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I'd like to start with a discussion

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about intraparenchymal hemorrhage.

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By that, I mean hemorrhage that is within the brain

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in the intraaxial compartment.

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Let's start with this patient.

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This is a 53-year-old patient who was in an altercation.

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In general,

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my approach to evaluating the patient is to start

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centrally, looking at the ventricular system

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because the degree of midline shift

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is one of the indications for surgery

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and is a very important point.

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It also is a marker for whether or not

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the patient may be herniating.

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And that's an emergent finding that I would want to get

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on the phone with immediately.

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So in this situation,

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we have a patient who has multiple parenchymal hemorrhages

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on the left side, and we see that the ventricles

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are displaced from left to right.

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So, we would measure the midline shift in this fashion

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with our electronic calipers,

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and measure it to the septum pellucidum.

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This measures 5 mm.

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And we'll talk about the importance of the degree

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of midline shift in just a moment.

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The septum pellucidum is a good marker

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for supratentorial displacement.

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Lower down, we have the uncus.

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The uncus is a portion of the temporal lobe which is

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in the medial most portion near the tentorial edge.

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We also would describe what is happening with the uncus.

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And this is this region here in the left temporal lobe.

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You'll notice that it is shifted over more medially

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compared to the contralateral side.

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So, this patient does have uncal herniation

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demonstrated on this section.

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Were we to look in the posterior fossa for midline shift,

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we would generally refer to the fourth ventricle and to

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the degree of effacement and/or displacement

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of the fourth ventricle from the midline.

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So, this patient has both subfalcine herniation,

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in that there is displacement across the falx

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from left to right by 5 mm,

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as well as uncal herniation at the level of the

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temporal lobe by these large hemorrhages.

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So, the next thing to do is to characterize

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the hemorrhages.

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The neurosurgeons evaluate and characterize the quantity

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of the hemorrhage by doing three volume measurements.

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That is, three different diameters.

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So initially,

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they will measure the AP diameter of a hemorrhage.

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In this case, 5.5 cm.

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They will measure the maximum transverse diameter

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of a hemorrhage, in this case, 2.8 cm.

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Then we would have to do a multiplanar reconstruction

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to identify the superior-inferior

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extent of the hemorrhage.

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If you want to measure it without necessarily creating

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a coronal or sagittal reconstruction,

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you can simply use the table position markers for

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identifying the beginning of the hemorrhage, say,

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on this slice,

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and then moving to the top of it and note the table

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position and do your mathematics by simple subtraction.

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This hemorrhage that we're looking

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at here has some unique features.

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It is showing a fluid,

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fluid level that is a hemorrhage level with

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some anterior portion, which is less dense,

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and a more dependent portion, which is more dense.

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This implies that the patient is actively extravasating,

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that is, that we have portions of the blood products that are

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clotted and portions of the blood products which are not

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clotted. Now, just to prove that I don't tell falsehoods,

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you'll notice that the hemorrhage in the anterior portion

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on the left side is down at the lower

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anterior cranial fossa floor,

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and this is the gyrus rectus region that I refer

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to with regard to the locations of hemorrhage.

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So this patient has a hemorrhage along

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the gyrus rectus on the left side,

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demarcated by the hyperdense collection here in the brain,

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as well as a hemorrhage along the anterior portion

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of the temporal lobe, which, as I mentioned

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in my previous discussion, is an injury that usually occurs

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due to the temporal lobe banging up against the greater

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wing of the sphenoid and leading to

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that hemorrhagic contusion.

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Now, I may use the term interchangeably between

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a contusion versus a hematoma.

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Contusion usually refers to a bruise and is usually not

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as large or dense or as well defined

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as a parenchymal hematoma,

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but quite often we use the terms interchangeably.

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So this patient has multiple

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hemorrhagic intraparenchymal collections, as you can see,

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in the left frontal, temporal, and parietal lobes.

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But also one sees that there is a lesion here in the right

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parietal lobe for an additional area of hemorrhage.

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As I said previously,

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it is useful to look at both the thick sections as well

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as the thin sections. On this thick section,

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which is 5 mm thick,

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it is somewhat difficult to identify that the patient also

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has a subdural collection along the left temporal lobe.

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However,

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if one looks at the thin section images, and these are the

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0.75 millimeter sections

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that I referred to previously,

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one can clearly see that the patient does have collection here.

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It's also useful to, as I said,

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use different windows. This is more of a subdural window,

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which is wider in its width and centering,

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and you can see that there is a hyperdense extra-axial

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collection outside the brain on the left side,

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which we would also use the measuring tool to

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characterize as far as its maximum width,

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which in this case is 8 mm of thickness.

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And this will go up further superiorly.

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You'll notice also that there is hemorrhage that

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is extending into the sulci of the brain.

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This refers to subarachnoid hemorrhage.

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So in this one image, in this one section here,

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one can see parenchymal hemorrhage, subdural hemorrhage,

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as well as subarachnoid hemorrhage along the left frontal,

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temporal, and parietal lobes.

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Another point to be made is the fact that what

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we are seeing actually is a contrecoup injury.

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The scalp swelling, which you see

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in the right parietal and posterior temporal region,

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is this location where the patient

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actually was initially hit.

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And so, the primary coup injury is

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identified here in the scalp.

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But the contrecoup injury is the

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more traumatic in this case,

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where one has all the parenchymal hemorrhage and the

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subdural hemorrhage and the subarachnoid hemorrhage.

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So again, points out the importance

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of coup-contrecoup injuries.