Case 11 - Epidural Hematoma: CT

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 without IV contrast

Exam: CTA and CTV of the head with IV contrast

INDICATION: Patient with fall and ICH near venous sinuses. 

COMPARISONS: None.

TECHNIQUE/PROTOCOL: Noncontrast CT head was performed. Contrast enhanced head CT arteriogram and venogram were performed. 3D reconstructions were performed to evaluate vascular anatomy. The timing of the venous portion of the examination was suboptimal.

CONTRAST: iohexoL (OMNIPAQUE) 350 mg/mL injection 50 mL

BRAIN FINDINGS: 

Brain Parenchyma, extra-axial spaces and sulci: No significant change in size of the 8 mm intraparenchymal hemorrhage right inferior temporal lobe and 9 mm intraparenchymal hemorrhage in the inferior right frontal lobe. Grossly unchanged vasogenic edema surrounding the foci of intraparenchymal hemorrhage. No significant change in size of the mixed attenuation extra-axial hematoma containing few foci of scattered air measuring up to 1.3 cm in maximal thickness overlaying the posterior left occipital lobe and extending inferiorly across the posterior left tentorial leaflet along the dorsal surface of the left cerebellar hemisphere. No new or increasing intracranial hemorrhage is seen. No significant mass effect or midline shift. Basal cisterns are patent.

Ventricles: Normal for age. 

Paranasal Sinuses: Mild mucosal thickening again the maxillary sinuses. The rest of the paranasal sinuses without significant mucosal thickening or secretions.

Mastoid Sinuses: Unchanged moderate effusion in right mastoid air cells and. Decreased diffusion in the left middle ear cavity. No obvious mastoid/temporal bone fracture identified. Right mastoid air cells and middle ear cavities are patent.

Orbits: Normal.

Cranium and Bones: Unchanged alignment of the nondisplaced nondepressed fracture of the left parieto-occipital calvarium with extension into the left lambdoid suture.

Soft Tissues: Unchanged mild soft tissue edema and contusion in the posterior scalp.

CTA FINDINGS

No flow limiting stenosis or aneurysm.

Intracranial ICAs: Patent bilaterally from the skull base to the carotid terminus.

MCAs: Normal bilaterally.

ACAs: Normal bilaterally.

ACom: Normal

Vertebral arteries: Normal to the confluence with the basilar artery. 

Basilar artery: Normal.

PCAs: Normal bilaterally.

CTV FINDINGS

Superior Sagittal Sinus: Normal.

Internal Cerebral Veins: Normal.

Vein of Galen: Normal.

Straight Sinus: Normal.

Confluence of Sinuses: Opacified.

Transverse Sinuses: Nonopacification of the left transverse sinus. The right transverse sinus is normal.

Sigmoid Sinuses: There is significant narrowing/nonopacification of the left sigmoid sinus. The right sigmoid sinus is patent.

Proximal Jugular Veins: The left proximal jugular vein is not opacified. The right proximal jugular vein appear normal.

IMPRESSION:

1. Unchanged foci of intraparenchymal hemorrhage in the right inferior temporal and right inferior frontal lobes. No new or increasing foci of intracranial hemorrhage.

2. Unchanged extra-axial hematomas overlying the left occipital lobe and left cerebellar hemisphere with foci of air. This is likely epidural in location the fact that it crosses the tentorium.

3. Nonopacification/significant narrowing of the left transverse and sigmoid sinuses adjacent to the left parieto-occipital skull fracture suggestive of dural venous sinus injury/thrombosis. The sinus may be traumatized itself.

4. Patent intracranial arteries without significant stenosis or filling defect.
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EXAM: CTA HEAD W/WO IV CONTRAST

INDICATION: Status post trauma. Seizure, right parietal pilocytic astrocytoma and likely alcohol abuse who presented after a fall from a flight of stairs. Imaging showed 1.2cm extra-axial hematoma extending from the right posterior fossa to the occipital lobes with associated depressed skull fracture extending from the occipital bone to the foramen magnum. 

TECHNIQUE: CT venogram of the head was performed, utilizing 65 mL Omnipaque 350 intravenous contrast. Coronal and sagittal reformatted images and 3D maximum intensity projection images were generated.

COMPARISON: CT head the same day at 6:24 PM.

FINDINGS:

Mass effect from the acute displaced occipital/suboccipital fractures and associated extra-axial hemorrhage on the right transverse sinus, which is nonopacified, possibly thrombosed. The right sigmoid sinus and jugular bulb are patent and there is prominent collateral venous flow along the right tentorial leaflet and right middle cerebral vein. Mass effect from extra-axial hemorrhage extending across the midline partially effaces the posterior superior sagittal sinus and venous confluence, also the proximal aspect of the left transverse sinus which is narrowed. The remainder of the superior sagittal sinus and central venous structures including the internal cerebral veins, vein of Galen, and straight sinus are patent. There is homogeneous symmetric enhancement of the cavernous sinus.

Configuration of skull fractures and size and mass effect of extra-axial hemorrhage has not substantially changed from prior exam, again measuring up to 1.2 cm in the right posterior fossa. Similar scattered pneumocephalus throughout the site of hematoma. Postoperative changes of right parietal craniotomy and mass resection with encephalomalacia in the right parietal lobe, as before. Please refer to prior CT head for additional findings.

IMPRESSION:

The right transverse sinus is not opacified, effaced by the right occipital/suboccipital extra-axial hemorrhage, and possibly thrombosed. The right sigmoid sinus is widely patent and there is evidence of collateral venous flow. Mass effect partially effaces the posterior superior sagittal sinus, venous confluence, and proximal left transverse sinus. The remaining dural venous sinuses are patent.

The presence of the blood products posterior to the superior sagittal sinus as well as crossing from the posterior fossa to the supratentorial space suggests epidural blood collection which has increased in size overall compared with the study from 6:25 

PM in the supratentorial compartment. There likely is a fracture associated with the craniotomy of the right parietal bone as there is air seen on series 5 image 94 outside and deep to the craniotomy site.