Case 10 - Head Trauma CT SDH SAH IPH

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

EXAM: CT HEAD/BRAIN WO CONTRAST, CT MAXILLOFACIAL WO CONTRAST COMPLEX, CT C-SPINE WO CONTRAST COMPLEX, CT T-SPINE WO CONTRAST COMPLEX, CT L-SPINE WO CONTRAST COMPLEX 

INDICATION: Trauma 

TECHNIQUE: Unenhanced axial CT images through the head/brain from the base of the skull to the vertex were obtained and reviewed. Coronal and sagittal reformats were generated from the axial data. Helically acquired CT images of the cervical, thoracic, and lumbar spine were obtained without intravenous contrast. Multiplanar reformations obtained. 

COMPARISON: None available. 

FINDINGS: 

HEAD/BRAIN: 

Hyperdense extra-axial collection over the left frontal and parietal convexity measuring up to 0.5 cm. Focal hyperdense blood products along the falx anteriorly, and hyperdense subarachnoid blood products along the falx posteriorly. Posteriorly there is a rounded area of hyperdensity seen best on series 2 image 26 and series 8 image 52 which may show some parenchymal extension in the medial left occipital parietal junction. 

No mass effect or midline shift. Focal hyperdensity within the left parietal lobe, reflecting prior infarct. Preservation of the remaining gray-white differentiation throughout. Scattered areas of hypoattenuation within the subcortical and periventricular white matter, reflecting chronic microvascular ischemic change. The basal ganglia, thalami, midbrain, pons, and cervicomedullary junction appear normal. The ventricular system and sulci are prominent, reflecting age-related parenchymal volume loss. Basal cisterns are patent. 

Scalp hematoma over the left frontoparietal region without subadjacent fracture. Calvarium appears intact. Orbits appear symmetric. 

MAXILLOFACIAL: 

Minimally displaced nasal bone fractures, deviated leftward. Hyperdense blood products within the ethmoidal sinuses. No additional fracture seen. Minimal mucosal thickening of the frontal and ethmoidal sinuses. The maxillary sinuses are clear without evidence of outflow obstruction. Nasal turbinates appear normal. Temporomandibular joints appear normal. Mastoid air cells are clear. Middle ear canals are clear. Streak artifact limits evaluation of the oral cavity. There is widening at the left sphenoethmoidal junction. Chronic osteitis in the walls of the right sphenoid sinus are also present. 

Degenerative changes in the temporomandibular joints are present bilaterally. 

CERVICAL SPINE: 

No acute fracture or dislocation. Craniocervical junction is normal in appearance. Reversal of the cervical lordosis about C7-C8. Heterogeneous moth-eaten appearance of the vertebral bodies of the cervical spine. No significant listhesis at any level. 

Facet joint alignment is within normal limits. Facet arthrosis throughout the cervical spine, though most pronounced at the C3-C6 levels. 

THORACIC SPINE: 

No acute fracture or dislocation in the thoracic spine. Normal curvature of the thoracic spine. No significant listhesis at any level. Facet joint alignment is within normal limits. No significant intervertebral disc height loss. Spinal canal and neural foraminal are patent. Diffuse heterogeneous sclerotic and lytic appearance of the vertebral bodies 

Moderate bilateral pleural effusions. 

LUMBAR SPINE: 

There are 5 lumbar type vertebrae. No acute fracture or dislocation in the lumbar spine. Normal lumbar lordotic curvature. Grade 1 anterolisthesis of L4 over L5. Minimal retrolisthesis of L1 over L2. No additional spondylolisthesis within the lumbar spine. Facet joint alignment is within normal limits. Severe facet arthrosis at the L4-L5 level. No significant intervertebral disc height loss. Spinal canal and neural foraminal are patent. 

IMPRESSION: 

1. Hyperdense subdural hematoma over the left frontal - parietal convexity as described above. Small foci of hyperdense subarachnoid blood products along the falx. 

2. Minimally leftward displaced nasal fractures. 

3. Small scalp hematoma overlying the left frontoparietal region without subadjacent fracture. 

4. Extensive heterogeneous sclerotic and lytic appearance of the spine, raising suspicion for metastatic disease such as prostate cancer, less likely multiple myeloma. No acute abnormality within the cervical, thoracic, or lumbar spine. 

5. Moderate bilateral pleural effusions.