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This is a nice case that brings together a lot of the

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concepts that we talked about with

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regard to traumatic brain injury.

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This was a 66-year-old patient who was involved

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in a motor vehicle collision.

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When we look at the initial thick section CT scan,

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we see that there is a large soft tissue hematoma

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over the left frontal calvarium.

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This is where the patient hit their

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head against the windshield.

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This would be therefore the coup injury.

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If we look opposite the coup injury

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and come to the right side,

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we see that the patient has an extra-axial collection

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which is actually lenticular in its shape.

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And it looks like there are low-density areas,

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as well as high-density areas,

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suggestive of active bleeding

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with unclotted blood and clotted blood.

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Since it's lenticular in shape,

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we're going to look at the calvarium to see whether there

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is a fracture that accounts for tearing of the right

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middle meningeal artery,

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accounting for an epidural hematoma.

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You also see that the patient has extensive subarachnoid

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hemorrhage and that subarachnoid hemorrhage seems to be more

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concentrated in the proximal Sylvian fissure.

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And along the subarachnoid space,

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adjacent to the left middle cerebral artery,

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going to the Sylvian fissure.

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This is another example where we would be concerned about

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the potential for injury to that blood vessel along

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the Sylvian fissure and along the M1 segment.

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You'll note also that the patient does have blood products

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superficial to the Sylvian fissure and in the extra

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axial space in the subarachnoid hemorrhage,

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as well as probably a small subdural hematoma.

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24 hours later,

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the patient presented with new onset of speech difficulty.

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When we look at the 24 hours delayed study,

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we again see similar findings as previously with the

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epidural collection, the subarachnoid hemorrhage.

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But again,

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it seems as if the subarachnoid hemorrhage is more

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concentrated in the proximal Sylvian

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region on the left side.

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And obviously, if we have subarachnoid

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hemorrhage in this region,

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we have to be concerned about injury

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to the left middle cerebral artery.

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You'll notice also that there is a new area of low density that

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has appeared in the anterior portion

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of the left temporal lobe,

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and this is an area of acute infarction that

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has occurred that was not present previously.

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This also implies injury to the middle cerebral artery.

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Now, at this juncture,

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we would probably recommend doing a CTA

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or potentially a conventional arteriogram.

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The conventional arteriogram benefit

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would be to be able to treat

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the patient at the time of the injury.

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However, in most instances,

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we want to make the diagnosis with a CTA first

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before proceeding to the arteriogram,

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and that is because of the expediency of doing a CTA,

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which can be done in the course of five minutes.

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And also, it could potentially rule

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out injury to the blood vessel,

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which would obviate the need for conventional arteriography.

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In this situation,

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the patient did indeed go on to have

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the conventional arteriogram,

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which demonstrated a middle cerebral

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artery dissection and clot,

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and the patient preceded to have additional areas of

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infarction within the left middle

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cerebral artery distribution.