Case Images
Case Notes
History
13 yo male with ATV accident (no helmet). Initially asymptomatic and shortly later had altered mental status and respiratory failure (intubated).Exam
Prior Study
Bone window CT head and upper C-spine1. Extensive fracture of the left facial bones, left orbital apex, left otomastoid, left greater & lesser sphenoid wings. There are inner bone table fractures of both frontal bones, both ethmoid bones and the roof of the left otomastoid bones.
Noncontrast head CT
1. Extensive fractures mainly involving the left face (i.e. LeFort-3 complex). There are bilateral frontal bone fractures and ethmoid fractures with inner table fracture, likely the source of the intracranial air. There is a transverse fracture of the left temporal bone. There are fractures involving the left orbital apex including a posterior ethmoid bone spicule in close proximity to the optic nerve.
2. There are left intraorbital injuries with retroconal hemorrhages, probable Tenon's space hematoma, and ocular proptosis without obvious tenting.
3. There is a 4-5 mm subdural hematoma within the left anterior temporal fossa extending laterally along the basilar and low convexity of the temporal lobe. The does not produce uncal herniation.
Noncontrast MR T1-w post contrast
1. The T1-w MR adds no additional information not supplied by the head CT.
MR flair & MR T2-w
1. There are multiple sites of brain contusion not evident on prior sequences, see above
2. There is focal edema in the left mesial globus pallidus, consistent with a vascular perforator shear injury.
3. There is optic hydrops consistent with raised intracranial pressure
MR susceptibility (SWI)
1. MR susceptibility confirms the presence of hemorrhage within the multiple sites of brain parenchyma on prior sequences, see above
2. MR susceptibility confirms the presence of micorhemorrhage within the left mesial globus pallidus in the site of apparent perforator shear injury.
3. MR susceptibility confirms the presence of linear micorhemorrhage within the left cerebellum consistent with a site of venous avulsion shear injury and parenchymal laceration.
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. |
Yes | 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. |
No | 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 answers are correct.
Your Answer
Recommendations & Acuity
Recommendations
Expert Answer
Proceed with additional MR imaging sequences.
Your Answer
Acuity
Expert Answer
Emergent (Action Necessary now)
