Wk 5, Case 2 - Review

Patient History
Pedestrian struck. Only reacts to painful stimuli. GCS of 5.

Findings
There is curvilinear high density along the left aspect of the septum pellucidum with extension into the frontal horn of the left lateral ventricle, thought to represent or acute hemorrhage. No pathologic mass effect.

No CT evidence of transcortical infarction. Basal cisterns are preserved. Calvarium is intact.

Minimal left maxillary mucosal thickening. Remaining paranasal sinuses and mastoid air cells are clear.

Bilateral parietal scalp contusions and subcutaneous emphysema with scattered punctate hyperdensities noted in the left parietal scalp compatible with foreign bodies.

Impressions
Small curvilinear intraventricular hemorrhage in the left lateral ventricle.

No hydrocephalus. No additional hemorrhage or pathologic mass effect.

Biparietal scalp contusions with scattered punctate foreign bodies in the left parietal scalp

Findings
A punctate focus of hyperattenuation is now seen in the posterior left internal capsule adjacent to the thalamus (series 2 slice 18). This was not definitely present on the prior exam. This measures no more than about 2 mm, and the possibility that this could reflect noise is considered.

Blood products previously seen along the left aspect of the septum pellucidum now predominantly layer within the occipital horn of the left lateral ventricle. The overall volume of blood products does not appear significantly changed. The caliber and configuration of the supratentorial ventricular system is similar to the prior exam, an appropriate for the patient's age. No midline shift. The gray-white matter differentiation is preserved. The basal cisterns are patent.

The orbits are normal. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Dental carious lesions, partially seen.

Bilateral parietal scalp contusions are present, with surgical staples over the left parietal scalp. Subcutaneous gas is present in the left parietal scalp, consistent with prior laceration. Bony calvarium intact.

Impressions
A punctate focus of hyperattenuation measuring about 2 mm is now present in the posterior left internal capsule compared to the prior exam, may likely be artifactual, although tiny microhemorrhage is possible. Attention on follow-up exam. MRI would be more sensitive for parenchymal microhemorrhages if indicated.

Layering blood within the left lateral ventricle, without appreciable change in volume compared to the prior exam. Bilateral scalp contusions, similar to the prior exam.

Findings
MRI Brain:

There is restricted diffusion seen in the splenium of the corpus callosum with extension to the body of the corpus callosum. This is associated with multiple areas of microhemorrhage to the left of midline affecting the top of the corpus callosum and the adjacent cortex. Microhemorrhages are present in the medial aspect of the left frontal lobe extensively as well. This includes involvement of the cingulum and supplemental motor area. Microhemorrhages are also seen in the subcortical white matter of the right frontal lobe, left parietal-occipital junction, right parietal-occipital junction. A focus along the posterior lateral left thalamus is also present. Study is limited secondary to motion artifact.Redemonstration of layering blood product within the left lateral ventricle, not significantly changed when compared to CT 8/22/2017. No evidence of extra axial fluid collection. Ventricles normal in size and shape for patient's age. Patent basal cisterns. Orbits and paranasal sinuses unremarkable.

MRA head:

Significant motion artifact severely limits visualization of the intracranial arteries above the level of the circle of Willis.The intracranial carotid arteries, M1 segment of the middle cerebral arteries, A1 segment of the anterior cerebral arteries, and posterior cerebral arteries appear patent. Codominant vertebrobasilar system which appears patent. SCAs and AICAs appear patent.No evidence of dissection or aneurysm as best as can be determined given limitations described above.

MRA Neck:

Study is limited secondary to motion artifact.Normal three-vessel aortic arch. The vertebral arteries arise from the subclavian arteries.No significant stenosis of the common or internal carotid arteries. No significant stenosis of the vertebral arteries, which appear patent along their course.

Impressions
1. Discrete focus of restricted diffusion in the splenium of the corpus callosum with hemorrhage in the top of the corpus callosum. Because of the absence of hemorrhage specifically in the splenium, this could either be due to the institution of Keppra (Levetiracetam) drug or non-hemorrhagic shearing injury.

2. Multifocal areas of susceptibility deposition bilaterally in the hemispheres and most affecting the cingulum and supraventricular medial left frontal lobe compatible with hemorrhagic shearing injuries at the gray-white junction also affecting the posterior lateral left thalamus.

3. Redemonstration of layering blood products within the left lateral ventricle, not significantly change from previous CT.