0:00

This was a 35-year-old male who was assaulted

0:04

with a baseball bat.

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As you can see,

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the patient has had scalp swelling overlying the left

0:13

frontal region, and we see a small collection overlying

0:17

the frontal lobe on the left side.

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However, we also see a collection that is present,

0:25

on the left side in the temporal region

0:29

and measuring probably around 5 mm.

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This collection extends into the subarachnoid space.

0:38

So, we have blood products which are coursing

0:40

along the M1 segment of the middle cerebral artery,

0:44

and then extending into the sylvian fissure

0:48

with subarachnoid hemorrhage,

0:50

and this extends up into this

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superior sylvian fissure, as well.

0:54

So, we are seeing is soft tissue swelling in the scalp,

0:59

we're seeing a small left frontal subdural hematoma,

1:03

we're seeing a left temporal subdural hematoma,

1:09

and we also see a small interhemispheric

1:12

subdural hematoma along the falx.

1:15

And this has multiple components to it.

1:19

When we look at the bone window,

1:25

we can see that the patient has a fracture through

1:31

the mastoid portion of the temporal bone.

1:35

It extends to involve the external auditory canal,

1:39

the tympanic portion of the temporal bone,

1:42

and there is opacification of the middle ear cavity,

1:46

likely with blood products.

1:49

If we follow this fracture further superiorly,

1:53

we see that it does extend into the squamosal portion

1:58

of the temporal bone from the mastoid portion.

2:03

What's the significance of that?

2:05

And here you can see this fracture continuing.

2:07

The fractures of the squamosal portion of the temporal

2:11

bone are the ones that are at risk for tearing the middle

2:15

meningeal artery, leading to an epidural hematoma.

2:20

So if we go back to our soft tissue windows,

2:24

we see a small amount of blood products in

2:28

the extra-axial space on the right side,

2:32

which could represent an early epidural hematoma.

2:38

At this time, there is no midline shift.

2:41

And at this time,

2:43

the subdural hematoma is less than 10 mm thickness.

2:48

So, this is not a neurosurgical emergency.

2:51

I want to get back to the presence

2:53

of the subarachnoid hemorrhage.

2:55

Shortly, I will talk to you about the potential complication

3:00

of pseudoaneurysm or dissecting aneurysm,

3:05

secondary to trauma, which may affect

3:08

the middle meningeal...

3:10

the middle cerebral artery.

3:11

When I see isolated subarachnoid hemorrhage without an

3:15

overlying parenchymal hemorrhage in the sylvian fissure,

3:19

I start to worry about the possibility of either a

3:23

dissecting aneurysm or a bleed from a pseudoaneurysm.

3:27

Unfortunately,

3:28

sometimes you have patients who

3:30

have motor vehicle collisions,

3:32

and the question that the clinicians will ask you is,

3:35

did the patient bleed from a berry aneurysm of the middle

3:40

cerebral artery, which led to the loss of consciousness,

3:44

and then the patient crashed?

3:46

Or did the patient crash and the subarachnoid

3:50

hemorrhage is secondary to the trauma?

3:52

Sometimes this question cannot be answered,

3:54

and this is one of the indications for CT angiography to

3:59

evaluate for either dissecting aneurysms or berry aneurysms

4:05

that may be the primary cause of

4:08

the motor vehicle collision.