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This was a 34-day-old infant who fell from a chair.

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On the initial CT scan,

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one can see that the patient has had significant

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soft tissue injury to the scalp.

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Not only that but of the soft tissue windows,

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one can already see that the patient has

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had a fracture of the calvarium.

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This is at the coup side of the injury.

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You'll notice that there is subarachnoid blood products

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which are accumulating under the fracture site,

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and there is also an extra-axial subdural hematoma appearing.

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If you look contrecoup,

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you'll see that there is an extra-axial collection overlying

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the temporal region, and this has mixed density,

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likely from

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acute bleeding with unclotted blood.

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You'll also see that the patient has some blood products that

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are accumulating at the top of the tentorium,

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near the pineal region.

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The patient was scanned serially,

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but before that, I want to make one point

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about fractures in the infant.

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We have found that creating three-dimensional

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reconstructions of the calvarium have been infinitely

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valuable in detecting fractures.

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This is a 3D reconstruction from the bone-thin section

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images, which were 0.75 mm thick.

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As you can see,

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it well demonstrates the wide fracture that occurred in

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this patient that communicated with

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the superior sagittal suture.

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There also was a fracture which crossed

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the midline on the right side,

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and you can also see an additional fracture of the

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calvarium which extends to the lambdoid suture.

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Therefore,

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I highly recommend that one takes the thin section images

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and reconstructs them in a three-dimensional fashion

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to look at the calvarium for fractures in infants.

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It really does show it well.

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Now, let's see the patient's six-hour follow-up scan.

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The patient continues to show the soft tissue swelling and

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continues to show a small amount of subarachnoid

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blood and extra-axial collection

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under the fracture site.

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There is more blood product

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which is seen at the tentorial incisura,

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that is the top of the tentorium

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along the superior vermis.

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And one continues to see an extra-axial collection

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which looks a little bit larger,

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more posteriorly on the right side.

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Again, with mixed density, suggesting that this may

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be unclotted blood.

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Blood that is still bleeding currently.

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You'll notice also a new area of hemorrhage in the cortical

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surface of the medial aspect of the left frontal lobe.

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Let's see the patient's MRI scan.

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This is the MRI scan of the patient four days later.

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It shows continued swelling of the soft tissues of the scalp,

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as well as the fracture site and blood products

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underlying the fracture site on the right side.

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We continue to see the hemorrhagic collection

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in the right temporal region as well.

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And it doesn't look like there's very

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much in the way of midline shift.

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The patient is doing much worse than one would expect,

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however,

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from this degree of imaging findings

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on the T2-weighted scan.

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Before I show the susceptibility-weighted scan,

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which is usually the money scan,

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I do want to show the diffusion-weighted scan.

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As I said previously,

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shearing injuries can lead to cytotoxic edema

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that is seen within the white matter.

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This is the trace image of the diffusion-weighted imaging,

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and almost immediately,

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you can see that there are areas of high signal intensity

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along the gyrus rectus region,

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in the subcortical white matter

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of the right posterior temporal lobe,

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extending to the occipital lobe,

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in the frontal lobe on the left side

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and in the high right frontal lobe and parietal lobe.

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So, these are areas where the brain has been damaged

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in a setting of diffuse axonal injury.

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The DWI shows the cytotoxic edema.

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However,

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the susceptibility-weighted scans will show

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the degree of hemorrhage.

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Unfortunately,

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the patient was moving quite a bit.

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However,

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I hope that this scan can still impress you with the

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amount and number of hemorrhagic injuries

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to the brain from the shearing

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injury that the child sustained.

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We tried it multiple times.

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You see all these little black areas which represent the

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deoxyhemoglobin of hemorrhagic shearing injury

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in this patient

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whose CT scan and initial fast spin echo

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T2 weighted scans were relatively unrevealing.

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This is the T1-weighted scan

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showing small extra axial fluid collections.

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So, once again,

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diffuse axonal injury can occur not just in adults,

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but can occur in children and may be associated

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with devastating consequences.