16 AJR:194, January 2010

rocognitive outcome, validated the assump-

tion that MRI is superior for lesion detection
[3]. CT and MRI were used to evaluate 36
patients with isolated relatively mild head
injury and a Glasgow Coma Scale (GCS)
score of 1315 [3]. All patients had loss of
consciousness for fewer than 30 minutes and
had posttraumatic amnesia. Not surprisingly,
MRI was substantially more sensitive than
CT for detection of parenchymal lesions,
which were detected in 50% of patients on
CT and 75% of patients on MRI. The rate
of detection of nonhemorrhagic diffuse ax-
onal injury (DAI) was 0% by CT and 11% by
MRI. Similarly, the rate of hemorrhagic DAI
detection was 22% by CT and 47% by MRI
and that for detection of contusion was 36%
by CT and 57% by MRI.
Diffusion-Weighted Imaging and
Diffusion Tensor Imaging
The use of diffusion-weighted imaging
(DWI) and diffusion tensor imaging (DTI)
in assessment of patients with traumatic brain
injury is widely gaining acceptance. DWI can
detect changes in the rate of microscopic wa-
ter motion, which is measured by the appar-
ent diffusion coefcient (ADC). On the other
hand, DTI is based on the fact that microscop-
ic water diffusion in white matter tracts tends
to occur in one direction rather than random-
ly, a phenomenon termed anisotropy. The
degree of aniso tropy in a white matter region
can be viewed as a reection of the degree
of the structural integrity of white matter. A
number of different measures of anisotropy
Imaging of Traumatic Brain Injury:
A Review of the Recent Medical
Literature
James M. Provenzale
1,2
Provenzale JM
1
Department of Radiology, Duke University Medical
Center, Box 3808, Durham, NC 27710. Address
correspondence to J. M. Provenzale.
2
Departments of Radiology, Oncology, and Biomedical
Engineering, Emory University School of Medicine,
Atlanta, GA.
Neuroradi ol ogy/ Head and Neck I magi ng Revi ew
AJR 2010; 194:1619
0361803X/10/194116
American Roentgen Ray Society
I
n recent years, many researchers
have emphasized the role of vari-
ous forms of brain injury in pro-
ducing neurocognitive decits
and neurobehavioral abnormalities. As a re-
sult, increased attention has turned to imaging
evaluation of the head trauma patient. This re-
view will examine some of the more impor-
tant articles on the topic of imaging of head
trauma in recent years. Specically, articles
published in the past 5 years (20052009) that
contain information of interest to the radiolo-
gist interpreting CT and MR ndings of head
trauma patients will be discussed. Space limi-
tations allow review of only a small number of
articles. Clearly, a number of excellent articles
containing important information have not
been included in this review.
Comparison of CT and MRI for
Lesion Detection
CT is standardly the rst imaging test per-
formed in the emergency department setting
for evaluation of head trauma. The goal of
emergency imaging is to depict lesions that
need emergent neurosurgical treatment or
in other ways alter therapy. In many institu-
tions, MRI is reserved for showing lesions
that could explain clinical symptoms and
signs that are not explained by prior CT or to
help better dene abnormalities seen on CT.
The increased sensitivity of MRI relative to
CT for detection of many forms of brain in-
jury has been well-documented [1, 2]. A re-
cent study, which was primarily designed to
compare CT and MRI for prediction of neu-
Keywords: brain, diffuse axonal injury, diffusion tensor
imaging, diffusion-weighted imaging, MRI, susceptibility,
trauma
DOI:10.2214/AJR.09.3687
Received September 27, 2009; accepted without revision
September 29, 2009.
F
O
C
U
S

O
N
:
OBJECTIVE. This article provides a summary of some of the important articles pub-
lished during the period 20052009 on the topic of imaging ndings in head trauma. The in-
tent is to provide the latest information regarding the diagnosis of important abnormalities
and new insights into their clinical signicance.
CONCLUSION. With the growing realization that even mild head injury can lead to
various types of neurocognitive decits, medical imaging of brain injury has assumed even
greater importance than previously.
Provenzale
Imaging of Traumatic Brain Injury
Neuroradiology/Head and Neck Imaging
Review
AJR:194, January 2010 17
Imaging of Traumatic Brain Injury
can be used; one of the more commonly used
is fractional anisotropy (FA).
Regions of acute DAI can be depicted
as bright lesions on DWI and dark regions
on ADC maps because of restricted diffu-
sion caused by acute cell death. In the past
5 years, many studies have shown that these
techniques can detect regions of DAI that
are subtle or undetected on T2-weighted and
FLAIR images as well as provide a quantita-
tive assessment of DAI for large areas of the
brain [4, 5]. A large number of articles have
been published on this topic, and it is possi-
ble to provide only some examples here rath-
er than an exhaustive review.
ADC values can be measured in specif-
ic regions or in the whole brain. In one arti-
cle, investigators measured ADC values us-
ing both methods and compared ndings in
37 children with various degrees of brain inju-
ry (measured by GCS scores) and neurologic
outcomes (measured by the Pediatric Cerebral
Performance Category Scale [PCPCS]) and
10 normal control subjects [4]. The authors
measured ADC values in normal-appearing
brain in the following regions: deep gray mat-
ter, peripheral gray matter, deep white matter,
peripheral white matter, posterior fossa, and
whole brain. The major goal of the study was
to determine whether ADC values in various
regions or in the whole brain could predict
outcome. The mean ADC value in peripher-
al white matter was able to predict outcome
in children with severe traumatic brain in-
jury. Overall, mean ADC in the whole brain
was the best predictor of outcome among all
degrees of traumatic brain injury. One of the
more interesting aspects of this study is that
the authors assessed only normal-appear-
ing white matterthat is, the study showed
that important prognostic information can be
gleaned from abnormalities that are not ap-
parent on conventional MR images.
DTI and another advanced MR tech-
nique, MR spectroscopy, were recently com-
pared for their ability to predict outcome in
a group of 43 traumatic brain injury patients
who were imaged, on average, approximate-
ly 3 weeks after trauma [6]. FA values were
measured at 16 sites within the supratentorial
and infratentorial white matter or brainstem.
The metabolite N-acetyl aspartate (NAA), a
marker of neuronal integrity, was measured
and compared with the stable metabolite cre-
atine (Cr) at ve locations on an axial im-
age through the level of the lentiform nucleus
and expressed as the NAA:Cr ratio. Patients
were divided into either a favorable outcome
group (n = 24) or an unfavorable outcome
group (n = 19) depending on scores on the
Glasgow Outcome Scale performed at 1-year
follow-up after trauma. In 15 of the 16 brain
regions studied, FA values were signicant-
ly reduced in the unfavorable outcome group
compared with both the favorable outcome
group and normal control subjects. In all of
these regions, FA values were signicantly
decreased in the favorable outcome group
compared with normal control subjects. The
authors attributed decreased FA to disrup-
tion of axonal membranes and the cytoskel-
etal network. With regard to MR spectros-
copy ndings, in all ve regions in which
the NAA:Cr ratio was measured, statistically
signicant differences were found between
the unfavorable outcome group and the oth-
er groups and between the favorable outcome
group and normal control subjects. The au-
thors attributed these ndings to axonal loss
or decreased metabolism.
Detection of Microhemorrhages
A type of lesion termed the cerebral micro-
hemorrhage has gained importance among
many researchers because such hemorrhages
frequently accompany DAI. For some inves-
tigators, such lesions serve as a biomarker of
DAI [7]. Interest in traumatic brain lesions of
all types, but especially DAI, in professional
and amateur athletes alike has increased be-
cause it is apparent that concussion and other
forms of head injury may have both acute and
long-lasting effects on neurocognitive func-
tion [8, 9]. Detection of microhemorrhages
depends on a fairly large number of factors,
such as pulse sequence, TE, slice thickness,
spatial resolution, and possibly imaging plane,
which have recently been explained in a de-
tailed review article [10]. For instance, the
susceptibility effect induced by gradient-re-
called echo and susceptibility-weighted im-
aging (SWI) sequences causes microhemor-
rhages to appear more conspicuous relative to
other pulse sequences. The term SWI refers
to a high-resolution MR technique in which
images containing the phase information, and
not solely images containing the magnitude
images, are provided [11]. The phase images
are sensitive for depiction of regions of local
alteration of the magnetic eld (i.e., suscepti-
bility) caused by various substances, such as
hemorrhage and iron and other metals. Thus,
SWI would be expected to be a sensitive
means to show microhemorrhages.
As mentioned earlier, the capacity of var-
ious forms of head trauma (in some cases,
even head trauma that is generally consid-
ered to be relatively mild) to produce im-
paired cognitive and memory function has
been increasingly recognized. As a result, the
study of brains of amateur and professional
athletes has assumed greater importance. As
an example, in one recent study, researchers
studied the prevalence of cerebral microhe-
morrhages in amateur boxers [12]. Forty-two
male amateur boxers underwent imaging on a
3-T scanner using an axial spin-echo MRI se-
quence, a 3D sagittal magnetization-prepared
rapid acquisition of gradient-echo sequence,
a coronal T2*-weighted sequence, and an ax-
ial time-of-ight MR angiography sequence.
Findings were correlated with a number of
boxer characteristics (total numbers of ghts
and knockouts, weight division, and duration
of boxing) and with MR ndings in 37 nor-
mal, nonboxing male volunteers. The study
showed more microhemorrhages in amateur
boxers (three of 42 individuals with micro-
hemorrhages) than in the normal population
(none of 37), but the difference was not statis-
tically signicant, which the authors believe
possibly to have been caused by the small pa-
tient sample.
A comparison of various MRI pulse se-
quences for detection of microhemorrhages
has been the subject of a number of studies.
Two such articles are briey reviewed here. In
one report, researchers compared the sensitiv-
ities of MRI using a T2*-weighted gradient-
echo sequence at two eld strengths, 1.5 T and
3 T [7]. The study population consisted of 14
adult patients who experienced head trauma
in road accidents. On average, approximately
twice as many microhemorrhages were seen
in each patient at 3 T compared with 1.5 T.
However, in only one patient were microhem-
orrhages seen solely at 3 T. The authors con-
cluded that scanners with a eld strength of
1.5 T appear to be sufcient for detecting mi-
crohemorrhages and that the increased sensi-
tivity offered by 3-T scanners may not provide
additional clinical information.
In another study, the sensitivities of SWI
and 2D gradient-echo T2*-weighted imaging,
another hemorrhage-sensitive sequence, for
detection of microhemorrhages were com-
pared recently in a small group of patients
with suspected brain injury [13]. The study
population consisted of 15 pediatric and adult
patients with GCS scores varying across a
wide range. The report found that SWI detect-
ed approximately four times as many hemor-
rhagic foci as T2*-weighted imaging. The
authors report that the difference between
18 AJR:194, January 2010
Provenzale
the two techniques was especially evident for
detecting lesions in the corpus callosum.
Notably, those studies solely addressed the
issue of the sensitivity of various imaging
techniques for detecting microhemorrhages;
the important topics of how the detection of
such lesions inuences patient care and the
impact of such lesions on patient outcome
were not addressed. However, such topics are
addressed in other articles in the Predictive
Models section of this article.
Predictive Models for Uses of Imaging
in Head Trauma
It is clear that simply knowing which im-
aging technique is superior for lesion detec-
tion does not allow us to fully assess the mer-
its of various techniques. For instance, one
technique might be twice as sensitive as an-
other for detecting regions of DAI, but the
increased sensitivity might not alter decision
making or translate into changes in clinical
outcome for patients. The elds of decision
analysis and outcomes research as applied to
radiology deal with the issues of how physi-
cians use data that imaging studies provide
[14, 15]. For example, studies have been per-
formed that examine how emergency de-
partment physicians make decisions about
ordering CT for patients with subarach-
noid hemorrhage [16]. However, little has
been written about the ways in which spe-
cic types of imaging guide the decisions of
physicians in treating head trauma patients
or the ways in which imaging studies benet
patients by producing improved clinical out-
comes. Nonetheless, a number of articles ex-
amining how well imaging techniques pre-
dict (rather than change) patient outcome
have been written in the past 5 years; some
of those articles are reviewed next.
CT for Prediction of Mortality in
Head Trauma Patients
Because almost all head trauma patients
undergo CT as the rst imaging test, re-
searchers have attempted to develop meth-
ods to use early CT ndings for determining
prognosis. For instance, in 1991, Marshall
et al. [17] proposed a scoring scale for de-
termining prognosis in head trauma patients
based on CT criteria. The scale categoriz-
es patients on the basis of the presence of a
space-occupying lesion (or recent evacuation
of such a lesion, e.g., a subdural hematoma),
intracranial abnormalities, and ndings of
increased intracranial pressure (e.g., obliter-
ation of basal cisterns or brain shift). Mul-
tiple studies have validated this scale and it
has gained widespread acceptance.
In a recent article, investigators used imag-
ing ndings of patients from a previously pub-
lished multicenter trial to rene the Marshall
classication [18]. The subjects were between
the ages of 15 and 65 years, had recent closed
head trauma, and were classied as having ei-
ther moderate (GCS score of 912) or severe
(GCS score of 38) injury. Outcome predic-
tion was based on CT ndings within 4 hours
of injury. The researchers rened the Mar-
shall classication scheme in two ways. First,
they provided a more detailed analysis of two
parameters: presence of mass lesions and sta-
tus of the basal cisterns (as a reection of in-
tracranial pressure). In addition, they added
two CT parameters that were not included
in the Marshall classication: traumatic in-
traventricular hemorrhage and subarachnoid
hemorrhage. Next, the investigators compared
the ability of this rened scheme to forecast
outcome against alternative predictive models
that the authors developed. Using this meth-
od, the authors conrmed the predictive value
of the Marshall classication. However, they
found that better discrimination was possible
using individual components of the classica-
tion scheme (rather than the entire scheme)
and adding the new hemorrhage parameters
previously outlined. Based on these results,
the authors devised a simple prognostic CT
scoring scale for probability of mortality in
patients with moderate or severe traumatic
brain injury.
In a discussion section published at the
end of the article, reviewers noted some study
limitations [18]. Among other items, they cit-
ed that the study does not assess patients with
mild traumatic brain injury; some imaging
criteria (e.g., assessment of size of basal cis-
terns) are quite subjective and might be open
to substantial interobserver variability be-
tween readers having different levels of train-
ing; and unlike some other scoring scales, the
study assessed CT scans very early in the clin-
ical course whereas CT ndings often pro-
gressively worsen after that initial period.
Comparison of CT and MRI for Prediction of
Neurocognitive Outcome
In the study cited earlier that compared
sensitivity of CT and MRI for detection of
traumatic lesions [3], 28 patients also under-
went neurocognitive testing at three time in-
tervals after head trauma: within 2 weeks, at
1 month, and at 1 year. Two blinded read-
ers assessed CT scans and MR images us-
ing a large number of ndings associated
with head trauma (e.g., extraaxial uid col-
lections, midline shift, etc.). MRI ndings
and neurocognitive scores were compared
with those of 18 healthy control subjects
matched to patients for various characteris-
tics. The control subjects underwent MRI but
not CT. Signicant differences were found in
neurocognitive scores between patients with
abnormal imaging ndings, normal imaging
ndings, and control subjects. However, neu-
rocognitive scores did not signicantly differ
between patients with normal imaging nd-
ings and those with abnormal imaging nd-
ings. In fact, neither CT nor MRI ndings
predicted neurocognitive decits soon after
injury or at 1-year follow-up. Thus, early im-
aging ndings were not found to have predic-
tive value for clinical outcome.
Although CT ndings were not found to be
predictive of neurocognitive outcome in the
study just described, in another, larger study,
early CT ndings were predictive of neurologic
outcome [19]. In that study, investigators exam-
ined the predictive value of CT for functional
outcome in a large group of patients with mi-
nor head injury (dened as GCS score of 13).
CT was assessed for many different forms of
parenchymal injury and various types of skull
fractures. The clinical outcomes measured in-
cluded the Glasgow Outcome Scale, modied
Rankin Scale, and Barthel Index. Parenchymal
injury (i.e., contusions and DAI) was predic-
tive of a poor clinical outcome in a statistically
meaningful way.
Finally, in yet another study, the researchers
compared CT and various MRI techniques for
predicting neurologic outcome at 612 months
in 40 children with traumatic brain injury [20].
All children underwent CT within 24 hours
of injury and MRI was performed using T2-
weighted, FLAIR, and SWI pulse sequences
at an average of 7 days after trauma. Regions
of parenchymal hemorrhage and edema were
analyzed using a computer software program
that semiautomatically counted and traced
lesion outlines. Imaging ndings were com-
pared with outcomes determined using the
PCPCS. Patients were assigned to one of
the following outcome categories based on
PCPCS score: normal, mild disability, or
poor outcome (i.e., moderate or severe dis-
ability or vegetative state). CT scores did not
discriminate between any of the three out-
come groups. Furthermore, within the poor
outcome group, 40% of children had normal
CT ndings. However, all MRI sequences
discriminated between outcome groups in a
AJR:194, January 2010 19
Imaging of Traumatic Brain Injury
statistically signicant manner by differenc-
es in both lesion counts and lesion volumes.
SWI showed substantially more lesions com-
pared with the T2-weighted and FLAIR
pulse sequences; on the other hand, lesion
volumes measured on either T2-weighted or
FLAIR pulse sequences were substantially
greater than those measured on SWI.
Summary
This review has outlined a variety of as-
pects of head trauma imaging in the recent
medical literature. It is worth summarizing
both the imaging advances and some issues
that remain to be addressed. First, it is clear
that MRI is much more sensitive than CT for
detection of small trauma-related brain ab-
normalities [3]. Furthermore, some MRI se-
quences are particularly sensitive to detection
of specic forms of brain injury. However,
the actual clinical relevance of this increased
sensitivity is relatively unclear. Although ar-
ticles reporting correlation of imaging nd-
ings and clinical outcome have some value,
more information is needed regarding how
the increased sensitivity of MRI techniques
affects physician decision making.
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