0:00

This is the same patient as I described previously.

0:04

After a few days, as you can see,

0:07

the patient has undergone surgery for evacuation

0:10

of the epidural hematoma on the right side.

0:15

And so, we see some air and blood products

0:17

on the right side.

0:19

Now,

0:19

this collection is no longer confined by the dura,

0:23

and therefore, it is crescentic in shape,

0:26

and therefore, represents a subdural hematoma

0:30

in the postoperative setting.

0:32

You'll notice that over the course of time,

0:34

the patient developed parenchymal hemorrhages

0:37

in the left lateral temporal lobe,

0:39

seen on the image on your left-hand side.

0:44

And this is not unusual to have a contusion that occurs.

0:49

You'll also see that the patient has developed

0:52

a subdural hematoma along the tentorium.

0:55

This is often better demonstrated in the coronal plane,

0:59

but you can see that extra density on the right side

1:03

compared to the left side,

1:05

representing a tentorial hematoma.

1:08

As we go further inferiorly,

1:10

you'll notice that the blood products have collected

1:12

along the left cerebellar hemisphere.

1:16

So, this patient has a significant amount of

1:19

damage to the brain with an epidural,

1:22

a subdural, an interhemispheric subdural hematoma.

1:25

We have the tentorial subdural hematoma,

1:29

all in the same example.

1:33

I want to show the MRI scan.

1:35

This is the susceptibility-weighted scan of the MRI scan,

1:40

which is our best technique for demonstrating blood products.

1:44

And anything dark here would be either a vein

1:47

or blood products.

1:49

As you look at the tentorium,

1:51

you can see that there is this black rim

1:53

around the edge of the tentorium.

1:55

What we're seeing is the superior vermis with blood

1:58

products in the sulci of the superior vermis,

2:02

as well as blood collecting along the tentorium.

2:06

Here we have our postoperative state with blood products

2:10

collecting the extra-axial compartment,

2:12

and there's also blood products in the extra-axial

2:15

compartment, overlying the left posterior

2:18

frontal and parietal lobes.

2:21

Here is the parenchymal hemorrhage that is demonstrated

2:26

on the MRI scan as an area of dark

2:29

signal from deoxyhemoglobin.

2:32

There's one more finding on this

2:35

MRI scan that is noteworthy,

2:37

and I want to go to the diffusion-weighted imaging.

2:42

This is the diffusion-weighted scan.

2:44

What one sees on the diffusion-weighted scans are lots of

2:48

small areas of high signal-intensity.

2:50

Blood products,

2:51

unfortunately,

2:52

on diffusion-weighted scans

2:54

can sometimes simulate cytotoxic edema.

2:57

Normally, when we look at the

2:59

diffusion-weighted scan,

3:00

we're looking for the presence of high-signal-intensity

3:04

that might suggest acute ischemia or a stroke.

3:08

I'm going to go to a two-one-one

3:11

and bring up the ADC map.

3:15

And these areas of high signal intensity on the diffusion

3:20

weighte imaging are not corresponding to low signal

3:23

intensity areas on the ADC map.

3:26

And so, they likely represent blood products

3:28

in the subarachnoid space.

3:29

Now, contrast that to this area.

3:32

So, here we have a very bright area in the splenium of the

3:36

corpus callosum on our diffusion-weighted imaging,

3:39

which corresponds with dark signal intensity

3:43

on the ADC map.

3:44

So, this is indeed cytotoxic edema.

3:48

Bright signal intensity on DWI in the splenium of the

3:52

corpus callosum can be due to a variety of causes.

3:56

The most common cause, in this situation, is a patient who

4:04

has had a shearing injury of the splenium

4:06

of the corpus callosum.

4:08

In this case,

4:09

what I would do is I would look at our susceptibility

4:13

weighted scans and look for blood products that would

4:15

indicate hemorrhage in the splenium of the corpus callosum.

4:19

There are a few tiny dots here,

4:22

and therefore, that is a possibility.

4:25

The other possibility is that the bright signal on the DWI

4:29

in the splenium could be due to the institution

4:32

of antiseizure medications.

4:35

It's not unusual for patients who have had head trauma to

4:38

be placed on antiseizure medications such as Keppra,

4:44

which is due to the irritation of the brain,

4:48

that is the etiology for the seizures, that is,

4:51

blood products in the brain.

4:53

And in this instance,

4:54

given the relative lack of hemorrhage in

4:57

the splenium of the corpus callosum,

4:59

I would suggest that this is most likely due to the

5:01

institution of antiepileptic drugs.

5:04

And look in the EMR,

5:06

the electronic medical record for that.

5:08

If this was not...

5:10

If the patient was not seizing and was

5:11

not on antiepileptic medications,

5:15

then we would suggest that maybe this is either

5:18

non-hemorrhagic shearing injury or due to the trauma,

5:23

or less likely, an ischemic injury.