0:01

This is a patient who presented from a

0:04

nursing home, having fallen in the nursing home.

0:08

For the evaluation of patients for trauma,

0:12

I'm looking predominantly for hemorrhage, and I would

0:16

not consider it sufficient to just look at the thin sec—

0:22

uh, the thick section images in patients for trauma.

0:26

This is the type of situation where sometimes the

0:29

findings are very subtle, so I would recommend

0:32

that you go to the thin section images of the

0:35

CT study, or at the very least, that you make

0:38

sure that you evaluate the patient both in

0:41

the axial plane as well as reconstructed planes

0:44

from the thin section image.

0:46

So what do I mean by thin section images?

0:48

These are three-millimeter thick sections,

0:50

and there are 52 images on this individual.

0:53

So let's look at the CT scan.

0:55

Almost immediately, I see that there is swelling

0:57

over the right orbital region, and therefore, I

1:01

recognize that the patient does indeed have trauma.

1:04

We'll talk about orbital trauma and fractures

1:07

when we look at the head and neck section

1:09

of this emergency department mastery course.

1:13

However, if we're looking intracranially, we're looking

1:16

for anything that might be bright in density, and

1:19

almost immediately, again, we see that there is

1:22

an area of high-density, bright signal here in

1:26

the medial left occipital region with hemorrhage

1:31

extending into the subarachnoid space, as well as

1:34

along the cortical surface of the brain tissue.

1:38

So this is cortical as well

1:40

as subarachnoid, based on its

1:42

appearance going into the sulci, as

1:45

well as more fully in the brain parenchyma.

1:47

36 00:01:48,555 --> 00:01:51,555 You notice as well that there is another area of

1:52

hyperdensity anteriorly, associated with the clivus on the

1:59

right side, and once again, it looks as if some of the

2:02

blood is in the extra-axial subarachnoid space as well.

2:07

As one would expect in an elderly individual,

2:10

there are areas of low density in the

2:13

periventricular region, which is typical of

2:16

what we call a small vessel ischemic injury.

2:19

Continuing up further superiorly, what we notice

2:23

is that there is an extra-axial collection,

2:27

which is outside the brain tissue—so extra-axial, not

2:32

in the brain tissue—which is seen in the occipital

2:35

and parietal and extends to the frontal lobe region.

2:40

And I'm going to adjust the window here so you can

2:43

see that extra-axial collection a little bit better.

2:47

Here's that collection over the frontal

2:51

region, and we also note that there is

2:53

some scalp swelling superficial to it.

2:58

So again, I would not stop here.

3:01

I would pull down the 308-image

3:05

0.75-millimeter thick thin sections.

3:10

Again, noticing the same elements of the edema over

3:14

the right orbit and identifying and characterizing

3:19

parenchymal and subarachnoid hemorrhage, as well as

3:24

subdural hematoma, as well as an additional

3:28

area of subarachnoid hemorrhage.

3:32

And what you notice further up superior here,

3:36

and this is not that uncommon, there's also

3:38

a low-density subdural collection, a chronic

3:42

subdural hematoma in this elderly individual.

3:45

So this is unlikely to represent something related

3:49

to the current injury, as opposed to the hyperdense

3:53

collection that we see over the frontal regions

3:56

and in the parenchyma and subarachnoid space.

3:59

If you look at this on the coronal

4:01

plane, again, we see that large area of

4:05

hemorrhage in the left occipital region.

4:07

It is a kind of a ball of hemorrhage,

4:10

so parenchymal as well as subarachnoid.

4:14

And then we have the collection over

4:18

the temporal region that is hyperdense,

4:22

as well as over the high frontal and

4:27

parietal convexities, which is hypodense.

4:31

So how do we summarize this case?

4:34

We summarize this case by saying that the patient

4:36

has bilateral subdural hematomas—acute on the

4:41

left side, chronic on the right side—associated

4:45

with parenchymal hemorrhage in the right lobe

4:51

and left medial occipital lobe, with

4:55

associated subarachnoid hemorrhage,

4:58

focally adjacent to the areas of parenchymal

5:03

hemorrhage. Some pertinent negatives:

5:07

No midline shift, no evidence of herniation,

5:10

no intraventricular hemorrhage, and were

5:14

we to look at the bone windows, we would

5:17

identify that there were no fractures

5:21

adjacent to the areas of scalp

5:24

swelling and orbital swelling.