Hemosiderin – the Marker of the Milder Brain Injury

Hemosiderin – The Trace of a Mild Traumatic Brain Injury

By Gordon Johnson

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Hemosiderin is essentially a blood stain, on human tissue.  In context of mild traumatic brain injury, hemosiderin is a blood stain on brain tissue. One area where there is a major advantage in a tailored protocol, (see previous page) is in the area of hemosiderin staining. Hemosiderin is a stain, left behind after a brain bleed, even after though the blood is reabsorbed into the blood system.

Think of getting a glob of ketchup on a white shirt. When the ketchup first lands, it is clearly visible, has three dimensional mass and continues to spread. You quickly wipe it off, stop the spreading.  Still, there is a bright red spot on your shirt. You wash the shirt, the ketchup is all gone, but a stain remains.

A brain bleed does the same thing to brain tissue. At first, the brain bleed has dimensional mass and will show up on a CT scan. Later, when still fresh, it will likely show up on a conventional MRI. But when the significant mass of the blood has been reabsorbed, all that will be left is the stain.  Neuropathologists have been familiar with hemosiderin, because they can see the hemosiderin stain on autopsy. Recent advances in MRI protocols, have created ways in which the magnet and the computer that interprets the data, can identify this “hemosidrin” staining. A decade ago, the favored protocol was called a Gradient Echo Imaging, or GRE.  Today, the Susceptibility Weighted Imaging or SWI, offers the best images of hemosiderin.

Smaller Slices for MRI of Brain

Other areas where tailored protocols may come into play is increasing the proximity of the MRI slices thru the brain from the standard 2 mm slices to one mm. In essence, this improvement allows us to see pathology that might exist between the layers of the 2mm slices.

Increase Pixel Dimensions of MRI of Brain

Another potential advancement which is not getting much attention is to increase the pixel size of the scan to 1024 by 768, (similar in size to the standard resolution of most laptops) from what is typically something more equivalent to 360 pixels by 240 (more the size of a typical Youtube video.) This type of resolution is now common when scanning for tumors. Why not brain injury? The failure to ask for a higher resolution images if partially because of priorities.  Tumors are thought to be more dangerous than hemosiderin.  But the fundamental reason a more focused and higher resolution scan isn’t asked for is that few neurologists or neuroradiologists have thought about the advantages to aiming a telescopic image.  Shouldn’t such higher processing power be directed at the frontal lobes? Wouldn’t those particularly vulnerable undersides of the frontal lobes and get a closer look? What about the lower brain structures and at the brain stem, areas that are difficult to image conventionally?

With all tailored protocols, there is always a cost benefit analysis. A tailored MRI protocol costs more. A tailored MRI protocol costs requires more attention from the neuroradiologist.   A tailored MRI protocol also extends the amount of time that the patient must stay in the scanner. Time in a scanner can be unpleasant and exceedingly boring. Faster scanning times are eliminating some of that disadvantage. The ultimate answer as to why these more tailored protocols aren’t done is that no one is demanding it.

Those who order imaging on someone with Post Concussion Symptoms, should insist on at least the hemosidrin investigation, and hopefully the 1 mm slices. Someday  1024 x 768 resolution will be the norm, at least in the areas most likely susceptible to mild brain injury pathology.  If scanning technology was increasing at the rate that computers do, by the time this is published we might be talking about 1920 x 1200.  Sadly, this discussion of the state of the art of neuroimaging may not be outdated even a decade from now.

 Next – SWI – Susceptibility Weight Imaging MRI


Gordon Johnson

Attorney Gordon Johnson is one of the nations leading brain injury advocates. He is Past-Chair of the TBILG, a national group of more than 150 brain injury advocates. He has spoken at numerous brain injury seminars and is the author of some of the most read brain injury web pages on the internet.

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