Wk 5, Case 4 - Review

Patient History
Young 12 year old passenger in a head on motor vehicle collision. Lacerations to the face, scalp hematoma, fixed equal pupils. L1 fracture.

Findings
Brain:

The noncontrast CT scan of the brain shows bilateral pneumocephalus as well as intraventricular air. There is subarachnoid hemorrhage along the basal cisterns as well as in the sella region and in the sphenoid sinus.
Air is seen collecting around the tentorium, the brainstem, and in the spinal canal.

Maxillofacial region:

Bilateral nasal bone fractures are present. There is fracture of the posterior right wall of the sphenoid sinus communicating with the carotid canal. There is fracture of the right mastoid portion of the temporal bone. An oblique fracture through the left mastoid temporal bone extending to the posterior external auditory canal is present. There is evidence of dislocation of the malleus from the short process of incus on the right side. A vertically oriented fracture is also present along the inferior temporal bone seen best on series 24 image 142. There are fractures of the anterior nasal spine bilaterally seen best on series 24 image 175 .

There likely is dislocation of the right incus from the right stapes.


There is a 1.2 cm lesion along the left globe seen best on image 23/69 which has calcification and fat and likely represents a lacrimal region dermoid.


CTA:

The origins of the common carotid arteries are normal. The carotid bifurcation show no evidence of stenosis. The petrous internal carotid arteries show minimal diminution in the caliber on the left side. The left petrous cavernous junction and the right petrous cavernous junction show diminution in the lumen of the vessels, right worse than left and there is early opacification of the left cavernous sinus. The right cavernous internal carotid artery shows incomplete opacification along its anterior margin suggesting dissection.

The patient has dissection of the left proximal cavernous internal carotid artery and the left cavernous sinus is opacified while in the arterial phase suggestive of a cavernous carotid artery fistula. The etiology of the injury to the left cavernous internal carotid artery is likely the fracture involving the sphenoid sinus and/or the temporal bone injury.

The vertebral arteries are unremarkable throughout their course.

The intracranial circulation shows normal appearance to anterior cerebral and middle cerebral artery branches. However the basilar artery has irregularity along its portion between the anterior-inferior cerebellar
artery and the superior cerebellar artery suggesting spasm.

Cervical spine:

The alignment of the cervical spine vertebral bodies is appropriate. No fractures are identified.

The patient is intubated and has a nasogastric tube in place. Edema around the right submandibular gland is evident with extensive subcutaneous emphysema in the neck.

Impressions
Extensive pneumocephalus throughout the supratentorial compartment with intraventricular air as well as subarachnoid hemorrhage and air in the basal cisterns likely from temporal bone and paranasal sinus fractures.

Right-sided dissection of the distal petrous internal carotid artery-cavernous carotid artery junction with partial occlusion of the vessel with thrombus in the right cavernous internal carotid artery.

Left sided cavernous ICA dissection with likely fistula to the cavernous sinus associated with comminuted fracture of the walls of the sphenoid sinus with extension to the carotid canals.

Bilateral oblique temporal bone fractures with dislocation of the malleus from the right incus and extension to involve the left external auditory canal posterior wall. Probable right incudostapedial dislocation. Bilateral nasal bone fractures and anterior nasal spine fracture.

Unremarkable evaluation of the cervical spine.