such patients
usually respond well to intravenously administered
diazepam or other antiepileptic drugs such as phenytoin, which are not ordinarily helpful for absence seizures in children [3].
The pathogenesis of seizures induced by metrizamide is uncertain. Bertoni and colleagues El] postulated either an effect on the cation pump enzyme complex or inhibition of hexokinase. They confirmed
hexokinase inhibition by metrizamide in vitro, demonstrating competitive inhibition of glucose metabolism,
and suggested that intrathecal glucose be given to minimize the adverse effects of metrizamide. As metrizamide enters the brain via direct diffusion into the
cerebral cortex, it is possible that it produces encephalopathy and seizures via transient “functional decortication” through inhibition of glucose metabolism.
Cranial Nuclear
Magnetic Resonance
ImLging in Head Trauma
Samuel E. Gandy, MD, PhD,
Robert B. Snow, MD, PhD,
Robert D. Zimmerman, MD,
and Michael D. F. Deck, M D
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Nuclear magnetic resonance imaging revealed focal intracranial lesions consisting of extraaxial hematomas or
nonhemorrhagic contusions in 3 patients with severe
neurological disability following head trauma. In all 3,
standard skull radiography and computed tomography
had been unremarkable.
Gandy SE, Snow RB, Zimmerman RD, Deck MDE::
Cranial nuclear magnetic resonance imaging i n
head trauma. Ann Neurol 16254-257, 1984
References
1. Bertoni JM, Schwarrzman RJ, Van Horn G, Partin J : Asrerixis
and encephalopathy following metrizamide myelography: investigations into possible mechanisms and review of the literature.
Ann Neurol 0:366-370, 1981
2. Buruma OJS, Hekster REM: Transient ,areflexla following
thoracolumbar myelography with metrizamide. Acta Radiol
(Suppl) 355371-372, 1977
3. Ellis JM, Lee SI: Acute prolonged confusion in later life as an
ictal state. Epilepsia 191 19-128, 1978
4. Gelmers HJ: Adverse side effects of metrizamide in myelography. Neuroradiology 18:119-123, 1979
5. Lungaresi E, Pazzaglia P, Tassinari CA: Differentiation of “Absence Status” and “Tempordi Lobe Status.” Epilepsia 12:77-87,
1971
6. Markand OM, Wheeler GL, Pollack SL: Complex partial status
epilepticus (psychomotor status). Neurology 28: 189- 196, 1978
7. Mayrux R, Lueders H: Complex partial status epileptirus: case
report and proposal for diagnostic criteria. Neurology 28957961, 1978
8. Niedermeyer E, Khalileh R: Petit mal status (“spike-wave
stupor”). An elecrroclinical approach. Epilepsia 6:250-262,
1965
9. Russell D, Anke IM, Nybeg-Hansen R, et al: Complex partial
status epilepticus following myelography with metrizamide. Ann
Neurol 8325-327, 1980
10. Sortland 0,Lundervold A, Nesbakken R. Mental confusion and
epileptic seizures following cervical myelography with metrizamide. Acta Radiol (Suppl) 355:403-406, 1977
Present neuroradiological evaluation often fails to aid
in the management of patients with head trauma because conventional imaging techniques, based on tissue
densities and interfaces, do not provide adequate definition and resolution [l]. This is particularly the case
among patients with parenchymal cerebral contusions
or small subdural hematomas. Nuclear magnetic resonance imaging (NMR) promises to improve diagnosis in such patients, as illustrated by the findirgs
in 3 patients recently studied at The New York
Hospital.
Materials and Methods
Computed tomography (CT) was performed using a General
Electric 8800 scanner. Magnetic resonance imaging was performed using a Technicare Teslacon system (Teslacon, Technicare Corp, Solon, OH), employing a 5.0 kG magnetic field.
Imaging was performed with two spin-echo techniques including (1) 500-ms repetition time and 30-ms echo delay, and
(2) 1500-ms repetition time and 90-ms echo delay. Sequence
1 produces images with proton density and spin-lattice
weighting (Tl), whereas sequence 2 produces images with
proton density and spin-spin weighting (T2). Pykett and coworkers [GI have recently summarized the principles of this
technique.
From the Departments of Neurology, Neurosurgery, and
Neuroradiology, The New York Hospital-Cornell Medical Center,
New York, NY.
Received Jan 13, 1984, and in revised form Jan 17. Accepted for
publication Jan 17, 1984.
Address reprint requests to Dr Gandy, Department of Neurology,
The New York Hospital-Cornell Medical Center, 525 East 68th St,
N e w York, N Y 1002 1.
254
A
B
Fig 1. Patient 1. (A) CT scan taken three days after injuly
shows no focal abnomzaiities or muss dfect. (B) N M R imaging
scan taken the same day reveals increased signal from the frontal,
occipital, and parietal lobes bilaterally, and from the right temporal lobe.
five days but anosmia has persisted. The patient resumed the
intake and retrieval of new memory 24 hours after the injury.
Case Reports
Patient I
A 36-year-old man was struck on the occiput with a wooden
club. Physical examination immediately afterward revealed an
alert man without external signs of surface trauma except for
a soft tissue hematoma over the occiput. However, he was
agitated, combative, and mute, although he lacked focal
motor or sensory deficits at bedside examination. Skull radiographs revealed a multilinear occipital fracture overlying the
inion. A C T scan corroborated this finding and demonstrated
a small occipital subdural hematoma and intracranial air in the
occipital region. Follow-up C T three days later was normal
(Fig 1A). NMR on the same day revealed markedly increased
bifrontal, bioccipital, biparietal, and right temporal lobe signals on a T 2 image, indicating multiple focal areas of edema
or nonhemorrhagic contusion (Fig IB).
The patient’s mental status cleared over the first 48 hours
of hospitalization, after which examination revealed bilateral
anosmia, graphanesthesia, and astereognosis of the hands.
He was amnestic for the 7 hours preceding and 24 hours after
the assault. The deficits in cortical sensation resolved after
Patient 2
A 59-year-old woman was receiving oral warfarin therapy to
prevent complications of hypercoagulability caused by an
idiopathic circulating anticoagulant. When examined after
twelve days of persistent headache after a fall with occipital
trauma, she was lethargic, disoriented, and had a mild right
hemiparesis with left-sided dysmetria of the extremities.
Skull radiographs revealed no fracture. An initial C T scan
was normal. A follow-up study nine days later demonstrated
a large right isodense subdural hematoma with midline shift.
After surgical drainage, a subdural collection remained visible on C T scan (Fig 2A). In addition, NMR imaging demonstrated bilateral convexity and interhemispheric collections
of subdural blood with increased signal on both T1 and T2
images (Fig 2B, C ) .The absence of a spurious signal from the
adjacent bone resulted in especially clear visualization of the
hematomas. Reoperation in the right frontal area resulted in a
good recovery.
Patient 3
A 22-year-old woman fell from a bicycle and struck her right
frontoparietal area. A C T scan taken elsewhere revealed an
acute epidural hematoma, which was drained by a right frontal craniotomy. The patient was discharged five days later
without neurological deficit.
Brief Communication: Gandy et al: NMR in Head Trauma
255
B
Fig 2. Patient 2. (A) Noncontrast CT scan shows compression of
the right lateral ventricle and a mild right-to-Left shift of the
midline. The isodense subdural hematoma is d;ff;cultto visualize
because of the density of adjacent calvaria. (Bi N M R T1 scan
demonstrates a crescentic extraaxial rollertion of increased activity
indicating a right subdural hematoma. Also nident are small
interhemisphericand lejl convexity collections not visualized by
C T . (C) N M R T2 image through the same region. The presence
of increased activity on both T 1 and T2 images is typical of recent hemorrhage.
C
The following day she became newly lethargic and came to
The New York Hospital. She was drowsy and mentally slow,
and she had difficulty with recent memory and decreased
hearing on the right. A right hemotympanum could be observed and she had a left extensor plantar response.
A C T scan showed poorly defined areas of decreased density in the left frontal and right temporal lobes (Fig 3A). A
small extraaxial hematoma was visualized at the surgical site
on more rostral tomograms. NMR imaging revealed a small
subdural collection on the right as well as a markedly increased signal from areas of both frontal and temporal lobes
and the left parietal lobe (Fig 3B), apparently corresponding
to posttraumatic edema or nonhemorrhagic contusions.
The patient recovered mentally over the next few days
while receiving steroid therapy, but her hearing deficit persisted at the time of discharge.
Discussion
The findings in these 3 patients demonstrate that in at
least some instances of head trauma, NMR provides
256 Annals of Neurology Vol 16 No 2 August 1984
A
B
Fig 3. Patient 3. (A)CT scan reveals bypodme areaj in the
right temporal and left frontal lobes. (B) N M R T2 image demonstrates an increased signal i n bilateral frontal and temporal lobes
and the ltft parietooccipital region, indicating areas of contusion.
Han and associates E31 have defined other instances
in which NMR imaging is potentially superior to CT in
defining intracranial abnormalities. NMR better visualizes small lesions at the vertex as well as most structures at the base of the skull and in the posterior fossa
because of the elimination of bone artifact. As noted
here, NMR can demonstrate small isodense subdural
hematomas that appear as only subtle abnormalities on
CT. The full advantages or disadvantages of NMR
await more extensive analysis.
diagnostic information far superior to that provided by
currently available CT scanning. Intracerebral lesions,
presumably contusions, were well identified on the
NMR images but only poorly defined by CT. Jennett
and Teasdale 141 have reviewed the shortcomings of
CT in the appraisal of severe head trauma. The nature
of the clinical changes in their patients suggests that
many of them may have had contusions that CT failed
to visualize.
Posttraumatic agitation and psychosis have traditionally been presumed to be the clinical manifestations of inferior frontal andor temporal lobe contusions 121. Levin and Grossman 151, however, observed
a lack of association between these symptoms and focal
CT lesions. Our findings suggest that their observations
may reflect more the limitations of CT than a refutation
of clinicopathological observations. The NMR results
support the inference that focal cortical lesions provide
the substrate for acute posttraumatic psychosis.
References
1. Brant-Zawadzki M, Davis PL, Crooks LE,et al: NMR demonstration of cerebral abnormalities: comparison with CT. AJNR
4:117-124, 1783
2. Courville CB: Pathology of the Central Nervous System. Mountain View, CA, Pacific Press, 1737
3. Han JS, Kaufman B, Altidi RJ, et al: Head trauma evaluated by
magnetic resonance and computed tomography: a comparison.
Radiology 150:71-77, 1984
4. Jennett B, Teasdale G: Special investigations and methods of
monitoring. In Management of Head Injuries. Philadelphia,
Davis, 1981, pp 112-116
5. Levin HS, Grossman RG: Behavioral sequelae of closed head
injury: a quantitative study. Arch Neurol 35:720-727, 1978
6. Pykett IL, Newhouse JH, Buonanno FS, et al: Principles of nuclear magnetic resonance imaging. Radiology 146:123-128, 1982
Brief Communication: Gandy et al: NMR in Head Trauma
257
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