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Cerebral Contusions

Last Updated: March 27, 2020

Figure 1: Multiple CT images over time demonstrate the evolution of a hemorrhagic parenchymal contusion in a typical location over the petrous ridge of the temporal bone. The hematoma is not visible on day 1 (top row left), but appears and enlarges over the next few days (top row right and middle row left), a typical course for contusion. At day 17 (middle row right), all that remains is a hypodense hematoma that has already begun to involute. 1 year from the initial trauma, the previous hematoma has evolved into a small amount of encephalomalacia (bottom row).

Figure 2: MRI of the brain after a 15-foot fall. Anterioinferiorfrontal lobes and anterior temporal lobes are the most common locations for coup/contrecoup contusions. Each MR sequence can contribute additional information about the location and extent of these abnormalities. On axial FLAIR (top row left), bilateral anterior frontal and left anterior temporal hyperintense edema is visible. On axial T1 (top row right), the hyperintense blood within the hemorrhagic contusions is more evident, and the posterior subdural hematomas are even more striking. On susceptibility-weighted imaging (SWI) (bottom row), the anterior left temporal and inferior right temporal (over the petrous ridge) hemosiderin is clearly visible as black signal.

  • Direct or indirect injury to brain tissue
  • Involves brain parenchyma abutting the skull adjacent to the impact (coup) and the opposite side of the impact (contrecoup)
  • Foci of hemorrhages often noted within edematous brain
  • Commonly located adjacent to
    • Irregular bony protuberances (notably anterior inferior frontal lobes and anterior inferior temporal lobes) and
    • Dural folds (parasagittal "gliding" contusions)

Neuroimaging

  • CT findings (See Figure 1)
    • Acute
      • Patchy hyperdense hemorrhagic foci surrounded by a hypodense area of edema
      • CT with perfusion increases the sensitivity for contusion
    • Chronic
      • Hemorrhagic foci turn isodense and then hypodense
      • Eventually, the area becomes encephalomalacic with volume loss and there is hypodensity of the involved parenchyma
  • MRI findings
    • Helps detect and also delineate the extent of the contusion
    • See Table 1
Table 1: Cerebral Contusion MRI Findings
  Acute Chronic
T1 WI Inhomogeneous isointensity with or without mass effect Focal or diffuse atrophy
FLAIR
  • Hyperintense demyelination and microglial scarring
  • Hypointense hemosiderin staining
  • Hypointense cavitation (cystic encephalomalacia)
T2*GRE Hypointense hemorrhagic foci "blooming artifact" Hypointense hemosiderin deposits
DWI
  • Hyperintense in areas of cell death
  • Decreased apparent diffusion coefficient (ADC) correlates with poor outcome
  • Diffusion tensor imaging can sometimes pick up white matter damage when CT and routine MRI appear normal
MRS Decreased N-acetyl aspartate, increased choline
  • Differential for cerebral contusion
    • Infarct with hemorrhagic transformation
    • Venous sinus thrombosis
    • Cerebritis
    • Low-grade neoplasm
    • Transient post-ictal changes

For more information, please see the corresponding chapter in Radiopaedia.

Contributor: Priya Rajagopalan, MD

DOI: https://doi.org/10.18791/nsatlas.v1.03.04.02.07

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