Age: 24
Sex: Male
Indication: Trauma
Save ("V")
Case #16
Findings
- Acute right cerebral convexity subdural hematoma measuring up to 10 mm in thickness
- Right greater than left cerebral hemispheric sulcal effacement with right to left midline shift measuring 9 mm at the level of the Foramen of Monro, downward transtentorial herniation with effacement of the basal cisterns, and descent of the cerebellar tonsils into the foramen magnum
- Scattered small volume acute subarachnoid hemorrhage layering within bilateral cerebral sulci and within the basal cisterns
- Trace acute subdural hemorrhage along the anterior aspect of the interhemispheric falx
- Mild rounding of the temporal horn of the left lateral ventricle
- Acute nondisplaced transverse right temporal bone fracture extending through the vestibule with gas in the otic capsule
- Acute nondisplaced fractures of the occipital bone at the midline as well as on the right extending into the base of the right occipital condyle
- Anterior fracture propagation with involvement of the right carotid canal and posterior wall of the right sphenoid sinus with hemosinus
- Right temporal scalp hematoma
Diagnosis
- Otic capsule involving temporal bone fracture
- Subdural hematoma
- Subarachnoid hemorrhage
- Downward transtentorial and cerebellar tonsillar herniation
Sample Report
Extensive skull base trauma including an otic capsule involving right temporal bone fracture and occipital calvarial fractures propogating into the skull base with involvement of the right occipital condyle and extension into the right carotid canal and right sphenoid sinus. Recommend head CTA for further evaluation given carotid canal involvement.
Multicompartmental acute hemorrhage including an acute right cerebral convexity subdural hematoma measuring up to 10 mm in thickness and scattered small volume subarachnoid hemorrhage.
Resultant right greater than left cerebral hemispheric sulcal effacement with right to left midline shift measuring 9 mm at the level of the Foramen of Monro, downward transtentorial herniation with effacement of the basal cisterns, and early cerebellar tonsillar herniation.
Mild rounding of the temporal horn of the left lateral ventricle concerning for early ventricular entrapment.
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