0:00

This is a 77-year-old from a nursing home who was,

0:06

"found down,"

0:08

and that is not an unusual indication in the

0:11

emergency department in this situation.

0:15

What one sees is a patient who has blood products along

0:19

the falx and subfalcine hemorrhages are a common location

0:27

for subdural hematomas. In this case, not that thick.

0:32

However,

0:32

one also notes that the patient has effacement of the

0:35

sulci overlying the right frontal and parietal regions,

0:40

compared to a more normal-looking nursing home

0:44

subarachnoid space on the left side.

0:47

As we proceed further inferiorly,

0:50

we note that the subdural hematoma comes along the

0:53

posterior falx and then extends along

0:56

the parietal occipital region.

0:58

And it also is nicely demonstrated if one uses

1:02

different windowing to show that hemorrhage.

1:05

Again, we continue to have effacement of the sulci

1:09

as we course further inferiorly.

1:12

Let's continue inferiorly.

1:13

So now, we are coming into a very large area of hemorrhage.

1:17

And the question is,

1:18

is this hemorrhage in the parenchyma or is this part

1:23

of the subdural hematoma? By virtue of the shape,

1:26

this would be very unusual for this

1:28

to represent a subdural hematoma,

1:31

which are usually more of the crescentic nature,

1:34

as I described previously.

1:36

So, this is a parenchymal hemorrhage with

1:39

an associated subdural hematoma.

1:43

In this case,

1:44

we do not see very much in the way of midline shift.

1:47

So if we measure,

1:51

we see that the degree of midline

1:53

shift is only 2 mm,

1:57

1.6 mm to be exact,

1:59

and therefore, does not meet the 5 mm criteria

2:03

for surgical indication.

2:05

We would also measure the subdural hematoma.

2:09

This measures 7 mm.

2:11

Remember that it was 10 mm for surgical indication.

2:15

However,

2:15

one has a very large parenchymal hematoma

2:18

in association with that.

2:21

And we would measure the parenchymal hematoma

2:25

as 4 cm by 4 cm,

2:32

and then perform the multiplanar reconstruction

2:35

and identify that it was also 4 cm in size.

2:39

So, if we multiply 4 cm by 4 cm, by 4 cm,

2:45

we would come to 64 cm.

2:47

Divide that by two and it would be 32 cm,

2:51

by the way the neurosurgeons measure it,

2:54

and that would be under the 50 CCs

2:56

that is required for surgical intervention

2:59

for a parenchymal hematoma.

3:02

So, this patient has pretty large degree of damage to the

3:08

brain and a nice demonstration of acute subdural hematoma.

3:13

Now,

3:14

how many of you were paying attention

3:16

as I scrolled past this slice?

3:21

Aha!

3:23

Intraventricular hemorrhage.

3:25

Now, in this case,

3:26

the patient has known other areas of hemorrhage.

3:30

However, that intraventricular hemorrhage

3:33

should spark your query

3:36

as to the quality of the corpus callosum and splenium.

3:41

And sure enough, as you can see,

3:43

there are higher density areas in the right side of the

3:48

splenium of the corpus callosum that likely represent a

3:52

shearing injury to the corpus callosum, associated with

3:55

bleeding into the occipital horn of the lateral ventricles.

3:59

Came back to haunt.