What is the diagnosis and treatment for cranial abnormalities (cranium)?

From the Guidelines

The diagnosis and treatment of cranial abnormalities should prioritize the use of MRI with intravenous contrast and high-field strength magnets (1.5-3.0T) for optimal evaluation of cranial neuropathy, as recommended by the American College of Radiology 1. When evaluating cranial abnormalities, it is essential to consider the complex anatomy of the cranium and the potential locations of lesions, including the brain stem nuclei, cisternae, skull base segments, and peripheral nerves.

• The primary plane of study for head and neck evaluation of cranial neuropathy is usually the axial plane, with additional orthogonal planes required depending on the course of the nerves.
• The use of intravenous contrast is imperative for the evaluation of cranial neuropathy with MRI, and neck CT also requires the use of contrast when evaluating pathology affecting the neck.
• High-field strength magnets (1.5-3.0T) are preferred to low-field-strength units due to their achievable signal-to-noise ratios, gradient strength, and spatial resolution. In cases of cranio-maxillofacial malformations, such as craniosynostoses and orofacial clefts, radiographic investigations should be proportionate to the diagnostic and therapeutic objectives of the single case, and the golden rule is that radiographic investigations should be carried out only when they are essential to diagnosis and treatment planning 1.
• Multislice computer tomography (MSCT) or CBCT is indicated in selected cases, when necessary for treatment planning, but not as a routine examination for cleft lip and palate or skeletal facial deformities involving bone and/or soft tissues. The diagnosis and treatment of cranial abnormalities require a comprehensive approach, taking into account the specific condition, patient age, and treatment objectives, and should always prioritize the use of the most recent and highest-quality imaging modalities, such as MRI with intravenous contrast and high-field strength magnets (1.5-3.0T) 1.

From the Research

Diagnosis of Cranial Abnormalities

• The diagnosis of cranial abnormalities can be made using clinical indicators such as a Glasgow Coma Scale (GCS) of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of fracture 2.
• Imaging studies such as computed tomography (CT) scans can be used to evaluate the severity of head injury and detect intracranial complications such as intracranial hemorrhage, hydrocephalus, and vascular injuries 3.
• The use of CT scans can be guided by clinical risk factors such as posttraumatic amnesia, loss of consciousness, posttraumatic seizure, headache, vomiting, focal neurological deficit, skull fracture, coagulopathy, and antecedent of treatment with anticoagulants 4.

Treatment of Cranial Abnormalities

• The treatment of cranial abnormalities depends on the severity of the injury and the presence of intracranial complications 3.
• Patients with severe head injury may require immediate neurosurgical intervention, while those with mild or moderate injury may be managed conservatively with close monitoring and repeat CT scans as needed 2, 5.
• The use of prophylactic antibiotics is not recommended for the management of basilar skull fractures, but operative debridement and thorough irrigation may be necessary for open-depressed skull fractures 3.
• Patients with cranial crush injuries may present with a distinctive clinical picture consisting of no loss of consciousness, epistaxis, otorrhagia, peripheral paralysis of the sixth and/or seventh cranial nerves, hearing loss, skull base fractures, pneumocephalus, and diabetes insipidus 6.

Indications for Repeat CT Scans

• Repeat CT scans are indicated for patients with severe head injury (GCS < or =8) and for those who undergo neurologic deterioration 5.
• Routine repeat CT scans may not be necessary for patients with mild or moderate head injury, but may be considered for those with clinical risk factors such as posttraumatic amnesia, loss of consciousness, or skull fracture 4.
• The decision to obtain a repeat CT scan should be individualized based on the patient's clinical condition and the presence of intracranial complications 2, 5.