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THE REQUISITES

Emergency
Radiology
SERIES EDITOR OTHER VOLUMES IN THE REQUISITES
RADIOLOGY SERIES
James H. Thrall, MD
Radiologist-in-Chief Emeritus Breast Imaging
Department of Radiology Cardiac Imaging
Massachusetts General Hospital Gastrointestinal Imaging
Distinguished Juan M.Taveras Professor of Radiology Genitourinary Imaging
Harvard Medical School Musculoskeletal Imaging
Boston, Massachusetts Neuroradiology
Nuclear Medicine
Pediatric Radiology
Thoracic Radiology
Ultrasound
Vascular and Interventional Radiology
 THE REQUISITES

Emergency
Radiology
SECOND EDITION
Jorge A. Soto, MD
Professor of Radiology
Department of Radiology
Boston University School of Medicine;
Vice Chairman
Department of Radiology
Boston Medical Center
Boston, Massachusetts

Brian C. Lucey, MD
Associate Professor
Department of Radiology
Boston University School of Medicine
Boston, Massachusetts;
Clinical Director
Department of Radiology
The Galway Clinic
Doughiska, County Galway, Ireland
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

EMERGENCY RADIOLOGY:THE REQUISITES, SECOND EDITION ISBN: 978-0-323-37640-2

Copyright © 2017 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
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With respect to any drug or pharmaceutical products identified, readers are advised to check the
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contained in the material herein.

Previous edition copyright © 2009 by Mosby, Inc., an affiliate of Elsevier, Inc.

Library of Congress Cataloging-in-Publication Data

Soto, Jorge A., editor.

Lucey, Brian C., editor.
Emergency radiology / [edited by] Jorge A. Soto, Brian C. Lucey.
Emergency radiology (Soto) | Requisites in radiology. | Requisites series.
Second edition. | Philadelphia, PA : Elsevier, [2017] | Requisites |Requisites radiology series
Includes bibliographical references and index.
LCCN 2015037285
ISBN 9780323376402 (hardcover : alk. paper)
MESH: Diagnostic Imaging. | Emergency Medical Services.
LCC RC78 | NLM WN 180 | DDC 616.07/572--dc23 LC record available at http://lccn.loc.gov/2015037285

Executive Content Strategist: Robin Carter

Content Development Specialist: Amy Meros
Publishing Services Manager: Patricia Tannian
Project Manager: Stephanie Turza
Senior Book Designer: Amy Buxton

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my parents, Jorge Sr. and Socorro, for their example and guidance, and to my
wife, Ana, and children, Andrea and Alejandro, for their sustained support and
patience as I devote my time to academic radiology.
J.A.S.

To my parents, James and Anne; sister, Suzanne; wife, Ciara; and son, James.
Thanks for the unconditional support.
B.C.L.
This page intentionally left blank

     
Contributors
Carlos A. Anaya, MD Ana Maria Gomez, MD
Medical Director Department of Radiology
Cardiovascular Interventional Institute Manati Medical Center
Department of Radiology Manati, Puerto Rico
Manati Medical Center
Manati, Puerto Rico Rathachai Kaewlai, MD
Instructor
Stephan W. Anderson, MD Division of Emergency Radiology
Associate Professor of Radiology Department of Diagnostic and Therapeutic Radiology
Boston University Medical Center Ramathibodi Hospital
Boston, Massachusetts Faculty of Medicine
Mahidol University
Laura L. Avery, MD Bangkok,Thailand
Assistant Professor
Massachusetts General Hospital Russ Kuker, MD
Harvard Medical School Department of Radiology
Boston, Massachusetts University of Miami Hospital
Miami, Florida
Glenn D. Barest, MD
Assistant Professor of Radiology Christina A. LeBedis, MD
Boston Medical Center Assistant Professor
Boston, Massachusetts Boston University Medical Center
Boston, Massachusetts
Sarah D. Bixby, MD
Assistant Professor of Radiology Brian C. Lucey, MD
Harvard Medical School; Associate Professor
Pediatric Radiologist Department of Radiology
Department of Radiology Boston University School of Medicine
Boston Children’s Hospital Boston, Massachusetts;
Boston, Massachusetts Clinical Director
Department of Radiology
Anna K. Chacko, MD The Galway Clinic
Adjunct Professor of Radiology Doughiska, County Galway, Ireland
Boston University
Boston, Massachusetts; Asim Z. Mian, MD
Professor of Telemedicine Assistant Professor of Radiology
John A. Burns School of Medicine Boston Medical Center
University of Hawaii Boston University
Honolulu, Hawaii Boston, Massachusetts

Margaret N. Chapman, MD Sarah S. Milla, MD

Chief of Neuroradiology Associate Professor
Boston VA Healthcare System; Department of Radiology and Imaging Sciences
Assistant Professor of Radiology Emory University;
Boston Medical Center Attending Pediatric Radiologist and Neuroradiologist
Boston University School of Medicine Children’s Healthcare of Atlanta
Boston, Massachusetts Egleston Hospital
Atlanta, Georgia
Luis E. Diaz, MD
Associate Chief of Radiology Felipe Munera, MD
VA Boston Health Care System; Department of Radiology
Associate Professor of Radiology University of Miami Hospital
Boston University Miami, Florida
Boston, Massachusetts
Rohini N. Nadgir, MD
Alejandra Duran-Mendicuti, MD Assistant Professor of Radiology and Radiological Science
Department of Radiology Johns Hopkins Medical Institutions
Brigham and Women’s Hospital Baltimore, Maryland
Boston, Massachusetts
vii
viii Contributors

Osamu Sakai, MD, PhD Joshua W. Stuhlfaut, MD

Chief of Neuroradiology Beth Israel Deaconess Hospital
Professor of Radiology, Otolaryngology–Head and Neck Plymouth, Massachusetts
Surgery and Radiation Oncology
Boston Medical Center Jennifer C. Talmadge, MD
Boston University School of Medicine Department of Radiology
Boston, Massachusetts Children’s Hospital Boston
Boston, Massachusetts
Rashmikant B. Shah, MD
Diagnostic Radiology Salvatore G. Viscomi, MD
St. James Healthcare Clinical Instructor
Butte, Montana Harvard Medical School;
Attending Radiologist
Ajay Singh, MD Department of Radiology
Department of Radiology Brigham and Women’s Hospital
Massachusetts General Hospital Boston, Massachusetts;
Boston, Massachusetts Chairman
Department of Radiology
Aaron D. Sodickson, MD, PhD Cape Cod Hospital
Department of Radiology Hyannis, Massachusetts
Brigham and Women’s Hospital
Boston, Massachusetts Scott White, MD
Department of Radiology
Jorge A. Soto, MD Brigham and Women’s Hospital
Professor of Radiology Boston, Massachusetts
Department of Radiology
Boston University School of Medicine; Ryan T. Whitesell, MD
Vice Chairman St. Paul Radiology
Department of Radiology Regions Hospital
Boston Medical Center St. Paul, Minnesota
Boston, Massachusetts

Michael Stella, MD
Department of Radiology
Brigham and Women’s Hospital
Boston, Massachusetts
Foreword
Time passes quickly, and it is now time to introduce the THE REQUISITES books have become old friends to
second edition of Emergency Radiology: THE REQUI- imagers for over 25 years. We have tried to remain true
SITES. Drs. Soto and Lucey, along with their coauthors, to the original philosophy of the series, which was to pro-
have once again created an excellent text that captures vide residents, fellows, and practicing radiologists with
the fundamental building blocks of emergency radiology a text that might be read within several days. From feed-
practice. back I have received, many residents do exactly that at
Drs. Soto and Lucey have maintained the logical division the ­beginning of each rotation. During first rotations this
of their book by both body part and indication—trauma ­allows them to acquire enough knowledge to really ben-
versus nontrauma with separate chapters for special con- efit from their day-to-day exposure to clinical material and
siderations in children and for nuclear medicine applica- the conditions about which they have just read. During
tions.This allows the reader of Emergency Radiology: THE subsequent rotations, a rereading imprints the knowledge
REQUISITES to go immediately to the material of interest. they will need subsequently for upcoming certification
As a side note, only two or so decades ago, nontrauma emer- exams. For the practicing radiologist, it serves as a useful
gency patients were not imaged nearly as often as they are refresher, like a booster shot.At the workstation, the books
today.Today, emergency applications for the nontrauma pa- in THE REQUISITES series are useful as a first reference
tient are just as important as the historic role of imaging source and guide to differential diagnosis.
in trauma. Imaging is truly the “guiding hand” of medical THE REQUISITES books are not intended to be exhaus-
practice, making possible rapid diagnosis, triage, and dispo- tive. There are other large reference books to catalog rare
sition, which are vitally important given the time and re- and unusual cases and to present different sides of con-
source constraints faced by busy emergency departments. troversies. Rather, THE REQUISITES books are intended
In the years between the preparation of the first edition to provide information on the vast majority of conditions
and the current work, much has happened to enhance that radiologists see every day, the ones that are at the core
the role of radiology in the emergency department and of radiology practice. In fact, one of the requests to authors
to reshape our thinking. These changes affect every area is to not look up anything they do not know but to put
of application and include, among many others, optimiza- in the book what they teach their own residents at the
tion of computed tomographic (CT ) protocols in every workstation. Since the authors are experienced experts in
organ system for lower radiation exposure, taking advan- their respective areas, this is predictably the most impor-
tage of fast CT scanning capabilities to reduce contrast us- tant material.
age and an increasing appreciation for the potential roles Drs. Soto and Lucey and their coauthors have again
of MRI for both traumatic and nontraumatic indications. done an outstanding job in sustaining the philosophy
Conventional radiography continues to play an important and excellence of THE REQUISITES series and deserve
role, especially for extremity trauma and some thoracic congratulations. Their book reflects the contemporary
imaging applications such as pneumonia and congestive practice of emergency imaging and should serve radiolo-
heart failure. However, for most applications, radiography gists, emergency medicine specialists, and other physi-
is being inexorably replaced by cross-sectional imaging. cians who deal with emergencies as a concise and useful
Drs. Soto and Lucey have again assembled an outstand- foundation for understanding the indications for imaging
ing team of coauthors to help ensure that Emergency and the significance of imaging findings in the emergency
Radiology: THE REQUISITES is as up to date as possible. setting.
Thanks to all the authors for their contributions.
Each chapter presents a different challenge in present- James H. Thrall, MD
ing material. All share a rich opportunity for illustrations, Chairman Emeritus
and Emergency Radiology: THE REQUISITES is extremely Department of Radiology
well illustrated. Otherwise the use of outline lists, boxes, Massachusetts General Hospital
and tables has been dictated by the material requiring Distinguished Taveras Professor of Radiology
presentation. Harvard Medical School

ix
This page intentionally left blank

     
Preface
Emergency Radiology is a unique title in THE REQUI- including CT angiography in the emergency department
SITES series. Although both the organ system–based and for coronary, aorta, brain/neck, visceral, and extremity ar-
modality-based divisions of radiology have existed for
­ teries, updated CT protocols in trauma and nontraumatic
some time, this REQUISITES title is the first to embrace a emergencies, and new and better quality images obtained
multimodality, multisystem approach to radiology. There with the latest imaging technology. Stepping away from
is an ongoing paradigm shift in medical management over the organ- and modality-based divisions, we acknowledge
the past 25 years or so, away from inpatient-oriented health that there is potential for overlap among this text and
care toward an increasingly outpatient-based system. No- others in THE REQUISITES series. However, to avoid this,
where is this more apparent than in emergency depart- we have endeavored to confine the text to medical and
ments across the United States and around the world. The surgical conditions that commonly present through the
reliance on imaging for diagnosis and guiding management emergency department rather than including every imag-
decisions throughout medicine has been increasing, and ing possibility that may present. We apologize in advance
this is exemplified in the emergency setting. All imaging if any overlap is identified—it was included for complete-
modalities are available to the emergency physician. More ness—or for any deficiencies; some rare entities may have
than in any other modality, the massive increase in the use been omitted for the sake of brevity.The fundamental divi-
of computed tomograpy (CT ) has led to the development sion of the book is in two parts, one dealing with acute
and growth of the specialty of emergency radiology. The trauma and the other with nontraumatic acute processes,
value of CT in the setting of trauma, investigation of severe and the division of the chapters reflects this. This makes it
headache, abdominal pain, and the evaluation of patients possible to easily select those chapters relevant to an in-
with suspected pulmonary embolus forms the bedrock of dividual radiology practice. Some departments, especially
emergency imaging, although there is an increasing role large academic departments with residency programs, will
for MR and ultrasound imaging in the emergency setting, have trauma units, whereas some community practices
particularly for the rapid evaluation of musculoskeletal in- may run an emergency department without dealing with
jury and emergent neurologic evaluation. The book is an acute trauma.
attempt to collate all the radiology information required We are pleased with how this revision has developed
in today’s emergency department setting into one suc- from an abstract concept into reality and built upon the
cinct, practical, and current text that can be used by both first edition. It has taken substantial effort, and we fully ap-
residents in training and general radiologists in practice, preciate the contributions from the authors, all of whom
as well as emergency department physicians and trauma have considerable experience in emergency imaging. We
surgeons. hope that the revision will be as well received as the first
The goal of this revision is to provide updates to address edition and will act as an integral resource for all radiology
the rapid changes in emergency imaging requirements, departments and training programs.

xi
This page intentionally left blank

     
Acknowledgments
We would like to thank many people who helped trans- are experienced radiologists with extensive knowledge
form the concept of this book into a reality. First, we owe in the various aspects of emergency radiology. Each au-
thanks to innumerable individuals (staff, residents, fel- thor has added his or her own subspecialty e­xpertise
lows, technologists, and nurses) at the Boston University to the chapters, which has resulted in the final product,
Medical Center who helped us and our colleagues build a textbook that we believe they should all be proud of.
multidisciplinary groups for the care of the acutely ill Finally, thanks to all the staff at Elsevier, especially Amy
patient. This was the principal driving force behind our Meros and Robin Carter, who waited patiently for us to
growing interest in the field of emergency ­radiology. We deliver the various parts of the book, sometimes at a
would also like to thank Dr. James Thrall for insisting on slower-than-hoped-for pace.
the timeliness and necessity of this text to add to THE J.A.S.
REQUISITES series. We would also like to extend a sin- B.C.L.
cere thank you to the contributing authors, all of whom

xiii
This page intentionally left blank

     
Contents
Chapter 1 Chapter 8
Traumatic and Nontraumatic Emergencies of the Nontraumatic Emergency Radiology of the
Brain, Head, and Neck 1 Thorax 243
Glenn D. Barest, Asim Z. Mian, Rohini N. Nadgir, and Osamu Sakai Alejandra Duran-Mendicuti, Scott White, Salvatore G. Viscomi,
Michael Stella, and Aaron D. Sodickson
Chapter 2
Chest Trauma 61 Chapter 9
Ryan T. Whitesell and Laura L. Avery Nontrauma Abdomen 281
Stephan W. Anderson, Brian C. Lucey, and Jorge A. Soto
Chapter 3
Abdomen Trauma 81 Chapter 10
Joshua W. Stuhlfaut, Christina A. LeBedis, and Jorge A. Soto Pelvic Emergencies 316
Brian C. Lucey
Chapter 4
Extremity Trauma 115 Chapter 11
Rathachai Kaewlai and Ajay Singh Vascular Emergencies 327
Russ Kuker, Carlos A. Anaya, Ana Maria Gomez, and Felipe Munera
Chapter 5
Extremities: Nontrauma 165 Chapter 12
Luis E. Diaz Emergency Nuclear Radiology 369
Anna K. Chacko and Rashmikant B. Shah
Chapter 6
Imaging Evaluation of Common Pediatric Index 395
Emergencies 186
Jennifer C. Talmadge, Sarah S. Milla, and Sarah D. Bixby

Chapter 7
Traumatic and Nontraumatic Spine
Emergencies 221
Glenn D. Barest and Margaret N. Chapman

xv
This page intentionally left blank

     
THE REQUISITES

Emergency
Radiology
This page intentionally left blank
     
Chapter 1
Traumatic and Nontraumatic
Emergencies of the Brain,
Head, and Neck
Glenn D. Barest, Asim Z. Mian, Rohini N. Nadgir, and Osamu Sakai

Imagine you are asked to create a list of the disorders of to study the other volumes in the Requisites series (es-
the brain, head, and neck that one might commonly expect pecially Neuroradiology, Musculoskeletal Imaging, and
to encounter at an emergency department (ED) and de- Pediatric Radiology), which cover this material in great
scribe the typical imaging features. At first, this challenge detail. In this attempt at condensing so much material
seems straightforward enough. However, upon beginning into one useful volume, important topics inevitably have
the task, it soon becomes clear that almost every disorder been neglected. We hope that this volume can serve as
within the realm of neuroradiology/head and neck radi- a starting point for further study and become a valuable
ology might at one time or another present as an acute reference to on-call radiologists, emergency department
emergency. Inclusion of certain diagnoses such as stroke, physicians, and residents of both specialties.
fractures, and epiglottitis is a must. Other diagnoses, such
as oligodendroglioma or perhaps a slowly growing le- INTRACRANIAL HEMORRHAGE AND
sion, might seem less clear-cut. Ultimately, it is important TRAUMATIC BRAIN INJURY
to realize that a wide variety of processes will result in
an alteration in mental status leading to an ED visit, with Whether in the setting of head trauma, spontaneous de-
imaging playing a key role in diagnosis and appropriate velopment of headache, or alteration of mental status, the
management. ability to diagnose intracranial hemorrhage (ICH) is of
Upon admission, inpatient workups now occur on a primary importance for all practitioners. These presenta-
24/7 basis, with many complex examinations completed tions are some of the most common indications for brain
during the night shift. On-call radiologists (often residents imaging in the emergency setting. Almost invariably, the
or fellows) are expected to provide “wet readings” or requisition will read, “Rule out bleed.” An understanding
complete interpretations for complex cases covering the of traumatic and nontraumatic causes of ICH, the usual
full spectrum of medicine, pediatrics, surgery, and related workup, and recognition of ICH is therefore important
subspecialties. It was not that many years ago that the ra- and seems like a natural starting point. A discussion of the
diologist was faced with a seemingly never-ending stack important types of mass effect resulting from ICH and
of plain films from the ED, inpatient wards, and intensive traumatic brain injury is also included in this section. An
care units requiring rapid interpretations. This work was understanding of hemorrhage and herniation syndromes
interrupted by an occasional computed tomography (CT) is central to the discussion of other topics that follow, such
scan. In this new millennium, during a typical shift the radi- as stroke and neoplasms.
ologist must maintain a rapid pace to review thousands of The word hemorrhage has Greek origins: the prefix
cross-sectional CT and magnetic resonance images (MRI) haima-, meaning “blood,” and the suffix -rrhage, meaning
with two-dimensional (2D) and three-dimensional (3D) re- “to gush or burst forth.” Incidence of ICH is approximate-
formats. For this reason, the majority of the discussion and ly 25 to 30 per 100,000 adults in the United States, with a
most of the examples in this chapter are based on these higher incidence in elderly hypertensive patients. ICH is
modalities and the latest techniques. typically more common in the African American and Asian
The most daunting part of preparing this chapter was populations. Bleeding may take place within the substance
to boil down all of the disorders and details to a set of req- of the brain (intraaxial) or along the surface of the brain
uisites. Division of this chapter into sections is not quite (extraaxial). Intraaxial hemorrhage implies parenchymal
as neat as one might think. For example, it is not possible hemorrhage located in the cerebrum, cerebellum, or brain-
to separate the vascular system from discussion of the stem. Extraaxial hemorrhages include epidural, subdural,
brain, head and neck, or spine, and the imaging methods and subarachnoid hemorrhages, and intraventricular hem-
applied to the extracranial vessels in the setting of stroke orrhage can be considered in this group as well. Hem-
are similar to those used for blunt or penetrating trauma orrhages can lead to different types of brain herniation,
to the neck. One may therefore notice mention of similar from direct mass effect and associated edema or develop-
techniques and findings in several places with examples ment of hydrocephalus, causing significant morbidity and
appropriate to the context. All readers would do well mortality.
1
2 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck

TABLE 1-1 Usual Magnetic Resonance Signal Characteristics of Hemorrhage

Stage Time Component T1 T2

Hyperacute (0-12 h) Oxyhemoglobin Isointense Hyperintense

Acute (12 h-3 days) Deoxyhemoglobin Isointense Hypointense
Early subacute (3-7 days) Methemoglobin Hyperintense Hypointense
(intracellular)
Late subacute (1 wk-1 mo) Methemoglobin Hyperintense Hyperintense
(extracellular)
Chronic (>1 mo) Hemosiderin Hypointense Hypointense

General Imaging Characteristics of the injury. Although it is beyond the scope of this
of Hemorrhage chapter, a description of the physics of the signal char-
acteristics of blood products on MRI is generally based
The appearance of ICH on a CT scan can vary depending on the paramagnetic effects of iron and the diamagnetic
on the age of the hemorrhage and the hemoglobin level. effects of protein in the hemoglobin molecule. The usual
The attenuation of blood is typically based on the protein signal characteristics of hemorrhage and the general time
content, of which hemoglobin contributes a major por- course over which hemorrhages evolve are summarized
tion. Therefore the appearance of hyperacute/acute blood in Table 1-1.
is easily detected on a CT scan in patients with normal
hemoglobin levels (approximately 15 g/dL) and typically EXTRAAXIAL HEMORRHAGE
appears as a hyperattenuating mass. This appearance is
typical because, immediately after extravasation, clot for- Extraaxial hemorrhage occurs within the cranial vault but
mation occurs with a progressive increase in attenuation outside of brain tissue. Hemorrhage can collect in the epi-
over 72 hours as a result of increased hemoglobin concen- dural, subdural, or subarachnoid spaces and may be trau-
tration and separation of low-density serum. On the other matic or spontaneous. It is important to recognize these
hand, in anemic patients with a hemoglobin level less than entities because of their potential for significant morbidity
10 g/dL, acute hemorrhage can appear isoattenuating to and mortality. Poor clinical outcomes are usually the result
the brain and can make detection difficult. Subsequently, of mass effect from the hemorrhage, which can lead to
after breakdown and hemolysis, the attenuation of the clot herniation, increased intracranial pressure, and ischemia.
decreases until it becomes nearly isoattenuating to cere- Intraventricular hemorrhage will be considered with these
brospinal fluid (CSF) by approximately 2 months. In the other types of extracerebral hemorrhage.
emergency setting, one should be aware of the “swirl” sign
with an unretracted clot that appears to be hypoattenuat-
Epidural Hemorrhage
ing and resembles a whirlpool; this sign may indicate ac-
tive bleeding and typically occurs in a posttraumatic set- Epidural hematoma is the term generally applied to a
ting. It is important to recognize this sign, because prompt hemorrhage that forms between the inner table of the cal-
surgical evacuation may be required. The amount of mass varium and the outer layer of the dura because of its mass-
effect on nearby tissues will depend on the size and loca- like behavior. More than 90% of epidural hematomas are
tion of the hemorrhage, as well as the amount of second- associated with fractures in the temporoparietal, frontal,
ary vasogenic edema that develops. and parieto-occipital regions. CT is usually the most effi-
Use of an intravenous contrast agent usually is not nec- cient method for evaluation of this type of hemorrhage.An
essary for CT detection of ICH. If a contrast agent is used, epidural hematoma typically has a hyperdense, biconvex
an intraaxial hemorrhage can demonstrate an enhancing appearance. It may cross the midline but generally does
ring that is usually due to reactive changes and formation not cross sutures (because the dura has its attachment at
of a vascularized capsule, which typically occurs 5 to 7 the sutures), although this might not hold true if a fracture
days after the event and can last up to 6 months. Subacute disrupts the suture. Epidural hematomas usually have an
and chronic extraaxial hematomas also can demonstrate arterial source, commonly a tear of the middle meningeal
peripheral enhancement, usually because of reactive artery, and much less commonly (in less than 10% of cases)
changes and formation of granulation tissue. Unexpected a tear of the middle meningeal vein, diploic vein, or ve-
areas of enhancement should raise concern, because ac- nous sinus (Figs. 1-1 and 1-2). The classic clinical presenta-
tive bleeding can appear as contrast pooling. Refer to the tion describes a patient with a “lucid” interval, although
section on aneurysms and vascular malformations in this the incidence of this finding varies from 5% to 50% in the
chapter for a discussion of CT angiography in the setting literature. Prompt identification of an epidural hematoma
of acute ICH. is critical, because evacuation or early reevaluation may
MRI has greatly revolutionized the evaluation of ICH. be required. Management is based on clinical status, and
The evolution of hemorrhage from the hyperacute to therefore alert and oriented patients with small hemato-
the chronic stage will have corresponding signal chang- mas may be safely observed. The timing of follow-up CT
es on T1-weighted images (T1WIs), T2-weighted images depends on the patient’s condition, but generally the first
(T2WIs), fluid-attenuated inversion recovery (FLAIR) im- follow-up CT scan may be obtained after 6 to 8 hours and,
ages, and gradient-echo sequences. These properties can if the patient is stable, follow-up may be extended to 24
assist in detection and understanding of the time course hours or more afterward.
 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck 3

A B

C
FIGURE 1-1 An epidural hematoma. A, Computed tomography (CT) shows a usual biconvex, hyperdense acute
epidural hematoma causing effacement of sulci and lateral ventricles and shift of midline structures. B, A CT
volume-rendered image shows a nondisplaced fracture at the vertex involving the coronal suture. C, Coronal
multiplanar reconstruction shows a biconvex epidural hematoma crossing midline over the superior sagittal sinus
(arrows).

Subdural Collections
hyperattenuating, crescentic appearance overlying the ce-
Subdural hematoma (SDH) is the term generally applied rebral hemisphere (Fig. 1-3).These hemorrhages can cross
to a hemorrhage that collects in the potential space sutures and may track along the falx and tentorium but do
between the inner layer of the dura and the arachnoid not cross the midline. Inward displacement of the cortical
membrane. It is typically the result of trauma (e.g., mo- vessels may be noted on a contrast-enhanced scan. SDHs
tor vehicle collisions [MVCs], assaults, and falls, with the have a high association with subarachnoid hemorrhage.
latter especially occurring in the elderly population). Acute SDHs thicker than 2 cm that occur with other pa-
An SDH causes a tear of the bridging vein(s) and has a renchymal injuries are associated with greater than 50%
4 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck

mortality. As the SDH evolves to the subacute stage (with- isoattenuating SDHs can be especially challenging be-
in 5 days to 3 weeks) and then to the chronic stage (after cause findings are symmetric. One should beware of bilat-
more than 3 weeks), it decreases in attenuation, becoming eral isoattenuating SDHs, particularly in elderly patients
isodense to the brain and finally to CSF. A subacute SDH who do not have generous sulci and ventricles. At this
can have a layered appearance as a result of separation stage, the SDH should be conspicuous on MRI, especially
of formed elements from serum. Subacute hemorrhages on FLAIR sequences. A subacute SDH also may be very
may be relatively inconspicuous when they are isodense, conspicuous on T1WIs because of the hyperintensity of
and therefore it is especially important to recognize signs methemoglobin.
of mass effect, such as sulcal effacement, asymmetry of Chronic subdural hematomas are collections that have
lateral ventricles, and shift of midline structures, as well been present for more than 3 weeks. Even a chronic he-
as sulci that do not extend to the skull (Fig. 1-4). Bilateral matoma may present in the emergency setting, such as

A B

C D
FIGURE 1-2 An epidural hematoma and complications demonstrate on noncontrast CT. A, The “swirl” sign in
this large epidural hematoma suggests continued bleeding. B, A pontine (Duret) hemorrhage (arrow) and efface-
ment of the basal cisterns as a result of downward herniation. C, Uncal herniation (the arrow shows the margin
of the left temporal lobe) and a resultant left posterior cerebral artery territory infarct. The brainstem is distorted
and also abnormally hypodense. D, Infarcts in bilateral anterior cerebral, left middle cerebral, and left posterior
cerebral artery territories as a result of herniations.
 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck 5

in a patient prone to repeated falls who is brought in a contrast agent. Calcification of chronic SDH can occur
because of a change in mental status. On both CT and and may be quite extensive (Fig. 1-5). Areas of hyperden-
MRI, these collections typically have a crescentic shape sity within a larger hypodense SDH may indicate an acute
and may demonstrate enhancing septations and mem- component due to recurrent bleeding, termed an “acute
branes surrounding the collection after administration of on chronic subdural hematoma.” Mixed density collec-
tions also may be acute as a result of active bleeding or
CSF accumulation as a result of tearing of the arachnoid
membrane. A chronic SDH is usually isointense to CSF on
both T1WIs and T2WIs, but the appearance can be vari-
able depending on any recurrent bleeding within the col-
lection.The FLAIR sequence is typically very sensitive for
detection of chronic SDH as a result of hyperintensity
based on protein content. Hemosiderin within the hema-
toma will cause a signal void because of the susceptibility
effect, and “blooming” (i.e., the hematoma appears to be
larger than its true size) will be noted on a gradient-echo
sequence.
A subdural hygroma is another type of collection that
is commonly thought to be synonymous with a chronic
subdural hematoma. The actual definition of a hygroma
is an accumulation of fluid due to a tear in the arachnoid
membrane, usually by some type of trauma or from rapid
ventricular decompression with associated accumulation
of CSF within the subdural space. Many persons still use
this term interchangeably with chronic subdural hema-
toma. CT demonstrates a fluid collection isodense to CSF
in the subdural space. MRI can be useful in differentiat-
ing CSF from a chronic hematoma based on the imaging
characteristics of the fluid on all sequences. Occasionally
hygromas are difficult to differentiate from the promi-
nence of the extraaxial CSF space associated with cere-
bral atrophy. The position of the cortical veins can be a
FIGURE 1-3 A subdural hematoma with a mixed density layered helpful clue. In the presence of atrophy, the cortical veins
pattern due to recurrent hemorrhages. The image (arrow) shows are visible traversing the subarachnoid space, whereas
one method of measuring midline shift.

A B
FIGURE 1-4 An isodense subdural hematoma. A, Sulcal effacement and a midline shift to the right are clues to
the presence of a left-sided subdural hematoma. B, Reexpansion of the left Sylvian fissure and a reduction in
midline shift after evacuation.
6 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck

A B
FIGURE 1-5 Calcified subdural hematomas. A, Colpocephaly configuration of the lateral ventricles. B, Bone
window/level settings more clearly show the calcified subdurals in this adult patient who, as a child, had a shunt
implanted because of congenital hydrocephalus.

with a hygroma, they are displaced inward along with the be confounded by artifacts from CSF pulsations, an el-
arachnoid membrane by the fluid in the subdural space. evated level of protein (meningitis), or oxygen concen-
tration (i.e., a high fraction of inspired oxygen) in CSF
Subarachnoid Hemorrhage on FLAIR images and the presence of blood products
from previous microhemorrhages on gradient-echo
Subarachnoid hemorrhage (SAH) fills the space between images.
the pia and the arachnoid membrane, outlining the sulci
and basilar cisterns. SAH can be due to a variety of causes, Intraventricular Hemorrhage
including trauma, a ruptured aneurysm, hypertension, ar-
teriovenous malformation, occult spinal vascular malfor- In the adult population, intraventricular hemorrhage
mation, and hemorrhagic transformation of an ischemic (IVH) is typically caused by trauma. It can result from ex-
infarction. SAH is often associated with overlying traumat- tension of a parenchymal hemorrhage into the ventricles
ic SDH. SAHs generally do not cause mass effect or focal or from redistribution of SAH. Primary IVH is uncommon
regions of edema. However, in patients presenting with and is usually caused by a ruptured aneurysm, an intra-
ominous signs on clinical grading scales, such as stupor or ventricular tumor, vascular malformation, or coagulopa-
coma, diffuse cerebral edema may be evident. On CT, hy- thy (Fig. 1-8). Large IVHs are quite conspicuous on CT or
perdensity is seen within the sulci and/or basilar cisterns MRI. They may occupy a majority of the ventricle(s) and
(Figs. 1-6 and 1-7). may result in hydrocephalus and increased intracranial
Although MRI may be as sensitive as CT for the de- pressure. Small amounts of IVH may be difficult to de-
tection of acute parenchymal hemorrhage and SAH, CT tect; one must check carefully for dependent densities
generally remains the modality of choice (and the im- within the atria and occipital horns of the lateral ventri-
aging gold standard). The sensitivity of CT for the de- cles. Normal choroid plexus calcifications in the atria of
tection of SAH compared with CSF analysis can vary lateral ventricles, in the fourth ventricle, and extending
from up to 98% to 100% within 12 hours to approxi- through the foramina of Luschka should not be mistaken
mately 85% to 90% after 24 hours of symptom onset. for acute IVH.
Other factors affecting sensitivity are the hemoglobin Another less common type of extracerebral ICH that
concentration and the size and location of the hemor- may present acutely is a pituitary hemorrhage, which is
rhage. CT is widely available, can be performed rapidly, usually associated with pituitary apoplexy due to pituitary
and is relatively inexpensive. In several small studies, necrosis that may become hemorrhagic. Presenting symp-
MRI has demonstrated sensitivity equivalent to CT for toms may include headache, visual loss, ophthalmoplegia,
detection of acute parenchymal hemorrhage and SAH. nausea, and vomiting. Other causes of pituitary hemor-
In some cases of “CT-negative” (subacute) hemorrhage, rhage include tumors (e.g., macroadenoma and germino-
MRI has shown greater sensitivity. However, results may ma) and, less commonly, trauma.
 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck 7

A B

C
FIGURE 1-6 Subarachnoid hemorrhage from a ruptured aneurysm. A, Noncontrast computed tomography (CT)
shows ill-defined hyperdense subarachnoid hemorrhage in the left Sylvian cistern (black arrow) and rim calcifica-
tion in the wall of the aneurysm (white arrow). B, A volume-rendered image from CT angiography shows a large
aneurysm (arrow) projecting above the lesser sphenoid wing. C, Reconstruction from a three-dimensional rota-
tional digital subtraction angiogram shows the carotid-ophthalmic aneurysm to the best advantage.

INTRAAXIAL HEMORRHAGE Contusion

The cause of intraaxial (parenchymal) hemorrhages can Parenchymal contusions result from blunt trauma and can
generally be categorized as spontaneous or traumatic.Trau- occur in the cortex or white matter. Their locations are
matic causes include blunt injury from MVCs, assault, and typically at the site of greatest impact of brain on bone,
penetrating injuries such as gunshot wounds. Intraaxial including the anterior/inferior frontal lobes and the tem-
hemorrhages have many spontaneous causes, which are poral lobes. They can be considered coup (occurring at
discussed in the section on hemorrhagic stroke. the site of impact) or contrecoup (opposite the site of
8 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck

B
FIGURE 1-7 Subarachnoid hemorrhage and complications. A, Three computed tomography (CT) images show
diffuse hyperdense subarachnoid hemorrhage filling basal cisterns and cerebral sulci bilaterally. Diffuse loss of
gray–white differentiation and effacement of the sulci and cisterns probably preclude the need for further work-
up. B, A volume-rendered image from CT angiography demonstrates lack of enhancement of intracranial vessels
suggesting poor intracranial flow consistent with the expected elevation of intracranial pressure.

impact) types. On CT, a contusion typically appears as an Diffuse Axonal Injury

area of hyperdensity with a surrounding rim of hypodense
edema. A parenchymal contusion can initially appear as a Diffuse axonal injury (DAI) is another type of traumatic
focal area of subtle hypodensity and may blossom on fol- brain injury that may present with parenchymal hemor-
low-up examination at 12 to 24 hours with development rhages and is distinct from a parenchymal contusion. DAI
of an obvious central area of hyperdensity and a larger sur- is an injury to the axons caused by acceleration/decelera-
rounding zone of hypodense edema (Fig. 1-9). On MRI, sig- tion injury with a rotational component (usually from an
nal characteristics reflect the hemorrhagic and edematous MVC or other blunt trauma to the head). Complete tran-
components. Over time, the density and signal character- section of axons may occur with injury to the associated
istics of the hemorrhage will evolve in a fashion similar capillaries, or partial disruption of the axons may occur.
to a spontaneous hemorrhage. Parenchymal hemorrhage DAI lesions typically occur at the interfaces of gray and
due to penetrating trauma, such as from a gunshot wound white matter in the cerebral hemispheres, the body and
or impalement, will follow the same general pattern of splenium of the corpus callosum, the midbrain, and the
evolution. upper pons. Lesions also may be seen in the basal ganglia.
 Chapter 1 Traumatic and Nontraumatic Emergencies of the Brain, Head, and Neck 9

A B
FIGURE 1-8 Intraventricular hemorrhage. A, A fluid-attenuated inversion recovery magnetic resonance image
shows a hyperintense hemorrhage isolated to the frontal horn of the right lateral ventricle. B, An image from a
right internal carotid artery digital subtraction angiogram in the late arterial phase shows a nidus (arrow) and an
early draining vein (arrowhead) diagnostic of an arteriovenous malformation.

A B
FIGURE 1-9 Blossoming of a contusion. A, Computed tomography (CT) shows a thin left frontoparietal subdural
hematoma tracking along the anterior falx and mild sulcal effacement. B, A follow-up CT scan after 24 hours
shows a hyperdense parenchymal hemorrhage and surrounding edema in left frontal lobe and a stable subdural
hematoma. Notice the mass effect on the left lateral ventricle.

Patients sustaining DAI typically lose consciousness who recover usually demonstrate lingering effects such
at the moment of impact. DAI may be suspected when as headaches and cognitive deficits. Initial CT scans in
the clinical examination is worse than expected based more than half of patients with DAI may be negative. CT
on the findings of an initial CT scan. Usually, the greater findings include hypodense foci due to edema in areas of
the number of lesions, the worse the prognosis. Persons incomplete axonal disruption and hyperdense foci due
 Another Random Document on
Scribd Without Any Related Topics
 ARCHITECTURE. 253 aquatic struggle, in which some of the
occupants of the canoes were killed and 'the fleet' sunk. Various
discoveries have been made of canoes beneath the waters of lakes,
beside the site of lake-dwellings, or under great accumulations of
peat; and owing to the preservative properties of peaty matter, these
canoes are in a fairly sound state when first dug up ; but they get
out of shape during the process of drying. Upwards of sixty recorded
specimens have been discovered up to the present. Irish single-piece
canoes may be roughly divided into three classes. The first (figs. 54,
55), generally either sharp or rounded at both extremities, average
20 feet in length and about 2 feet in breadth ; some, however, have
been discovered square at both ends ; again, some are flat-
bottomed, and others round. The inside depth varies, according to
their state of preservation. The second kind of canoe (fig. 56) is of
greater length. One found, measuring 40 feet, was round in the
bow, but square in the stern, which was formed of a separate piece
let into a groove within a few inches of the extremity. This make of
boat is more heavy and clumsy than the preceding one. The third
variety of canoe is trough-shaped, and has been very appropriately
designated ' the portable canoe.' Its length is from 8 to 12 feet. It is
square at both ends, round in the bottom, having projections at
either extremity, apparently for the convenience of carrying it. There
is a peculiarity in the construction of some of these canoes, for
which, up to the present, no theory accounts in a satisfactory
manner, i.e. the number of holes which, in many specimens, are
drilled through the sides or bottom of the canoe. In one large
'single-piece'
 254 PAGAN IRELAND I boat (upwards of 42 feet in length)
the total amounted to 48 perforations. This extraordinary number is
unusual, for some have but three, some six, &c. These holes are
drilled with apparent regularity, and their relative positions
emphatically proclaim marks of design. Some are pierced right
through the bottom, generally about 5 inches in thickness. In some
of them plugs of pine were found, evidently inserted from the
interior. Their great number preclude the possibility of their being
drainage-holes. Numbers of wooden canoe-paddles have been
found. Fig. 57 represents one 2 feet 7 inches long by 5+ inches
across the blade. Fig. 58 is supposed to have been emFig- 57-
ployed as an anchor. The shank must WPadIle from & haVe been °f
W0°d> and lashed t0 the Toome Bar. stone. There is yet another
kind of boat, the currach, that was employed by the early
inhabitants. Of it, however, on account of the perishable materials of
which it was composed, no materials have been exhumed. Nothing
can be more simple than the construction of these skiffs. Only two
materials are requisite, and they the most accessible in the country,
willow-rods and hides of animals. When stone, probably Caesar had
boats constructed in Spain, use asananc after the manner learnt by
him in Britain, it is said that ' the keels and ribs were made of light
timber, Fig. 58.
 ARCHITECTURE. 255 the rest of the hull being woven
together with basketwork, and covered with hides.' ' The bending
willow into barks they twine, Then line the work with spoils of
slaughtered kine. On such to neighbouring Gaul, allured by gain, The
bolder Britons cross the swelling main.' Pliny describes these boats
as being in use in the British Channel. Solinus, describing the rough
sea between Britain and Ireland, mentions a similar class of skiffs.
Adamnan (in his Life of St. Columba) refers to a voyage made in a
currach by St. Cormac. The currach, the carabns of classic writers, is
thus described by Isidorus : — ' Carabus, parva scapha ex vimine
facta, quae contexta crudo corio genus navigii praebet.' It is also
mentioned by Festus Avienus. According to a rare pamphlet entitled
A Short Tour of the County of Clare, by John Lloyd, printed in 1780,
the currach seems to have been then still in general use off the
coast. The author styles it, 'an artificial curiosity made use of by
certain Individuals. . . . It's a kind of Canoe or Currach, compos'd of
Wattles, cover'd with Raw Hydes. With this Indian-like construction,
they Fish successfully in the proper Season, and Paddle some
Leagues out in calm weather; In the Month of August there is often
a large Squadron of them together in the Bay of Liscanor, and in this
Fishing Posture they appear like so many Porpoises on the Surface ;
Each Man carries his Wicker Boat, or Canoe, on his Back,
occasionally to and from the Shore' (fig. 59). The currach is still in
use in remote parts of England and on some parts of the coast of
Ireland, in shape and build similar to that of thousands of years ago.
 256 PA GAN IRELAND : There seems to be no foundation,
in fact, for the extravagant accounts of the ancient glories of the
Irish .=*§£ Fig. 50. — Currach, as recently used in Ireland. navy,
which consisted, until the advent of Christianity, of some kind of
large currachs; these were in use in Ire 
 ARCHITECTURE. •lot land at a very early date. One
monarch of ancient Erin was known as Eochaidh Uairceas, in
consequence of his having either invented or developed the
fabrication of small boats. Now Eochaid {anglice Achy) signifies a
horseman, and uairceas, a small skiff, so the expression ' horse
marine,' in its inception, is not a modern Irish bull, but the very
appropriate name of an Irish king who, it is alleged, lived nearly
2500 years ago. The civilization of a nation may, to a certain extent,
be gauged by the architectural outcome of its religion ; up to the
present time no authenticated remains of any temples or religious
edifices of the ancient Irish can be pointed out. A fierce and warlike
race, who raised megalithic monuments to the honour of their
chiefs, appear to have erected these memorials to commemorate
their dead, and the worship of a deity or deities in nowise entered
the imagination of their builders, though, in aftertimes, the dead
became to a certain extent deified. Although the ancient inhabitants,
at this stage of human existence in Erin, were doubtless somewhat
removed from what we would now regard as mere savagery, yet the
architectural remains which they have left do not exhibit traces of
the high culture and civilization claimed for them by many
enthusiastic writers.
 258 PAGAN IRELAND : CHAPTER VII. SEPULCHRES —
PILLAR-STONES — SPEAKING-STONES — HOLED-STONES — STONE
CHAIRS — ROCKING-STONES. ot only from the face of the country,
but also from the memory of its present inhabitants, the memorials
of its dead are rapidly vanishing, and it is apt to be forgotten that,
from the gigantic chambered earn of New Grange to the simplest
cist, the megalithic structures of Ireland are but the graves of a
primitive race. Since these huge weather-beaten blocks were piled
up by primitive man, how often the form of worship has changed.
Time has effaced the race that reared them, together with their
religion, but the monuments remain. The most important of our
megalithic mortuary structures are, by Act of Parliament, protected
from dilapidation and destruction, but unfortunately the protection
afforded is more nominal than real. Any person can now delve
amongst the bones of primitive interments without impediment.
Such should not be permitted, except under proper restrictions and
supervision, for the contents of sepulchres are often of more
importance than the structures themselves, and are more likely to
throw light on the unwritten history of the remote past ; yet, despite
many disadvantages, and much apathy in archaeological
investigation, we have vaguely ascertained the manner in which the
early
 . SEPULCHRES. 259 inhabitants treated their dead. Except
in remote and mountainous localities, the peasantry do not now take
the same interest as formerly in the megalithic structures reared by
their ' rude forefathers ' ; they do not venerate monuments from
which legend and glamour have alike fled, and of which they do not
understand the origin. Fortunately those monuments that still exist
are, as a rule, situated on ground unfitted for cultivation, or they are
of, perhaps, such magnitude as places an effectual barrier against
removal for purposes of agricultural improvement. Climate, the
productions of the country in which they dwell, and the habits of life
thereby engendered, influence strongly the character and acts of a
people ; and although the general instinctive feelings of primitive
man led him to honour the last resting-place of his dead, yet the
memorials thus erected necessarily depended upon the kind of
materials at hand that were available for the purpose ; thus the
geological nature of the surroundings must be taken into
consideration, not merely with regard to megalithic structures, but
also to cashels, some of which, according to the districts in which
they were found, had been constructed with stones of small size,
whilst, in other instances, the stones are of greater magnitude. The
first species of megalithic sepulchral-structure to be considered is
the 'cromleac,' the 'dolmen' of English and French writers, the 'labby'
of the Irishspeaking peasant. In the Abbey of Knockmoy, countv
Galway, there is an Irish inscription belonging to the close of the
fourteenth century, which offers an unquestionable example of the
use of the word leaba (labby), i.e. bed, to designate a sepulchre. It
shows that the natives thoroughly understood the term, when
applied to the rude stone monuments of Ireland, to indicate, s 2
 260 PAGAN IRELAND: not merely sepulchres, but places of
rest. To the mind of the primitive race who reared them, they were,
most probably, as truly the habitations of the spirit of the dead, as
were their dwellings the abode of the living- ; they were the 'beds'
into which all the members of the clan or family were ultimately to
be laid in their long repose. Hence reverence to the dead developed
into worship of the dead, then to their deification ; and upon the
appearance of new creeds, a deterioration in their attributes set in,
and finallv even of their personal appearance. When the two
daughters of King Leoghaire saw St. Patrick with his attendants, they
regarded them as apparitions, Duine sidhe, gods of the earth, or
phantoms, whilst in Colgan's time such spirits had degenerated into
fairies. We, nowadays, bury our dead out of sight and shrink from all
associations connected with death ; but with the ancient Irish there
was such a constant communication with the receptacles of the
dead, that of all the monuments left by the primitive inhabitants
none bring us into such close contact with them as a careful
examination of their last resting-places. The ancient Irish believed
that their dead, though deposited underground, still lived the same
life as on earth. This idea is exemplified in the story of the ' Cave of
Ainged,' preserved in several mss. t.c.d. The plot is as follows : Ailell
and the celebrated Medb, king and queen of Connaught, were
celebrating the feast of Samain — on November night — in their
palace of Croghan. On that night the siJ, or spirits inhabiting the
tombs and other localities, were allowed to emerge from their
retreats and run to and fro upon the earth. To test the valour of his
household the
 SEPULCHRES. 2G1 king offered a suitable reward to any
young warrior who would sally from the banqueting-hall and tie a
coil of twisted twigs upon the leg of a man whom he had caused to
be hanged, and who was then suspended just outside the palace.
The only one who succeeded was a hero named Nera ; but on
completion of the act the hanged man came to life and imposed
numerous commands on his resuscitator, with all of which he had to
comply. When released from his task he saw the palace of Croghan
in flames, and a host of strange men plundering the buildings. He
followed them into the cave of Croghan, and into ' the sid of the
cave.' Here he was immediately taken prisoner, kept at hard work,
and was compelled to marry one of the women of the sid. He finally
managed to escape to upper air, and returned to the king of
Connaught, with such an amount of information regarding the sid
and its contents, that on a succeeding Samai?i or November day
earthly forces broke into the treasure-house of the underground
spiritworld, and carried off great booty and costly treasure. Even the
Greek mind did not rise to the conception that the soul after death
might become a greater spirit power than when on earth, or that it
could exist without a physical body. Their departed lived — like the
characters represented in the Irish legend — the life they had been
accustomed to on earth, and hankered after the fleshpots of the
upper world. When we trench on the commencement of written
records the idea of a spirit or soul comes into existence ; but it
cannot even then be quite divorced from the body. In ' The Pursuit
of Dermod and Grania,' Aengus, the magician, arrived on the scene
after the hero's death, and he carried the corpse from the heights of
Benbulbin
 262 PA GAN IRELAND : to ' the Brngh on the Boyne,'
explaining his action by stating that although he could not restore
him to life, he would ' send a soul into him, so that he may talk to
me each day.' This strange passage is also elucidatory of the
constant communication supposed to be carried on between the
abodes of the living and of the dead. In pagan sepulchres the
cromleac occupies a leading position for its grandeur and simplicity.
The theory of progressive development naturally suggests that the
more simple the construction, the more remote is its age, and the
best authorities who have studied the megalithic structures of
Ireland are of opinion that they are not all of one period, although
they may be the work of one race. If the remains deposited under
cromleacs are similar to those found under the other rude-stone
monuments, and if we can trace these characteristic forms of
sepulchral monuments back to the East, it is likely that the race who
reared them came also from the East; for modern research traces
such an early and megalithic building people from the far East — a
people who once spread themselves over the greater part of Europe,
Asia, and the north coast of Africa. Between the lowly cist,
composed of four or more flags with a covering-stone, and a
gigantic chambered earn, there is seemingly a great difference; but
that the latter is a development of the former, through such
connectins; links as varieties of cromleac-like monuments afford,
there can be but little question. The cromleac consists of a large
mass of rock, poised on three or more upright blocks, all of unhewn
stone, forming a rude chamber, usually open at one end, and
sometimes divided internally by an upright slab ; the whole bearing
evidence of having been constructed on
 SEPULCHRES. 263 the surface of the ground, and of having
been always sub-aerial, i.e. never covered by a mound of earth or
stones. The covering-slab, or massive rock, is generally in an inclined
position ; but this, it is thought, may be occasioned by the sinking of
the uprights on which they are poised, for it is unlikely that, without
carefully prepared foundations, all the supporting pillars would sink
in an equal degree, under the superincumbent weight. ' This general
disposition of the " table," ' remarks W. F. Wakeman, ' has been
largely seized by advocates of the " Druid's Altar" theory as a proof
of the soundness of their opinion that these monuments were
erected for the purpose of human sacrifice. Some enthusiastic
dreamers have gone so far as to discover — in the hollows worn by
the rains and storms of centuries on the upper surface of these
venerable stones — channels artificially excavated, for the purpose
of facilitating the passage of a victim's blood earthwards ! '*
Cromleacs are, when undisturbed, almost invariably surrounded by a
circle of large stones. The circle is often double; the inner one is
formed of smaller stones placed edge to edge, and these being in
many instances very diminutive in size, they generally escape
observation on a cursory examination, as the gradual increase in
height of the surface-soil has either covered them completely, or
they now protrude, at intervals, only slightly above the present level.
In rare instances there occurs a third circle within the second.
Whatever form, however, the enclosure around cromleacs or other
megalithic structures may assume, it is certain that it formed the
external mark or barrier, by which the place of interment was
distinguished and cut off from * ArchcEologia Hibernica, p. 5;
 264 PA GAN IRELAND : the surrounding area, as regarded
trespass of man or beast. Keats thus happily compares his ' bruised '
Titans to a ruined stone circle : — ' . . . . one here and there Lay
vast and edgeways like a dismal cirque Of Druid stones upon a
forlorn moor.' The finest stone circle in Ireland may be seen at
Wattle Bridge, near Newtownbutler ; some of the boulders
composing it are over sixteen feet in length. Many Irish prehistoric
remains are, in extent and rude grandeur of construction,
unmatched by the same class of monuments in Great Britain.*
Cromleacs are sometimes styled ' Giants' Graves' by the peasantry,
who probably made the very pardonable mistake of confusing great
men with big men ; perhaps the size of some of the monuments first
gave rise to the idea that giants were buried in them. It is not,
however, always the greatest men — either mentally or physically—
that have the largest monuments erected over them, and if some of
these hitherto undisturbed tombs were scientifically examined, it
might be discovered that their occupants belonged to a primitive and
undersized race. Some antiquaries hold that all our cromleacs, great
and small, had been originally covered either by a earn of stones or
by a mound of earth. That such was not the case, with very many
examples, can be abundantly proved, particularly with regard to
those monuments still existing in remote localities, and as yet '
untouched by Time's rude hand ' or that of the modern agricultural
vandal ; also those situated on the summits * Journal R.H.A.A. I.,
vol. v., 4th series, p. 538 : W. F. Wakeman.
 SEPULCHRES. 265 of mountains, or in localities so
abounding in stone, that no temptation was presented to the spoiler.
Chambers, or cists covered with flat stones, have been found under
a mound of earth or of stones, but universal tradition and the
present appearance of cromleacs assure us that they were ever in
the same sub-aerial state. On this subject G. H. Kinahan remarks
that ' in the barony of Burren, county Clare, there are, in different
places, cromleac-like structures ; these could never have been
enclosed in either stone or earthen mounds, as they are erected on
the bare limestone crags.' Cromleacs, as a rule, occupy situations
similar to those in which tumuli occur ; yet, notwithstanding this,
cromleacs invariably stand alone, i. e. are sub-aerial — uncovered
save by the table-stone — in contradistinction to the cists which are
frequently covered. It cannot be supposed that, had the cromleacs
been denuded by human agency, no vestige of an original covering
of stones or clay would remain ; or, admitting the complete and
unaccountable removal of the superincumbent layer or layers, why
then should this part, containing the largest, best, and most useful
stones for building purposes, remain perfect, with its interment
sometimes untouched ? It is evident that, as a rule, cromleacs were
erected without much attempt at nice adjustment of the side-stones,
or supports ; whilst on the other hand, traces of care and trouble are
observable in the construction of most of the covered cists. The top-
stone of the cromleac of Mount Brown, near Carlow, is computed to
weigh no tons. The table or covering-stone of a fine cromleac at
Howth measures 18 by 20 feet in length, its thickness being upwards
of 8 feet ; the block has been computed
 266 PAGAN IRELAND : to weigh about 90 tons. Many fine
examples of this class of megalithic monument are in close proximity
to Dublin, and will, to an antiquary, well repay the trouble of a visit.
The finest monument of the Moytirra series of rude stone
monuments in the county Sligo presents a good example of a large
cromleac (fig. 60). The country people commonly call it ' The Labby,'
the Irishspeaking natives Leaba Dhiarmada agus GrainnL The
covering-stone, oblong in shape, is of immense size; it averages 15
feet 6 inches on two sides, 8 feet 6 inches at the extremities (fig.
61), and the same in depth. There are apparently six supports to
this stone, but the weight rests really on only four ; it is composed
of limestone, and taking its usual weight per cubic foot, the mass
must weigh close upon 75 tons. Fig. 62 gives a good idea of the
Ballymascallan cromleac, near Dundalk, locally known as the ' Puleek
Stone.' The cap-stone, a basaltic erratic, computed to weigh 46 tons,
rests on three slender supports, the entire structure having a total
height of 12 feet. The small stones on top of the table-stone are said
to be there thrown by the credulous, who believe that, if one rests
there, the thrower will be married before the expiration of a year.
Fig. 63 is a view of Legananny cromleac, situated on the slope of
Legananny mountain, about nine miles from Castlewellan, county
Down. It is 10 feet in height, the cap-stone being 1 1 feet 4 inches
by 5 feet, and about 2 feet thick. In the townland of
Tawnnatruffaun, parish of Kilmacshalgan, county Sligo, may be seen
a fine example of a cromleac (lig. 64). Unfortunately the support at
its north-west termination has fallen inwards, thus
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 SEPULCHRES. 267 diminishing the average height above
ground of the level of the under surface of the covering-slab, which
had been originally in all probability upwards of 6 feet. The table-
stone measures 1 1 feet 6 inches by about 9 feet, but only averages
a little over 2 feet in thickness. Of the entire series of cromleacs at
Carrowmore, near the town of Sligo, that represented by fig. 65 is
the finest and best preserved. Indeed it, and its surFig. 64.—
Tavvnatruffaun Cromleac, county Sligo. About 7 feet in height.
rounding circle (fig. 66), may be considered perfect ; whilst its
situation on the ridge of a hill gives it an imposing and picturesque
effect ; its porch-like entrance is very remarkable. The cromleac,
though the largest of the group, is but 7 feet in extreme height. Dr.
Petrie, who examined most of these sepulchres, left no record of a
search having been made in it, yet it had evidently undergone a
thorough clearing out. The soil, however, was well re-siftedj and the
corners and crevices carefully examined. The
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