Imaging assessment of penetrating craniocerebral and spinal trauma

Internal and terminal ballistic appearances. Hollow-point bullet: (from left to right) unfired; in cross-section to demonstrate hollowed construct; and deformation following soft tissue simulant impact. Note the grooves created on the jacket of the discharged bullet rendered by the gun of source. Acknowledgements to Dr Derek Allosop (Cranfield Forensic Institute).

Unenhanced CT images of the brain of a 17-year-old female shot at close range with a handgun. (a) There is amelioration of some of the streak artefact when images are viewed on bone windows. Fragmentation of the bullet associated with in-driven bone fragments are present in the right parietal lobe and assist in determining the trajectory of the penetrating bullet. The entry site can be identified by the pattern of beveling of the outer and inner table of the right parietal calvarium. A large fragment of the bullet has remained superficial in the extracranial soft tissues. (b) The bullet was “jacketed” and this has separated and lodged intracranially in the midline superiorly close to the lambda. This should not be confused with a second bullet.

Unenhanced CT images of the brain of a patient who sustained a superficial gunshot injury to the head involving the left temporo-occipital region. The bullet is lodged predominantly in the extracranial soft tissues but there is spallation of the inner table of the skull vault evident at the site of bullet impaction.

Close range shotgun injury to the face. The billiard-ball effect of the pellets within a single shotgun shot causes dramatic devastating injury as a result of pellet spread despite close-range of the shot. The billiard-ball effect also means that the range of the shot cannot be estimated from the radiographic pattern of pellet spread. Unenhanced CT images of the brain: (a) soft-tissue windows illustrate the marked obscuration of detail created by streak artefact from the innumerable pellets. However, right hemispheric subdural haematoma, intraventricular blood, and subfalcine herniation to the left is evident. (b) Bone windows clarify the location of intracranial and extracranial pellets. Marked orbito-cranial injury was evident (images not shown). (c) Imaging performed 9 days after injury. An extensive right craniectomy has been performed to accommodate cerebral swelling and alleviate elevated intracranial pressure. Mild “fungus cerebri” is evident as brain parenchyma “mushrooms” through the craniectomy site as a result of persisting brain swelling.

A 16-year-old male who sustained a non-missile craniocerebral penetrating injury. Unenhanced CT images of the brain: (a) the implement is clearly identifiable on the scout image. (b) Bone window settings enable identification of a tiny intraparenchymal in-driven bone fragment adjacent to the blade anteriorly. These can act as foci of inflammation and infection, as well as epileptogenic source postoperatively, if not removed during debridement. The treating neurosurgeon should be alerted to their presence.

A 16-year-old male who presented with a penetrating knife wound to the left occiput (imaging not shown). Unenhanced CT brain image of the examination performed less than 12h after the knife was surgically removed. The intraparenchymal haemorrhagic knife track, as well as intraventricular and extra-axial blood, is evident, but the generalized bland grey–white matter appearance demonstrated is a poor prognostic sign indicative of severe hypoxic ischaemic decompensation. The patient died a few hours after this examination.

A 28-year-old male shot with a handgun. Axial image through the T12 vertebra level of a CT myelogram performed 1 day after injury as an alternative to MRI because of a retained bullet. The bullet (not shown) had traversed the left hemithorax and upper abdomen, fractured the left posterior elements of L1 vertebra, and lodged within the spinal canal. As well as subdural and subarachnoid haematoma most notable on the left, note the associated in-driven bone fragments. There is an epidural collection of contrast medium on the right as a result of CSF leak secondary to dural tear.

Stab injury sustained to the back of the neck with a knife. The patient presented with Brown–Sequard syndrome. Sagittal, T2-weighted, MRI image demonstrates surgical emphysema in the paraspinal soft tissues and a linear transverse fracture of the posterior cortex and body of C4 with marrow oedema caused by penetration of the blade of the weapon. A high signal track consistent with the hemi-transection of the cervical spinal cord, as well as surrounding parenchymal oedema is present.