Case Notes
History
37yo female who fell out of a moving vehicle presenting with altered mental status and confused at sceneExam
MR diffusion (DWI & ADC maps)
Prior Study
Bone window CT head and upper Cspine1. Bilateral, uncomplicated (other than minimal free intracranial air) longitudinal temporal bone fractures. A nondisplaced vertical linear calvarial fracture connects with the right temporal bone fracture. There is minimal diastasis of the lambdoid sutures in the area near the temporal bones bilaterally. There is no fracture of the sigmoid plate on either side. The bilaterality of the temporal fractures is unlikely with a single blunt force event therefore multiple direction cranial injuries are likely.
Noncontrast head CT
1. There are bilateral longitudinal temporal bone fractures and a vertical temporo-parietal nondisplaced fracture. However the intracranial CT demonstrates superficial cortical subpial contusions in the right temporal and bifrontal area (worse on the right than the left), plus a right basifrontal hemorrhagic (gliding injury) contusion. There are subtle microhemorrhages in the major forceps of the right caudate also consistent with accelleration-decelleration white matter injuries likely superimposed on the multidirectional blunt force traumatic mechanisms.
Noncontrast MR T1-w post contrast
1. Persistent post traumatic parenchymal injury with progressive vasogenic edema in the right frontal regions with persistent right to left 8 mm subfalcine shift and substantial transcranial frontal lobe herniation into the craniectomy defect. There is only minimal post traumatic edema in the left frontal parenchyma.
2. Interval accumulation of small volume caudal, supratentorial, subdural hematomas. Linear brain tracts are present on the right consistent with prior ventriculostomy catheter placements.
MR flair
1. Persistent post traumatic parenchymal injury with progressive vasogenic edema in the right frontal regions with persistent right to left 8mm subfalcine shift and substantial transcranial frontal lobe herniation into the craniectomy defect.
2. Interval accumulation of small volume caudal, supratentorial subdural hematomas. Linear brain tracts are present on the right consistent with prior ventriculostomy catheter placements.
MR susceptibility (SWI)
1. The SWI is positive in areas of known intraaxial and extraaxial concussive injuries and along the ventriculostomy catheter tracts. However, there are subtle change of DAI.