Interactive Transcript
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In most academic centers, the evaluation
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of children with trauma is being done more
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and more with fast MRI scanning in order to
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reduce the radiation exposure to children.
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So this is part of the ALARA, as Low
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as possible radiation dosage.
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So in the— at Johns Hopkins, when a child comes in with
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head trauma, they're getting fast spin-echo T2-weighted
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scans rather than CT scans for their evaluation.
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So this was a child who had head trauma, and a protocol
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was performed for a traumatic brain injury in a child.
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This consists of sagittal,
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axial, and coronal HASTE images.
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The HASTE pulse sequence is
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unique in that it's very rapid.
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It does sequential scanning rather
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than a group of scanning, so it reduces
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the possibility of motion artifact with
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children moving around in the scanner.
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And this is followed by diffusion-weighted imaging in
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order to look for ischemic foci, susceptibility-weighted
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scanning in order to look for hemorrhagic products.
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And often, we do a black bone scan
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in order to look for fractures.
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Remember that fractures are not that important from
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the standpoint of surgical intervention unless they're
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depressed or open, which is usually obvious clinically.
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So, MRI is now even being
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used to look for fractured bones.
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So here was a patient where the initial
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HASTE image showed some prominence to the
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high signal intensity anteriorly here.
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And the interpretation here was: are these blood vessels
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crossing the subarachnoid space, or are they not?
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If they cross the subarachnoid space, then this
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may be a young patient who has benign macrocephaly
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of infancy with a dilated subarachnoid space.
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Or, if the blood vessels are compressed inward,
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these could be subdural hematomas chronic.
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So, I thought that the diffusion-weighted
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scan on this case was very helpful.
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So here is our DWI scan, where it shows absence
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of parenchymal cytotoxic edema, but up anteriorly—
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I'm going to window this a little bit differently—
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you can see that the collections anteriorly
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are not isointense to cerebrospinal fluid.
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They're different.
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Here is the subjacent subarachnoid
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space—cerebrospinal fluid.
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Here is hyperintense—slightly hyperintense to CSF.
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So that raises the suspicion that
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this represents blood collections.
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The next sequence in line is going
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to be our susceptibility-weighted
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scan, and this is pretty traumatic.
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Notice that in the susceptibility-weighted scan,
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there are areas here that are too thick to just be veins.
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Obviously, the veins are black on SWI
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because of the presence of deoxyhemoglobin.
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But here, we're seeing blood products on
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the surface of the brain that is too thick.
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There's no vein that's going to be that thick.
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And it's also present along the posterior falx here.
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And anteriorly, now we see that there are actually
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two different intensities of collection.
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There is the darker area here, anteriorly,
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and then a brighter area of signal
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intensity just to the left of midline.
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So, what I'm talking about is the brighter
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area here is different than the lower
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signal intensity collection here.
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And these are collections.
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So now we have subdural collections of different ages,
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associated with some more diffuse hemorrhage over
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the high convexities in the subarachnoid space.
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This should alert you to non-accidental trauma.
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There are lots of different names for non-accidental
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trauma: child abuse, or shaken baby syndrome, etc.
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But the bottom line is that this is not from
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just a fall—this is likely multiple
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aged hemorrhages from child abuse.
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And this is something that you would
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immediately alert the clinicians that you
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raise the possibility of non-accidental trauma.
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They will then get social services
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involved to interview the family about the
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circumstances surrounding this child's trauma.
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Whenever I see this phenomenon, the next thing I
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want to do is to look at the orbits carefully.
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One of the findings associated with non-accidental
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trauma in children is retinal hemorrhages.
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And this is from the shaking or the
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acceleration-deceleration injury.
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So, if there's any type of blood product
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that you can identify associated with the
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retina, it's going to increase your certainty
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that the patient has non-accidental trauma.
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