Learning Objectives
Tutorial Bedah Saraf
Presentator:
Kelompok 19202
RSUP Dr. Sardjito
1. Mechanism of Pneumocephalus
Mechanism of Developing
Pneumocephalus
The Inverted-Soda-Bottle
The Ball-Valve
Mechanism of Horowitz
Mechanism of Dandy
and Lunsford
The Inverted-Soda-Bottle Mechanism of
Horowitz and Lunsford
• Continuous leakage of CSF results in a
negative intracranial pressure in the
subarachnoid space.
• As a result, air can be drawn in
through an existing dural defect.
• The air will ascend and replace the CSF
that leaked out, until the pressure
gradient is stable.
The Inverted-Soda-Bottle Mechanism of
Horowitz and Lunsford
• This mechanism depends upon air
being sucked into the cranium as
CSF leaks out.
• The CSF pours as air rushes in the
cranial cavity to equilibrate the
pressure gradient.
• The sudden loss of liquid results in
intracranial hypotension relative to
the atmosphere and allows
intracranial entrapment of air
through a cranial-dural defect.
The Ball-Valve Mechanism of Dandy
• A pressure gradient arises a large collection of
intracranial air.
• This pressure gradient develops when:
extracranial pressure exceeds intracranial
pressure, and when a dural injury is present.
• Pressure-increasing moments induce a sudden
pressure increase in the paranasal cavities, which
pulls air intracranially through the dural defect.
• The intracranial tissue then blocks the dural
entrance, preventing the air from flowing back.
2. Mechanism of Depressed Fracture
Depressed Fracture Mechanism
Depressed Fracture Mechanism
• Impact with a flat surface linear type fractures
• Impact with a blunt object localized depressed fractures
Depressed Fracture Mechanism
• Depressed skull fractures result from a high-energy
direct blow to a small surface area of the skull with
a blunt object (such as a baseball bat).
• Comminution of fragments starts from the point of
maximum impact and spreads centrifugally.
• Most of the depressed fractures are over the
frontoparietal region bone is thin and the specific
location is prone to an assailant's attack.
• A free piece of bone should be depressed greater
than the adjacent inner table of the skull to be of
clinical significance.
Depressed Fracture Mechanism
• A depressed fracture may be open or closed.
• Open fractures have either a skin laceration over the fracture or the
fracture runs through the paranasal sinuses and the middle ear
structures, resulting in communication between the external
environment and the cranial cavity.
• Open fractures may be clean or contaminated/dirty.
3. X-ray : Cervical Spine
Views
• AP
Anteroposterior projection of the cervical spine demonstrating the
vertebral bodies and intervertebral spaces
• Lateral
Often utilised in trauma demonstrated
• zygapophyseal joints
• soft tissue structures around the c spine
• spinous processes
• anterior-posterior relationship of the vertebral bodies
• Odontoid
Also known as a 'peg' projection it demonstrates the C1 (atlas) and C2
(axis)
• AP oblique
Demonstrates the intervertebral foramina of the side positioned further
from the image receptor
• PA oblique
Demonstrated the intervertebral foramina of the side positioned closer Lateral view
to the image receptor
Patient Position
• the patient is erect, left side against the upright detector
• the detector is placed portrait, parallel to the long axis of the cervical
spine on the patients left side
• the patient will have the neck in the extended (chin up) or flexion
(chin down) position depending on the projection
Image Technical Evaluation
• there should be clear visualisation of C7 to T1
• the image is labelled as 'flexion' or 'extension'
• flexion images should demonstrate well separated spinous process
• extension images should demonstrate crowding of the spinous
process
ABC Rule
•A: Adequacy.
The C7/T1 junction must be visible
•A: Alignment.
Ensure all 4 lines are contiguous/uninterrupted
1. Anterior longitudinal line
2. Posterior longitudinal line
3. Spinolaminal line
4. Spinous process line
•B: Bones.
- Each vertebrae must be examined for
fracture/collapse/avulsion.
- Parallel facet joints.
•C: Cartilage (aka. disc spaces).
Examine for symmetry/normality of the intervertebral discs
between each vertebrae
•S: Soft tissue and Space + line
Prevertebral swelling of <2/3 of adjacent vertebral width
Alternatively:
•<7 mm anterior to C2
•<2 cm anterior to C7
Referensi
• Gorissen, Z., Hakvoort, K., van den Boogaart, M., Klinkenberg, S., & Schijns, O.
(2019). Pneumocephalus: a rare and life-threatening, but reversible, complication
after penetrating lumbar injury. Acta Neurochirurgica. doi:10.1007/s00701-018-
03796-y
• Gurdjian, E. S., Webster, J. E., & Lissner, H. R. (1950). The Mechanism of Skull
Fracture. Radiology, 54(3), 313–339. doi:10.1148/54.3.313
[Link]/10.1148/54.3.313
• Murphy, A., 2020. Cervical Spine (Flexion And Extension Views) | Radiology Reference
Article | [Link]. [online] [Link]. Available at:
<[Link]
[Accessed 7 August 2020].
• Paiva, W., Andrade, A., Figueiredo, E., Amorim, R., Prudente, & Jacobsen, M.
(2014). Effects of hyperbaric oxygenation therapy on symptomatic pneumocephalus.
Therapeutics and Clinical Risk Management, 769. doi:10.2147/tcrm.s45220
TERIMA KASIH