rospedРоссийский педиатрический журнал имени М.Я. СтуденикинаM.Ya. Studenikin Russian Pediatric JournalФГАУ «НМИЦ здоровья детей» Минздрава России10.46563/1560-9561-2023-26-1-32-38bwezpcrosped-35Research ArticleОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯORIGINAL INVESTIGATIONSКомпьютерная томография переломов костей основания черепа у младенцев и детей младшего возрастаComputed tomography in skull base fractures in infants and young childrenhttps://orcid.org/0000-0002-6949-3072ЗайцеваЕкатерина СергеевнаZaitsevaEkaterina S.

Врач-рентгенолог, отдел лучевых методов диагностики НИИ НДХиТ.

e-mail: katarina0594@mail.ru

katarina0594@mail.ruhttps://orcid.org/0000-0002-3235-8854АхадовТолибджон АбдуллаевичAkhadovTolibdzhon A.

Доктор мед. наук, проф., руководитель отдела лучевых методов диагностики, НИИ НДХиТ.

e-mail: akhadov@mail.ru

akhadov@mail.ruhttps://orcid.org/0000-0002-6349-5739МаматкуловАлишер ДжахангировичMamatkulovAlisher D.

Аспирант отделения нейрохирургии НИИ НДХиТ.

e-mail: md-uz7@mail.ru

md-uz7@mail.ruhttps://orcid.org/0000-0002-4709-9461БожкоОльга ВасильевнаBozhkoOlga V.

Канд. мед. наук, вед. науч. сотр., отдел лучевых методов диагностики, НИИ НДХиТ.

e-mail: bozhko_olga@mail.ru

bozhko_olga@mail.ruhttps://orcid.org/0000-0002-4627-9874УблинскийМаксим ВадимовичUblinskiyMaxim V.

Канд. биол. наук, науч. сотр., НИИ НДХиТ.

e-mail: maxublinsk@mail.ru

Researcher, MD, PhD, Clinical and Research Institute of Emergency Pediatric Surgery and Trauma, Moscow, 119180, Russian Federation.

e-mail: maxublinsk@mail.ru

maxublinsk@mail.ruhttps://orcid.org/0000-0002-2910-3711МельниковИлья АндреевичMelnikovIlia A.

Канд. мед. наук, зав. отделением КТ и МРТ отдела лучевых методов диагностики, НИИ НДХиТ.

e-mail: ilyamed@mail.ru

ilyamed@mail.ruhttps://orcid.org/0000-0003-1260-4509ДмитренкоДмитрий МихайловичDmitrenkoDmitriy M.

Зав. отделением рентгенодиагностики НИИ НДХиТ.

e-mail: dmitrenich@mail.ru

dmitrenich@mail.ruhttps://orcid.org/0000-0001-5022-9952МанжурцевАндрей ВалерьевичManzhurtsevAndrey V.

Науч. сотр., НИИ НДХиТ.

e-mail: andrey.man.93@gmail.com

andrey.man.93@gmail.comhttps://orcid.org/0000-0002-1698-0547ХусаиноваДарья НиколаевнаKhusainovaDaria N.

Науч. сотр., отдел IT НИИ НДХиТ.

e-mail: dsavina@yandex.ru

dsavina@yandex.ruГБУЗ «НИИ неотложной детской хирургии и травматологии» Департамента здравоохранения города МосквыClinical and Research Institute of Emergency Pediatric Surgery and Trauma2023070920232613238Copyright © Зайцева Е.С., Ахадов Т.А., Маматкулов А.Д., Божко О.В., Ублинский М.В., Мельников И.А., Дмитренко Д.М., Манжурцев А.В., Хусаинова Д.Н., 20232023Зайцева Е.С., Ахадов Т.А., Маматкулов А.Д., Божко О.В., Ублинский М.В., Мельников И.А., Дмитренко Д.М., Манжурцев А.В., Хусаинова Д.Н.Zaitseva E.S., Akhadov T.A., Mamatkulov A.D., Bozhko O.V., Ublinskiy M.V., Melnikov I.A., Dmitrenko D.M., Manzhurtsev A.V., Khusainova D.N.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.rosped.ru/jour/article/view/35Цель работы

Цель работы: определить возможности многоплоскостного переформатирования и 3D-реконструкций компьютерной томографии (КТ) в диагностике переломов основания черепа (ПОЧ) у детей раннего возраста.

Материалы и методы

Материалы и методы. КТ проведена у 1334 детей (730 мальчиков и 604 девочки) в возрасте до 3 лет с черепно-мозговой травмой (ЧМТ) на 128-срезовом томографе «Philips Ingenuity CT»; у 707 (53%) в первые 6 ч, у 254 (19%) — позднее 6 ч, но в течение первых 24 ч, у 205 (15%) — в течение 3 сут, у 168 (13%) — позднее 3 сут после травмы. Сканирование зоны интереса (голова + шейный отдел позвоночника) проводилось с максимально возможным снижением параметров для минимизации дозы облучения. Контрастирование у детей от 0 до 3 лет при ЧМТ не использовалось. Постпроцессинговая обработка включала изотропные многоплоскостные переформатированные (MIP) и 3D-изображения.

Результаты

Результаты. У 448 (33,58%) детей диагностированы переломы костей черепа, у 366 (81,7%) из них переломы сочетались с внутричерепными повреждениями, у 83 (18,52%) были ПОЧ. В 54 (65%) случаях ПОЧ сочетался с переломами височных костей, у 17 (31,5%) этих детей была ликворея. Переломы передней ямки основания черепа (12% ПОЧ) или лобно-базальные переломы сопровождались дополнительными переломами орбит и/или других костей лицевого черепа в 47 (56,6%) наблюдениях. Переломы средней черепной ямки диагностированы у 54 (65%) детей. Переломы задней черепной ямки установлены у 19 (23%) из 83 детей. Помимо переломов костей основания черепа у 32 (38,6%) детей диагностированы переломы костей свода черепа, а также интракраниальные повреждения.

Заключение

Заключение. Использование многоплоскостного переформатирования и 3D-реконструкции увеличило чувствительность и специфичность диагностики ПОЧ у детей по сравнению с обычной аксиальной КТ. Существенными преимуществами использования 3D-реконструкции являются доступность методики, отсутствие дополнительных времени сканирования и лучевой нагрузки.

Участие авторов

Участие авторов:Зайцева Е.С., Ахадов T.A., Мельников И.А. — концепция и дизайн исследованияЗайцева Е.С., Маматкулов А.Д., Божко О.В., Дмитренко Д.М. — проведение исследований;Зайцева Е.С., Маматкулов А.Д. — cбор и обработка материала;Ублинский М.В., Манжурцев А.В., Хусаинова Д.Н. — статистическая обработка;Ахадов T.A. — написание текста;Зайцева Е.С., Божко О.В., Ублинский М.В. — редактирование.Все соавторы — утверждение окончательного варианта статьи, ответственность за целостность всех частей статьи.

Финансирование

Финансирование. Исследование не имело финансовой поддержки.

Конфликт интересов

Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.

Поступила 14

Поступила 14.12.2022Принята к печати 17.01.2023Опубликована 28.02.2023

Aim of the study is to show the possibilities of multiplanar reformation and 3D reconstructions of computed tomography in the diagnosis of skull base fractures in young children.

Materials and methods

Materials and methods. In one thousand three hundred thirty four children under 3 years of age with traumatic brain injury (TBI) CT was performed on a 128-slice Philips Ingenuity CT scanner; in 707 (53%) in the first 6 hours, in 254 (19%) — after 6 hours, but during the first 24 hours, in 205 (15%) children within 3 days and in 168 (13%) children later on 3 days after injury. Scanning of the area of interest (head + cervical spine) was made with the maximum possible reduction in parameters to minimize the radiation dose. Contrast was not used in children from 0 to 3 years of age with TBI. Post-processing included isotropic multi-planar reformatted (MPR) and 3D images.

Results

Results. Of the 1334 children examined, 730 were boys and 604 were girls. In 448 (33.58%) children, fractures of the skull bones were diagnosed, in 366 (81.7%) of them, fractures were combined with intracranial injuries. Fractures of the skull base were in 83 (18.52%) of 448 children. In 65% (n = 54) of cases, basal fractures were combined with fractures of the temporal bones, 31.5% (n = 17) of these children had liquorrhea. Fractures of the anterior fossa (12% of the total number of fractures of the base of the skull) of the base of the skull or fronto-basal fractures were accompanied by additional fractures of the orbits and/or other bones of the facial skull in 56.6% of cases. Fractures of the middle cranial fossa were diagnosed in 54 (65%) children. Fractures of the posterior cranial fossa were found in 19 (23%) of 83 children. In addition to fractures of the bones of the base of the skull, 32 (38.6%) children were diagnosed with fractures of the bones of the vault and intracranial injuries.

Conclusion

Conclusion. The use of multiplanar reformation and 3D reconstruction increased the sensitivity and specificity of diagnosing skull base fractures in children compared to conventional axial CT. The essential advantages of using 3D reconstruction are the availability of the technique, the absence of additional scanning time and radiation exposure.

Contribution

Contribution:Zaitseva E.S., Akhadov T.A., Melnikov I.A. — research concept and design;Zaitseva E.S., Mamatkulov A.D., Bozhko O.V., Dmitrenko D.M. — conducting research;Zaitseva E.S., Mamatkulov A.D. — collection and analysis of data;Ublinskiy M.V., Manzhurtsev A.V., Khusainova D.N. — statistical analysis;Akhadov T.A. — writing text;Zaitseva E.S., Bozhko O.V., Ublinskiy M.V. — editing.All co-authors — approval of the final version of the article, responsibility for the integrity of all parts of the article.

Acknowledgment

Acknowledgment. The study had no sponsorship. 

Conflict of interest

Conflict of interest. The authors declare no conflict of interest.

Received

Received: December 14, 2022Accepted: January 17, 2023Published: February 28, 2023

детикомпьютерная томографияпереломы костей свода черепачерепно-мозговая травмавнутричерепные поврежденияchildrencomputed tomographyfractures of the cranial vault bonestraumatic brain injuryintracranial injuriesReferencesЗайцева Е.С., Маматкулов А.Д., Ахадов Т.А. Компьютерная томография при черепно-мозговой травме у младенцев и детей младшего возраста (обзор литературы). Медицинская визуализация. 2022; 26(2): 39–57. https://doi.org/10.24835/1607-0763-1116Zaytseva E.S., Mamatkulov A.D., Akhadov T.A. Computed tomography of traumatic brain injury in infants and young children (a literature review). Meditsinskaya vizualizatsiya. 2022; 26(2): 39–57. https://doi.org/10.24835/1607-0763-1116 (in Russian)John S.M., Kelly P., Vincent A. Patterns of structural head injury in children younger than 3 years: a ten-year review of 519 patients. J. Trauma. Acute Care Surg. 2013; 74(1): 276–81. https://doi.org/10.1097/TA.0b013e318270d82eJohn S.M., Kelly P., Vincent A. Patterns of structural head injury in children younger than 3 years: a ten-year review of 519 patients. J. Trauma. Acute Care Surg. 2013; 74(1): 276–81. https://doi.org/10.1097/TA.0b013e318270d82eEaster J.S., Bakes K., Dhaliwal J., Miller M., Caruso E., Haukoos J.S. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann. Emerg. Med. 2014; 64(2): 145–52. https://doi.org/10.1016/j.annemergmed.2014.01.030Easter J.S., Bakes K., Dhaliwal J., Miller M., Caruso E., Haukoos J.S. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann. Emerg. Med. 2014; 64(2): 145–52. https://doi.org/10.1016/j.annemergmed.2014.01.030Ringl H., Schernthaner R.E., Schueller G., Balassy C., Kienzl D., Botosaneanu A., et al. The skull unfolded: a cranial CT visualization algorithm for fast and easy detection of skull fractures. Radiology. 2010; 255(2): 553–62. https://doi.org/10.1148/radiol.10091096Ringl H., Schernthaner R.E., Schueller G., Balassy C., Kienzl D., Botosaneanu A., et al. The skull unfolded: a cranial CT visualization algorithm for fast and easy detection of skull fractures. Radiology. 2010; 255(2): 553–62. https://doi.org/10.1148/radiol.10091096Lee H.R., Kim J.Y., Lim Y.C., Yoon S.H. Pediatric skull fractures based on three-dimensional computed tomography: correlation of skull fracture types, location, severity, and accompanying head injuries with surgical risk in 291 children. The Nerve. 2019; 5(2): 55–9. https://doi.org/10.21129/nerve.2019.5.2.55Lee H.R., Kim J.Y., Lim Y.C., Yoon S.H. Pediatric skull fractures based on three-dimensional computed tomography: correlation of skull fracture types, location, severity, and accompanying head injuries with surgical risk in 291 children. The Nerve. 2019; 5(2): 55–9. https://doi.org/10.21129/nerve.2019.5.2.55Juliano A.F., Ginat D.T., Moonis G. Imaging review of the temporal bone. II. Traumatic, postoperative, and noninflammatory nonneoplastic conditions. Radiology. 2015; 276(3): 655–72. https://doi.org/10.1148/radiol.2015140800Juliano A.F., Ginat D.T., Moonis G. Imaging review of the temporal bone. II. Traumatic, postoperative, and noninflammatory nonneoplastic conditions. Radiology. 2015; 276(3): 655–72. https://doi.org/10.1148/radiol.2015140800Baugnon K.L., Hudgins P.A. Skull base fractures and their complications. Neuroimaging Clin. N. Am. 2014; 24(3): 439–65. https://doi.org/10.1016/j.nic.2014.03.001Baugnon K.L., Hudgins P.A. Skull base fractures and their complications. Neuroimaging Clin. N. Am. 2014; 24(3): 439–65. https://doi.org/10.1016/j.nic.2014.03.001Bonfield C.M., Naran S., Adetayo O.A., Pollack I.F., Losee J.E. Pediatric skull fractures: the need for surgical intervention, characte­ristics, complications, and outcomes. J. Neurosurg. Pediatr. 2014; 14(2): 205–11. https://doi.org/10.3171/2014.5.PEDS13414Bonfield C.M., Naran S., Adetayo O.A., Pollack I.F., Losee J.E. Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J. Neurosurg. Pediatr. 2014; 14(2): 205–11. https://doi.org/10.3171/2014.5.PEDS13414Orman G., Wagner M.W., Seeburg D., Zamora C.A., Oshmyansky A., Tekes A., et al. Pediatric skull fracture diagnosis: should 3D CT reconstructions be added as routine imaging? J. Neurosurg. Pediatr. 2015; 16(4): 426–31. https://doi.org/10.3171/2015.3.PEDS1553Orman G., Wagner M.W., Seeburg D., Zamora C.A., Oshmyansky A., Tekes A., et al. Pediatric skull fracture diagnosis: should 3D CT reconstructions be added as routine imaging? J. Neurosurg. Pediatr. 2015; 16(4): 426–31. https://doi.org/10.3171/2015.3.PEDS1553Faried A., Halim D., Widjaya I.A., Badri R.F., Sulaiman S.F., Arifin M.Z. Correlation between the skull base fracture and the incidence of intracranial hemorrhage in patients with traumatic brain injury. Chin. J. Traumatol. 2019; 22(5): 286–9. https://doi.org/10.1016/j.cjtee.2019.05.006Faried A., Halim D., Widjaya I.A., Badri R.F., Sulaiman S.F., Arifin M.Z. Correlation between the skull base fracture and the incidence of intracranial hemorrhage in patients with traumatic brain injury. Chin. J. Traumatol. 2019; 22(5): 286–9. https://doi.org/10.1016/j.cjtee.2019.05.006Sim S.Y., Kim H.G., Yoon S.H., Choi J.W., Cho S.M., Choi M.S. Reappraisal of pediatric diastatic skull fractures in the 3-dimensional CT era: Clinical characteristics and comparison of diagnostic accuracy of simple skull X-ray, 2-dimensional CT, and 3-dimensional CT. World Neurosurg. 2017; 108: 399–406. https://doi.org/10.1016/j.wneu.2017.08.107Sim S.Y., Kim H.G., Yoon S.H., Choi J.W., Cho S.M., Choi M.S. Reappraisal of pediatric diastatic skull fractures in the 3-dimensional CT era: Clinical characteristics and comparison of diagnostic accuracy of simple skull X-ray, 2-dimensional CT, and 3-dimensional CT. World Neurosurg. 2017; 108: 399–406. https://doi.org/10.1016/j.wneu.2017.08.107Archer J.B., Sun H., Bonney P.A., Zhao Y.D., Hiebert J.C., Sanclement J.A., et al. Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps. J. Neurosurg. 2016; 124(3): 647–56. https://doi.org/10.3171/2015.4.JNS1528Archer J.B., Sun H., Bonney P.A., Zhao Y.D., Hiebert J.C., Sanclement J.A., et al. Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps. J. Neurosurg. 2016; 124(3): 647–56. https://doi.org/10.3171/2015.4.JNS1528Bell R.B., Chen J. Frontobasilar fractures: contemporary management. Atlas Oral. Maxillofac. Surg. Clin. North Am. 2010; 18(2): 181–96. https://doi.org/10.1016/j.cxom.2010.08.003Bell R.B., Chen J. Frontobasilar fractures: contemporary management. Atlas Oral. Maxillofac. Surg. Clin. North Am. 2010; 18(2): 181–96. https://doi.org/10.1016/j.cxom.2010.08.003Baráth K., Huber A.M., Stämpfli P., Varga Z., Kollias S. Neuroradiology of cholesteatomas. AJNR Am. J. Neuroradiol. 2011; 32(2): 221–9. https://doi.org/10.3174/ajnr.A2052Baráth K., Huber A.M., Stämpfli P., Varga Z., Kollias S. Neuroradiology of cholesteatomas. AJNR Am. J. Neuroradiol. 2011; 32(2): 221–9. https://doi.org/10.3174/ajnr.A2052Feldman J.S., Farnoosh S., Kellman R.M., Tatum S.A. Skull base trauma: clinical considerations in evaluation and diagnosis and review of management techniques and surgical approaches. Semin. Plast. Surg. 2017; 31(4): 177–88. https://doi.org/10.1055/s-0037-1607275Feldman J.S., Farnoosh S., Kellman R.M., Tatum S.A. Skull base trauma: clinical considerations in evaluation and diagnosis and review of management techniques and surgical approaches. Semin. Plast. Surg. 2017; 31(4): 177–88. https://doi.org/10.1055/s-0037-1607275Jin H., Gong S., Han K., Wang J., Lv L., Dong Y., et al. Clinical management of traumatic superior orbital fissure and orbital apex syndromes. Clin. Neurol. Neurosurg. 2018; 165: 50–4. https://doi.org/10.1016/j.clineuro.2017.12.022Jin H., Gong S., Han K., Wang J., Lv L., Dong Y., et al. Clinical management of traumatic superior orbital fissure and orbital apex syndromes. Clin. Neurol. Neurosurg. 2018; 165: 50–4. https://doi.org/10.1016/j.clineuro.2017.12.022Martin A., Paddock M., Johns C.S., Smith J., Raghavan A., Connolly D.J.A., et al. Avoiding skull radiographs in infants with suspected inflicted injury who also undergo head CT: “a no-brainer?”. Eur. Radiol. 2020; 30(3): 1480–7. https://doi.org/10.1007/s00330-019-06579-wMartin A., Paddock M., Johns C.S., Smith J., Raghavan A., Connolly D.J.A., et al. Avoiding skull radiographs in infants with suspected inflicted injury who also undergo head CT: “a no-brainer?”. Eur. Radiol. 2020; 30(3): 1480–7. https://doi.org/10.1007/s00330-019-06579-wAraki T., Yokota H., Morit A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol. Med. Chir (Tokyo). 2017; 57(2): 82–93. https://doi.org/10.2176/nmc.ra.2016-0191Araki T., Yokota H., Morit A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol. Med. Chir (Tokyo). 2017; 57(2): 82–93. https://doi.org/10.2176/nmc.ra.2016-0191Alhelali I., Stewart T.C., Foster J., Alharfi I.M., Ranger A., Daoud H., et al. Basal skull fractures are associated with mortality in pediatric severe traumatic brain injury. J. Trauma. Acute. Care. Surg. 2015; 78(6): 1155–61. https://doi.org/10.1097/TA.0000000000000662Alhelali I., Stewart T.C., Foster J., Alharfi I.M., Ranger A., Daoud H., et al. Basal skull fractures are associated with mortality in pediatric severe traumatic brain injury. J. Trauma. Acute. Care. Surg. 2015; 78(6): 1155–61. https://doi.org/10.1097/TA.0000000000000662Nigrovic L.E., Kuppermann N. Children with minor blunt head trauma presenting to the emergency department. Pediatrics. 2019; 144(6): e20191495. https://doi.org/10.1542/peds.2019-1495Nigrovic L.E., Kuppermann N. Children with minor blunt head trauma presenting to the emergency department. Pediatrics. 2019; 144(6): e20191495. https://doi.org/10.1542/peds.2019-1495Hagga J.R., Dogra V.S., Forsting M., Gilkeson R.C., Ha H.K., Sundaram M. CT and MRI of the whole body, 5th ed, 2-Vol. set. Am. J. Neuroradiol. 2009; 30(7): e103–4. https://doi.org/10.3174/ajnr.A1609Hagga J.R., Dogra V.S., Forsting M., Gilkeson R.C., Ha H.K., Sundaram M. CT and MRI of the whole body, 5th ed, 2-Vol. set. Am. J. Neuroradiol. 2009; 30(7): e103–4. https://doi.org/10.3174/ajnr.A1609Nakahara K., Shimizu S., Kitahara T., Oka H., Utsuki S., Soma K., et al. Linear fractures invisible on routine axial computed tomography: a pitfall at radiological screening for minor head injury. Neurol. Med. Chir. (Tokyo). 2011; 51(4): 272–4. https://doi.org/10.2176/nmc.51.272Nakahara K., Shimizu S., Kitahara T., Oka H., Utsuki S., Soma K., et al. Linear fractures invisible on routine axial computed tomography: a pitfall at radiological screening for minor head injury. Neurol. Med. Chir. (Tokyo). 2011; 51(4): 272–4. https://doi.org/10.2176/nmc.51.272Zayas J.O., Feliciano Y.Z., Hadley C.R., Gomez A.A., Vidal J.A. Temporal bone trauma and the role of multidetector CT in the emergency department. Radiographics. 2011; 31(6): 1741–55. https://doi.org/10.1148/rg.316115506Zayas J.O., Feliciano Y.Z., Hadley C.R., Gomez A.A., Vidal J.A. Temporal bone trauma and the role of multidetector CT in the emergency department. Radiographics. 2011; 31(6): 1741–55. https://doi.org/10.1148/rg.316115506Menon A., Kanchan T., Rao N.K.G. Skull fractures in fatal head injuries –a comparative analysis of ct and autopsy findings. Intl. J. Med. Toxicol. Leg. Med. 2010; 13(1): 11–4.Menon A., Kanchan T., Rao N.K.G. Skull fractures in fatal head injuries –a comparative analysis of ct and autopsy findings. Intl. J. Med. Toxicol. Leg. Med. 2010; 13(1): 11–4.Henningsen M.J., Harving M.L., Jacobsen C., Villa C. Fractures of the neuro-cranium: sensitivity and specificity of post-mortem computed tomography compared with autopsy. Int. J. Legal. Med. 2022; 136(5): 1379–89. https://doi.org/10.1007/s00414-022-02779-0Henningsen M.J., Harving M.L., Jacobsen C., Villa C. Fractures of the neuro-cranium: sensitivity and specificity of post-mortem computed tomography compared with autopsy. Int. J. Legal. Med. 2022; 136(5): 1379–89. https://doi.org/10.1007/s00414-022-02779-0Chawla H., Yadav R.K., Griwan M.S., Malhotra R., Paliwal P.K. Sensitivity and specificity of CT scan in revealing skull fracture in medico-legal head injury victims. Australas. Med. J. 2015; 8(7): 235–8. https://doi.org/10.4066/AMJ.2015.2418Chawla H., Yadav R.K., Griwan M.S., Malhotra R., Paliwal P.K. Sensitivity and specificity of CT scan in revealing skull fracture in medico-legal head injury victims. Australas. Med. J. 2015; 8(7): 235–8. https://doi.org/10.4066/AMJ.2015.2418

The authors declare that there are no conflicts of interest present.