Head Trauma Imaging — MCQs
Lucid Interval is seen in?
A neonate born at home is found dead with skull base fracture, depressed temporal bone fracture, and brain contusions. What is the most likely manner of death?
Which of the following is not true about non-contrast CT scan in head injury?
What will be the Glasgow Coma Scale (GCS) score for a head injury patient who opens eyes to painful stimulus, uses inappropriate words, and localizes pain?
Which one of the following is a secondary brain injury?
A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?
A 20 year old male comes to casualty with head injury. Examination reveals normal consciousness and blood in the tympanic membrane. Most likely cause is-
A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?
Lucid interval is most commonly seen in -
Reversible dementia is seen in all EXCEPT:
Head Trauma Imaging Indian Medical PG Practice Questions and MCQs
Question 1: Lucid Interval is seen in?
- A. All of these
- B. Subarachnoid hemorrhage
- C. Extradural hemorrhage (Correct Answer)
- D. Subdural hemorrhage
Explanation: ***Extradural hemorrhage*** - A **lucid interval** is a hallmark feature of an **extradural (epidural) hemorrhage**, where a patient briefly regains consciousness after initial head trauma before deteriorating [3]. - This transient improvement occurs due to a temporary cessation of bleeding or accommodation by the brain before the hematoma expands significantly, compressing the brain. *All of these* - While other forms of intracranial hemorrhage can cause fluctuating consciousness, the classic and most distinct **lucid interval** is traditionally associated with extradural hemorrhage [3]. - It is not a consistent or characteristic feature across all types of intracranial bleeds. *Subarachnoid hemorrhage* - Patients with **subarachnoid hemorrhage** typically present with a sudden, severe headache (**worst headache of life**) and often rapidly develop neurological deficits or loss of consciousness without a clear lucid interval [2]. - The bleeding is usually arterial and rapid, leading to immediate symptom onset. *Subdural hemorrhage* - **Subdural hemorrhages** often present with a more gradual onset of symptoms (hours to days or even weeks), especially in chronic cases, due to venous bleeding [1]. - While fluctuations in consciousness can occur, a distinct **lucid interval** followed by rapid deterioration is less common than in extradural bleeds [3].
Question 2: A neonate born at home is found dead with skull base fracture, depressed temporal bone fracture, and brain contusions. What is the most likely manner of death?
- A. Natural causes
- B. Homicide (Correct Answer)
- C. Undetermined
- D. Accidental death
Explanation: ***Homicide*** - The combination of **skull base fracture**, **depressed temporal bone fracture**, and **brain contusions** in a neonate strongly indicates **non-accidental trauma** (infanticide) - These are **high-energy injuries** requiring **forceful impact**, incompatible with normal birth trauma or typical handling - The pattern of multiple severe traumatic injuries points to **intentional harm** *Natural causes* - Natural infant deaths result from congenital anomalies, infections, or genetic disorders - **Traumatic skull fractures** and **brain contusions** are not manifestations of natural disease processes *Undetermined* - Used when insufficient evidence exists to classify the manner of death - The **specific pattern of severe traumatic injuries** provides clear evidence of non-natural violent death, making this classification inappropriate *Accidental death* - Normal birth trauma may cause minor injuries (cephalohematoma, linear skull fractures) - The presence of **multiple severe fractures** (skull base + depressed temporal bone) with **brain contusions** exceeds the injury pattern of accidental birth trauma or postnatal accidents - Such extensive injuries in a neonate indicate intentional violence rather than accident
Question 3: Which of the following is not true about non-contrast CT scan in head injury?
- A. Extradural hematomas are usually lens-shaped
- B. Acute subdural hematoma appears as crescent shadow of increased density
- C. Subdural hematoma increases in density on serial CT scans over weeks (Correct Answer)
- D. Subarachnoid hemorrhage appears as areas of increased density in basilar cisterns
Explanation: ***Subdural hematoma increases in density on serial CT scans over weeks*** - A **subdural hematoma (SDH)** typically **decreases in density** over weeks due to clot lysis and absorption of its proteinaceous components, transitioning from hyperdense (acute) to isodense (subacute) and then hypodense (chronic). - An increase in density on serial CT scans would imply continued bleeding or re-hemorrhage, which is not the typical natural progression of an acute SDH. *Extradural hematomas are usually lens-shaped* - **Extradural hematomas (EDH)** are typically **biconvex** or **lens-shaped** because they accumulate in the epidural space and are limited by cranial sutures where the dura is tightly adhered to the skull. - This characteristic shape helps distinguish them from subdural hematomas. *Acute subdural hematoma appears as crescent shadow of increased density* - An **acute subdural hematoma (SDH)** appears as a **crescent or crescent-shaped shadow** of increased density (hyperdense) on a non-contrast CT scan because it spreads along the inner surface of the dura, conforming to the brain's convexity. - This indicates active bleeding that is relatively fresh, usually within the first 3-7 days. *Subarachnoid hemorrhage appears as areas of increased density in basilar cisterns* - **Subarachnoid hemorrhage (SAH)** manifests as areas of **increased density (hyperdensity)** within the **basilar cisterns**, Sylvian fissures, or sulci, due to blood filling these cerebrospinal fluid (CSF)-containing spaces. - This finding is a key indicator of SAH on non-contrast CT.
Question 4: What will be the Glasgow Coma Scale (GCS) score for a head injury patient who opens eyes to painful stimulus, uses inappropriate words, and localizes pain?
- A. 10 (Correct Answer)
- B. 14
- C. 8
- D. 12
Explanation: ***10*** - The patient opens eyes to **painful stimulus (E2)**, uses **inappropriate words (V3)**, and **localizes pain (M5)**. - Summing these scores: **E2 + V3 + M5 = 10**. - This represents a **moderate head injury** (GCS 9-12). *14* - This score would require higher functioning in multiple domains. - Would need responses such as opening eyes to **speech (E3)**, **confused conversation (V4)**, and **localizing or obeying commands (M5-M6)**. - The described patient's responses do not reach this level of function. *8* - A GCS of **8 or less** indicates **severe head injury** requiring immediate **airway protection and intubation**. - The patient's ability to **localize pain (M5)** and use **inappropriate words (V3)** indicates a consciousness level above severe injury threshold. - This patient does not meet criteria for severe head injury. *12* - This score would require better responses in at least two categories. - Could include: opening eyes to **speech (E3)**, **confused conversation (V4)**, or **obeying commands (M6)**. - The patient's specified responses (E2 + V3 + M5) sum to only 10, not 12.
Question 5: Which one of the following is a secondary brain injury?
- A. Intracerebral haematoma with raised intracranial pressure (Correct Answer)
- B. Diffuse axonal injury
- C. Cortical lacerations
- D. Brainstem and hemispheric contusions
Explanation: ***Intracerebral haematoma with raised intracranial pressure*** - **Intracerebral haematoma** is a potentially treatable, secondary injury directly contributing to **raised intracranial pressure (ICP)**, leading to further brain damage if not managed. - **Secondary brain injuries** occur minutes to days after the initial impact, resulting from a cascade of events like ischaemia, oedema, and intracranial hypertension. *Diffuse axonal injury* - **Diffuse axonal injury (DAI)** is a **primary brain injury** caused by shearing forces at the moment of impact. - It is a direct consequence of the initial trauma, not a subsequent physiological process. *Cortical lacerations* - **Cortical lacerations** are **primary injuries**, representing a direct tearing or cutting of brain tissue due to the initial traumatic force. - These are immediately present at the time of injury and are not a consequence of subsequent physiological changes. *Brainstem and hemispheric contusions* - **Contusions** are localised areas of bruising on the brain, characteristic of a **primary brain injury**, occurring directly from the impact. - While contusions can evolve and contribute to secondary injury mechanisms like oedema, the contusion itself is a direct result of the initial trauma.
Question 6: A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?
- A. EDH
- B. SDH (Correct Answer)
- C. Contusion
- D. Diffuse axonal injury
Explanation: ***SDH*** - The image shows a **crescent-shaped collection** of hemorrhage with a concave inner margin, consistent with a **subdural hematoma** (SDH). - SDHs result from the tearing of **bridging veins** and typically conform to the brain's surface, crossing suture lines but not limited by bony sutures. *EDH* - An **epidural hematoma (EDH)** characteristically appears as a **lenticular** or **biconvex** shape on CT, not crescent-shaped. - EDHs are typically caused by arterial bleeding, often from the **middle meningeal artery**, and are limited by cranial sutures. *Contusion* - A **contusion** is brain tissue bruising that appears as **heterogeneous areas** of hemorrhage and edema within the brain parenchyma itself. - It would not manifest as a distinct extra-axial collection with a smooth, concave margin. *Diffuse axonal injury* - **Diffuse axonal injury (DAI)** involves widespread microscopic damage to axons, often at the gray-white matter junction. - It may appear as *punctate hemorrhages* or **small lesions** at these junctions on CT, but often the CT can be normal, and it would not present as a large extra-axial collection.
Question 7: A 20 year old male comes to casualty with head injury. Examination reveals normal consciousness and blood in the tympanic membrane. Most likely cause is-
- A. Intraventricular hemorrhage
- B. Extradural hemorrhage
- C. Subdural hemorrhage
- D. Basilar fracture (Correct Answer)
Explanation: ***Basilar fracture*** - **Blood in the tympanic membrane (hemotympanum)** in a trauma setting is a strong indicator of a **basilar skull fracture**, as it signifies bleeding in the middle ear space. - While other signs like **raccoon eyes** and **Battle's sign** confirm basilar fracture, hemotympanum is an earlier and common finding suggesting fracture at the skull base. *Extradural hemorrhage* - Extradural hemorrhage is typically an arterial bleed leading to rapid neurological deterioration and often a **"lucid interval"**, followed by loss of consciousness, which is inconsistent with the normal consciousness observed. - While head trauma is the cause, hemotympanum is not a direct or primary sign of extradural hemorrhage itself. *Intraventricular hemorrhage* - Intraventricular hemorrhage usually presents with signs of increased **intracranial pressure** and neurological deficits related to ventricular compression, which are not described. - It does not directly cause hemotympanum, as it involves bleeding within the brain's ventricular system. *Subdural hemorrhage* - Subdural hemorrhage is a venous bleed, often presenting with a slower onset of symptoms like headache, confusion, or weakness, and consciousness can fluctuate or decline. - Hemotympanum is not a characteristic sign of subdural hemorrhage; it points more specifically to structural damage to the skull base.
Question 8: A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?
- A. MRI
- B. CECT
- C. NCCT (Correct Answer)
- D. X-ray
Explanation: ***NCCT*** - **Non-contrast Computed Tomography (NCCT)** of the head is the **investigation of choice** for acute head trauma due to its rapid acquisition, wide availability, and excellent sensitivity for detecting acute hemorrhage, fractures, and mass effects. - It rapidly identifies life-threatening conditions such as **epidural, subdural, and intracerebral hemorrhages**, which require immediate intervention. *MRI* - **MRI** is superior for detecting subtle brain tissue injuries, diffuse axonal injury, and non-hemorrhagic lesions but is generally **not the first-line investigation** in acute trauma due to longer scan times, limited availability in the emergency setting, and inability to detect acute hemorrhage as clearly as CT. - Its use is typically reserved for follow-up studies or when CT findings are inconclusive or specific soft tissue detail is required. *CECT* - **Contrast-enhanced CT (CECT)** of the head is reserved for specific indications like evaluating vascular lesions (e.g., aneurysms, arteriovenous malformations) or tumors, which are generally **not the primary concern** in the initial assessment of acute head trauma. - Administering contrast agents can delay imaging, may pose risks to patients with renal impairment or allergies, and does not significantly improve the detection of acute traumatic hemorrhage compared to NCCT. *X-ray* - **X-rays** of the skull are useful for detecting **skull fractures**, but they provide **limited information** regarding intracranial injuries or soft tissue damage, which are critical in head trauma. - They have largely been superseded by CT scans, which offer a more comprehensive view of both bony structures and intracranial contents.
Question 9: Lucid interval is most commonly seen in -
- A. Subarachnoid hemorrhage
- B. Acute extradural hemorrhage (Correct Answer)
- C. Acute Subdural Hemorrhage
- D. Chronic Subdural Hemorrhage
Explanation: ***Acute extradural hemorrhage*** - A **lucid interval** is a classic feature where the patient initially loses consciousness from the injury, regains consciousness and appears relatively normal, only to deteriorate rapidly later due to the expanding hematoma. [1] - This is due to the arterial bleeding, typically from the **middle meningeal artery**, which quickly accumulates blood, compressing the brain. [1] *Subarachnoid hemorrhage* - Patients with subarachnoid hemorrhage typically present with a **sudden, severe headache** (thunderclap headache) and often do not experience a distinct lucid interval. [2] - The bleeding occurs within the **subarachnoid space** and is usually diffuse, causing immediate widespread neurological symptoms. [2] *Acute Subdural Hemorrhage* - While loss of consciousness occurs, a clear **lucid interval** is less common or prominent compared to extradural hemorrhage. [1] - Bleeding is usually venous, causing a slower but steady accumulation of blood, and the patient's neurological status tends to **deteriorate more gradually** or remain continuously impaired. [3] *Chronic Subdural Hemorrhage* - This typically occurs in older individuals or alcoholics, often following minor trauma, and symptoms develop **insidiously over weeks**. [3] - There is generally no acute **lucid interval**; instead, patients experience a gradual onset of headache, confusion, and neurological deficits.
Question 10: Reversible dementia is seen in all EXCEPT:
- A. Hypothyroidism
- B. Alzheimer's (Correct Answer)
- C. Wernicke's encephalopathy
- D. Head trauma
Explanation: ***Alzheimer's*** - Alzheimer's disease is a **progressive neurodegenerative disorder** characterized by the accumulation of **beta-amyloid plaques** and **neurofibrillary tangles**, leading to irreversible cognitive decline. - While symptoms can be managed, the underlying pathology of Alzheimer's is **irreversible** and gets progressively worse. *Hypothyroidism* - **Severe or untreated hypothyroidism** can lead to cognitive impairment resembling dementia, often referred to as "myxedema madness." - This cognitive dysfunction is typically **reversible** with appropriate **thyroid hormone replacement therapy**. *Wernicke's encephalopathy* - This condition is caused by a **thiamine (vitamin B1) deficiency**, commonly seen in chronic alcoholics. - The cognitive deficits, including confusion and memory problems, are **reversible** if treated promptly with **thiamine supplementation**. *Head trauma* - **Acute cognitive deficits** following mild to moderate traumatic brain injury (TBI) can be **reversible** with rehabilitation and recovery time. - However, it's important to note that **severe TBI** and **chronic traumatic encephalopathy (CTE)** typically cause **irreversible** dementia. - In the context of this question, head trauma is generally classified under reversible causes when referring to **acute post-traumatic cognitive impairment** that can improve with treatment.
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