Case Images
Case Notes
History
54 yo male unwitnessed ATV accident. Found down by bystanders. Suspicion of Etoh intoxication. Intubated on scene, hemodynamically stableExam
Prior Study
Bone window CT head and upper Cspine1. Multiple sites of bone injury including a LeFort-3 fracture complex on the right, a high convexity laterofrontal comminuted fracture with 4 mm depressed fracture, a fracture of the right orbital apex, a fracture of the left EAC likely extending into the adjacent mandibular space, and there is minimal diastasis of the left lambdoid suture. There are multiple nondisplaced upper Cspine chronic fractures without canal compression. However, the multiplicity and the overall severe impact cerebral injuries would suggest that these cervical injuries be considered unstable at the present time.
2. Depressed right orbital roof fracture has produced right orbital (non-focal) intraconal, extraconal retroglobal hemorrhage leading to ocular proptosis without ocular tenting. There is possible focal blood within Tenon's space.
Noncontrast head CT
1. Focal hemorrhagic contusion of brain beneath the right high convexity laterofrontal comminuted and depressed fracture. There is no focal hematoma.
2. Extensive post traumatic fractures of the right orbit (LeFort-3 complex, comminuted laterofrontal, high convexity calvarial fracture complex with a 4 mm depressed fragment. The right orbital fracture extends into the anterior temporal fossa bone and causes displaced fractures of the posterior orbit, but sparing the optic canal.
3. Depressed right orbital roof fracture has produced right orbital (nonfocal) intraconal, extraconal retroglobal hemorrhage leading to ocular proptosis without ocular tenting. There is possible focal blood within Tenon's space.
4. There is a nondisplace fracture of the left external auditory canal.
Noncontrast MR T1-w
1. Multiple right orbital, right high laterofrontal calvarium, and right squamous temporal fractures with mainly right intraorbital blood product and high-convexity, lateral, frontal contusion.
2. It appears that the superficial cortex in the site of contusion is actually herniated into the inner table fracture diastasis. This raises the possibility of later transcranial herniation with "growing fracture".
MR flair
1. The parenchymal edema on MR flair is consistent with right frontal and occipital brain contusions, plus element of the white matter shear injuries in the frontal regions bilaterally. Correlate with MR SWI and MR diffusion.
2. The facial, orbital, and skull fracture sites are again identified, as discussed on prior sequences.
MR susceptibility (SWI)
1. MR-SWI evidence of multiple intracranial injuries including right frontal contusion, right anterior temporal pole, and bilateral suboccipital superficial cerebellar contusions. Additionally, there are white matter accelleration-decelleration injuries in the right anterior and posterior frontal regions.
Dicom
Findings
| MR diffusion (DWI & ADC maps) | Correct Answer | Your Answer |
|---|---|---|
|
There is evidence of positive MR-diffusion but negative ADC (edema shine-through effect) associated with intraaxial parenchymal injury not evident on CT or other MR sequences. |
Yes | NA |
|
There is evidence of positive MR-diffusion and ADC (actual positive restriction) in areas of post traumatic or hypoxic cytogenic edema or intercurrent arterial occlusion. |
No | NA |
|
The distribution of the positive sites on the DWI are consistent with a single trauma vector versus vectors of different directions (shaking) in NAI patients. |
Yes | NA |
|
There is positive diffusion and positive ADC associated with intraaxial parenchymal injury and local ischemic effects not evident on CT or other MR sequences. This is especially evident in infants (< 1 year old) with NAI. |
No | NA |
| Other | Correct Answer | Your Answer |
|---|---|---|
|
There is evidence of concurrent abnormalities not likely related to recent brain injury. |
No | NA |
Impression
Expert Answer
All of the above are correct
Your Answer
Recommendations & Acuity
Recommendations
Expert Answer
Proceed with additional MR imaging sequences.
Your Answer
Acuity
Expert Answer
Emergent (Action Necessary now)
