Age: 46
Sex: Male
Indication: Trauma
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Case #30
Findings
- Acute large intraparenchymal hematoma in the inferior right temporal lobe. Additional smaller intraparenchymal hematomas in the left greater than right inferior frontal lobes
- Thin acute extra-axial hematoma (likely subdural) layering along the right frontal convexity as well as along the right cerebellar tentorium
- Scattered small volume acute subarachnoid hemorrhage, particularly layering in the right sylvian fissure
- Diffuse sulcal effacement suggestive of cerebral edema with right to left midline shift, downward transtentorial herniation, effacement of the basal cisterns, and displacement of the cerebellar tonsils into the foramen magnum
- Multifocal pneumocephalus
- Acute otic capsule involving complex right temporal bone fracture with a dominant transverse component extending through the cochlea
- Acute otic capsule sparing, longitudinally oriented left temporal bone fracture extending through the middle ear
- Acute comminuted, depressed fracture of the squamosal right temporal bone
- Acute nondisplaced left frontal bone fracture extending through the inner and outer margins of the left frontal sinus and through the orbital roof with associated hemosinus and pneumocephalus. Gas and hemorrhage in the superior retrobulbar right orbit without proptosis
- Extensive facial crush injury with likely right Le Fort type I, II, and III fractures and right zygomaticomaxillary complex fracture, incompletely evaluated on this study.
- Partial opacification of the bilateral middle ears, mastoid air cells, and throughout the visualized aspects of the paranasal sinuses
- Multifocal scalp and facial contusions/lacerations
Diagnosis
- Otic capsule involving and otic capsule sparing temporal bone fractures
Sample Report
Acute multicompartmental intracranial hemorrhage with a large intraparenchymal hematoma in the inferior right temporal lobe measuring 4 x 3.5 x 4 cm, additional smaller intraparenchymal hematomas in the left greater than right inferior frontal lobes, right frontal convexity acute subdural hematoma measuring up to 1.3 cm in thickness as well as trace subdural hemorrhage layering along the right cerebellar tentorium, and scattered small volume acute subarachnoid hemorrhage, particularly layering in the right sylvian fissure.
Diffuse cerebral edema with generalized sulcal effacement, 1 cm right to left midline shift, downward transtentorial herniation, effacement of the basal cisterns, and cerebellar tonsillar herniation. No hydrocephalus.
Multifocal pneumocephalus.
Acute otic capsule involving complex right temporal bone fracture with a dominant transverse component extending through the cochlea. No evidence of ossicular disruption. Anterior fracture extension as a comminuted fracture of the squamosal right temporal bone with 3 mm depression.
Acute otic capsule sparing, longitudinally oriented left temporal bone fracture extending through the middle ear. No evidence of ossicular disruption.
Acute nondisplaced left frontal bone fracture extending through the inner and outer margins of the left frontal sinus and through the orbital roof. Gas and hemorrhage in the superior retrobulbar right orbit without proptosis or evidence of globe injury.
Extensive facial crush injury with likely right Le Fort type I, II, and III fractures and right zygomaticomaxillary complex fracture, incompletely evaluated on this study. Recommend dedicated face CT for further evaluation.
Partial opacification of the bilateral middle ears, mastoid air cells, and throughout the visualized aspects of the paranasal sinuses. The facial and skull base fractures place the patient at risk for CSF otorrhea and rhinorrhea.
Multifocal scalp and facial contusions/lacerations.
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