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(Ebook) Interpretation of Emergency Head CT. A Practical Handbook by Rakesh R. Misra Erskine J. Holmes ISBN 9781316178881, 1316178889 Full

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Interpretation of Emergency
Head CT
A practical handbook
Second Edition

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Interpretation of
Emergency Head CT
A practical handbook
Second Edition
Erskine J. Holmes, MRCS, FCEM, CFEU
Consultant in Emergency Medicine
Craigavon Area Hospital, Southern Trust, Northern Ireland

Rakesh R. Misra, BSc (Hons), FRCS (Eng), FRCR


Consultant Radiologist, Wycombe Hospital
Buckinghamshire Healthcare NHS Trust

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Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/9781316178881
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
4843/24, 2nd Floor, Ansari Road, Daryaganj, Delhi – 110002, India
79 Anson Road, #06–04/06, Singapore 079906

Cambridge University Press is part of the University of Cambridge.


It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107495937
10.1017/9781316178881
© E. J. Holmes and R. R. Misra 2017
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2009
Second edition 2017
Printed in the United Kingdom by Clays, St Ives plc, March 2017
A catalogue record for this publication is available from the British Library
Library of Congress Cataloguing in Publication data
Names: Holmes, Erskine J., author. | Misra, Rakesh R., author.
Title: Interpretation of emergency head CT : a practical handbook / Erskine J. Holmes, Rakesh R. Misra.
Other titles: Interpretation of emergency head computed tomography
Description: Second edition. | Cambridge, United Kingdom ; New York : Cambridge University Press,
2016. | Includes bibliographical references and index.
Identifiers: LCCN 2016058545 | ISBN 9781107495937 (alk. paper)
Subjects: | MESH: Brain – diagnostic imaging | Head – diagnostic imaging | Radiography | Emergencies |
Tomography, X-Ray Computed | Handbooks
Classification: LCC RC349.R3 | NLM WL 39 | DDC 616.8/047572–dc23
LC record available at https://lccn.loc.gov/2016058545
ISBN 978-1-107-49593-7
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
..........................................................................................................................
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time of publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Downloaded from https:/www.cambridge.org/core. Boston University Theology Library, on 22 May 2017 at 13:52:58, subject to the Cambridge
Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/9781316178881
Interpretation of Emergency
Head CT
A practical handbook
Second Edition

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Interpretation of
Emergency Head CT
A practical handbook
Second Edition
Erskine J. Holmes, MRCS, FCEM, CFEU
Consultant in Emergency Medicine
Craigavon Area Hospital, Southern Trust, Northern Ireland

Rakesh R. Misra, BSc (Hons), FRCS (Eng), FRCR


Consultant Radiologist, Wycombe Hospital
Buckinghamshire Healthcare NHS Trust

Downloaded from https:/www.cambridge.org/core. Boston University Theology Library, on 22 May 2017 at 13:52:36, subject to the Cambridge
Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/9781316178881
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
4843/24, 2nd Floor, Ansari Road, Daryaganj, Delhi – 110002, India
79 Anson Road, #06–04/06, Singapore 079906

Cambridge University Press is part of the University of Cambridge.


It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107495937
10.1017/9781316178881
© E. J. Holmes and R. R. Misra 2017
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2009
Second edition 2017
Printed in the United Kingdom by Clays, St Ives plc, March 2017
A catalogue record for this publication is available from the British Library
Library of Congress Cataloguing in Publication data
Names: Holmes, Erskine J., author. | Misra, Rakesh R., author.
Title: Interpretation of emergency head CT : a practical handbook / Erskine J. Holmes, Rakesh R. Misra.
Other titles: Interpretation of emergency head computed tomography
Description: Second edition. | Cambridge, United Kingdom ; New York : Cambridge University Press,
2016. | Includes bibliographical references and index.
Identifiers: LCCN 2016058545 | ISBN 9781107495937 (alk. paper)
Subjects: | MESH: Brain – diagnostic imaging | Head – diagnostic imaging | Radiography | Emergencies |
Tomography, X-Ray Computed | Handbooks
Classification: LCC RC349.R3 | NLM WL 39 | DDC 616.8/047572–dc23
LC record available at https://lccn.loc.gov/2016058545
ISBN 978-1-107-49593-7
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
..........................................................................................................................
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time of publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Downloaded from https:/www.cambridge.org/core. Boston University Theology Library, on 22 May 2017 at 13:52:36, subject to the Cambridge
Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/9781316178881
Interpretation of Emergency
Head CT
A practical handbook
Second Edition

Downloaded from https:/www.cambridge.org/core. Boston University Theology Library, on 22 May 2017 at 13:52:36, subject to the Cambridge
Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/9781316178881
Downloaded from https:/www.cambridge.org/core. Boston University Theology Library, on 22 May 2017 at 13:52:36, subject to the Cambridge
Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/9781316178881
Interpretation of
Emergency Head CT
A practical handbook
Second Edition
Erskine J. Holmes, MRCS, FCEM, CFEU
Consultant in Emergency Medicine
Craigavon Area Hospital, Southern Trust, Northern Ireland

Rakesh R. Misra, BSc (Hons), FRCS (Eng), FRCR


Consultant Radiologist, Wycombe Hospital
Buckinghamshire Healthcare NHS Trust

Downloaded from https:/www.cambridge.org/core. Boston University Theology Library, on 22 May 2017 at 13:52:36, subject to the Cambridge
Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/9781316178881
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
4843/24, 2nd Floor, Ansari Road, Daryaganj, Delhi – 110002, India
79 Anson Road, #06–04/06, Singapore 079906

Cambridge University Press is part of the University of Cambridge.


It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107495937
10.1017/9781316178881
© E. J. Holmes and R. R. Misra 2017
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2009
Second edition 2017
Printed in the United Kingdom by Clays, St Ives plc, March 2017
A catalogue record for this publication is available from the British Library
Library of Congress Cataloguing in Publication data
Names: Holmes, Erskine J., author. | Misra, Rakesh R., author.
Title: Interpretation of emergency head CT : a practical handbook / Erskine J. Holmes, Rakesh R. Misra.
Other titles: Interpretation of emergency head computed tomography
Description: Second edition. | Cambridge, United Kingdom ; New York : Cambridge University Press,
2016. | Includes bibliographical references and index.
Identifiers: LCCN 2016058545 | ISBN 9781107495937 (alk. paper)
Subjects: | MESH: Brain – diagnostic imaging | Head – diagnostic imaging | Radiography | Emergencies |
Tomography, X-Ray Computed | Handbooks
Classification: LCC RC349.R3 | NLM WL 39 | DDC 616.8/047572–dc23
LC record available at https://lccn.loc.gov/2016058545
ISBN 978-1-107-49593-7
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
..........................................................................................................................
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time of publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Downloaded from https:/www.cambridge.org/core. Boston University Theology Library, on 22 May 2017 at 13:52:36, subject to the Cambridge
Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/9781316178881
Dedicated to my parents, Sally and Erskine Holmes,
for making me the person I am today. E. J. H.
Dedicated to my late mother, Darshan Misra. You
sacrificed so much to allow me to grow into the person
I am. R. R. M.

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Contents
Preface ix
Acknowledgement x
Abbreviations xi
Introduction xiii

Section 1 6. Cerebral Venous Sinus


Thrombosis 72
Fundamentals of Computer 7. Hypoxic–Ischaemic Injury (HII) 75
Tomography Imaging 1 8. Skull Fractures 77
History 1 9. Raised Intracranial Pressure 80
Technical Details 1 10. Hydrocephalus 83
Windowing and Grey-scale 4 11. Meningitis 86
Tissue Characteristics and Contrast 12. Cerebral Abscess 88
Medium 4 13. Arteriovenous Malformation 91
Image Artefacts 5 14. Solitary Lesions 94
Important Anatomical 15. Multiple Lesions 98
Considerations 8 16. Neck Vessel Dissection 101
Review of Normal Axial Anatomy 8
Review of Normal Coronal Anatomy 20
Review of Normal Sagittal Section 3
Anatomy 22
Review of Normal Bony Axial Cervical Spine 103
Anatomy 24 ‘ABCs’ Approach to Interpreting
Review of Normal Bony Coronal Multiplanar Reformats
Anatomy 28 of the CT Cervical Spine 104
Review of Surface-rendered Bony Types of Spine Fractures 107
Anatomy 29 Types of Cervical Spine Fractures 109
Review of Vascular Territories 35
Review of Vascular Anatomy 46
Section 4
Self-assessment Section 119
Section 2 Self Assessment – Answers 123
Reviewing a CT Scan 47
1. Acute Stroke 49
2. Subdural Haematoma (SDH) 56
3. Extradural/Epidural Appendix 1 – ABCD2 Scoring
Haematoma 60 System 127
4. Subarachnoid Haemorrhage 63 Appendix 2 – ROSIER Score 128
5. Traumatic Parenchymal Brain Appendix 3 – NICE Acute Stroke Flow
Injury 68 Pathway 129

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viii Contents

Appendix 4 – Glasgow Coma Scale Appendix 8 – NICE Guideline for


(GCS) Assessment 130 Paediatric CT Neck 134
Appendix 5 – NICE Guideline for Adult Appendix 9 – Information Required
CT Head 131 Prior to Neurosurgical Transfer 135
Appendix 6 – NICE Guideline Appendix 10 – Differential Diagnosis
for Adult CT Neck 132 for Intracerebral Lesions 136
Appendix 7 – NICE Guideline
for Paediatric CT Head 133

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Preface
Welcome to the second edition of Interpretation of Emergency Head CT.
The aim of this book is again to prepare interested specialists with a structured, image-
driven handbook for CT Head and Neck interpretation. With the advances and refinement
of imaging protocols in trauma, we felt it was time to include guidance on trauma CT neck
interpretation. A schema is provided by which to analyse the images, in order to develop
greater confidence in diagnosing the most common and time-critical problems. Up-to-date
images, with accompanying text, make this book an accessible reference and aide-memoire
for medical and allied professionals. The topics included should be useful for anybody
revising for postgraduate examinations, and it should also prove to be an invaluable text for
medical and radiography students alike. Small enough to carry around, we hope that we
have once again provided a reliable reference for use anytime, regardless of the time of day
or night.

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Abbreviations
ACom Anterior communicating
ADC Apparent diffusion coefficient
APTT Activated partial rhromboplastln time
AYM Arterioveuous malformenon
BP Blood pressure
CCF Congestive cardiac failure
CPP Cerebral perfusion pressure
CSP Cerebrospinal fluid
CT Computer tomography
CJV er vcnogram
CVA Cerebrovascular accident
DWI Diffusion-weighted imaging
£CA External carotid artery
EGG Electrocardiogram
EDH Extradural haemorrhage
ETA Estimated time of arrival
ETT Endotracheal tube
FB Frontal bone
GCS Glasgow Coma Scale
GI Gastrointestinal
Hn Hypoxic-Ischaenuc injut')r
HR Heart rate
HU Hounsfield Unit
ICA Internal carotid artery
ICP lntracranial pressure
i.m. Intramuscular
INR lntccnalloual normalised ratio
l.v. Intravenous
LP Lumbar puncture
M:P Male:female
MCA Middle cerebral artery
MR Magnetic resonance
MRI Magnetic resonance imaging
NICE National Institute of Clinical Excellence
OB Occipital bone
PACS Patient Archive and Communication S}1Sten1
Pll Parietal bone
PCom Posterior communicating
RIND Reversible Ischaemic neurological de6cit
RR Respiratory rate
SAH Subarachnoid haemorrhage
SDH Subdural haematoma

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