0:00

This was a patient who had a sports injury,

0:04

a 14-year-old who had a sports injury.

0:07

This is the initial scan,

0:09

which was read as demonstrating scalp swelling

0:14

over the right frontal region.

0:17

Once again,

0:17

whenever I see the scalp swelling,

0:19

I'm going to be looking contrecoup,

0:21

and I notice that there is a little bit of

0:24

swelling of the scalp up contralaterally,

0:26

as if the patient may have had a two-part injury.

0:30

But I'm not seeing anything with regard to

0:33

midline shift nor parenchymal hemorrhage.

0:37

I would then look at this with a subdural-based window and

0:41

see whether I see any blood collections around the periphery.

0:44

I would then look at my typical areas.

0:46

I would look at the gyrus rectus region.

0:48

Looks pretty good.

0:49

I would look at the anterior temporal lobes where

0:51

the greater wing of the sphenoid is.

0:53

That looks pretty good.

0:54

I would look at the brainstem to see whether the

0:57

brainstem had banged up against the tentorium.

0:59

That looks good.

1:00

So, the initial scan was read as merely showing

1:04

the scalp abnormality. Of course,

1:07

you want to look on bone windows to see whether

1:09

or not there's a fracture underlying the scalp.

1:12

However, the patient wasn't doing very well.

1:14

The patient had severe headaches and had some level

1:18

of reduction in the level of consciousness.

1:21

So, the patient was scanned 24 hours later as part of the

1:25

follow-up while in the hospital under observation.

1:28

This is the follow-up scan.

1:30

And once again,

1:31

we see the soft tissue swelling over the right frontal scalp.

1:36

Nothing immediately evident contrecoup.

1:40

However, when one examines the posterior fossa,

1:43

we find this area of hemorrhage that,

1:47

even in retrospect,

1:48

was not present previously.

1:50

Now, some might say, well,

1:52

could there have been a little non-hemorrhagic contusion,

1:55

a little bruise back here that evolved

1:57

into the hemorrhage?

1:59

That is possible.

2:00

In the posterior fossa,

2:02

we usually have beam hardening artifact which sometimes

2:05

will make this kind of an obscured area.

2:08

But suffice it to say,

2:09

the patient had a delayed intraparenchymal hematoma.

2:13

Delayed intraparenchymal hematoma is correlated

2:17

with a worse prognosis.

2:19

Not only that,

2:20

but this patient has a posterior fossa hematoma.

2:23

And as I mentioned previously,

2:25

the posterior fossa hematomas generally do worse than the

2:28

same-sized supratentorial hematoma because the posterior

2:32

fossa cannot handle the extra volume, if you will,

2:36

of the hemorrhage.

2:37

So, as with any hemorrhage,

2:39

in order to determine surgical

2:41

indication for intervention,

2:43

we will measure this.

2:45

Measuring 1.37 cm in AP dimension.

2:49

We give it in the transverse dimension, 1.1 cm.

2:53

Unfortunately,

2:53

a coronal reconstruction had already been made for us

2:58

and we can measure the superior inferior dimension as 1.8 cm.

3:03

So, doing our mathematics,

3:05

we would multiply 1.3 by 1.1 by 1.8,

3:10

arrive at a product and divide that by two for the

3:14

neurosurgeons to make a determination about whether or not

3:17

they should intervene for the hematoma.

3:20

In the posterior fossa,

3:22

the other thing to make sure that you mention is the

3:25

impact on the fourth ventricle

3:27

as far as whether or not it's displaced.

3:29

Doesn't appear to be in this situation,

3:32

whether or not any of the basal cisterns are effaced,

3:35

that is, we can no longer see the low-density

3:38

subarachnoid space around the brainstem.

3:40

And this looks perfectly fine.

3:42

And then we would look inferiorly to make sure that the

3:45

cerebellar tonsils are not herniating through

3:47

the foramen magnum down this way.

3:50

And just as the brain tissue can herniate downward,

3:54

we can have superior herniation through the tentorium.

3:59

This is the area of the tentorial edge.

4:01

This is the superior vermis.

4:03

And this looks normal.

4:04

There's no effacement of the basal cistern or the

4:07

perimesencephalic cistern seen on this CT scan.

4:10

So a delayed hematoma in the posterior fossa,

4:15

measuring 1.3 by 1.1 by 1.8 cm.