Case 15 - DAI on MRI

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

CLINICAL INDICATION: Trauma.   
TECHNIQUE: Routine brain MRI exam using standard pulse sequences pre- and post- intravenous administration of Gadolinium contrast 9.4 cc Gadovist. Noncontrast enhanced 3D time-of-flight MRA of the brain as well as pre-and post-contrast 2D and 3D MRA exam of the neck also performed with review of axial raw data and 3D/MIP images.   
COMPARISON: None available   
     
 FINDINGS:    
 Brain MRI:   
 On the FLAIR sequence, diffuse increased signal intensity in the subarachnoid space bilateral cerebral hemispheres and infratentorial posterior fossa subarachnoid space demonstrated. Those hyperintensities are compatible with a subarachnoid hemorrhage. Part of those signal intensities could also be caused by hyperoxygenation intubation. Blood product also seen in the bilateral lateral ventricles especially on the right side layering in the occipital horn. Small subdural hemorrhage   
 along the posterior cerebral falx extending along the superior surface of the left cerebellar tentorium leaflet present with maximum thickness measuring 4 mm. Minimal blood product also seen in the suprasellar cistern along the vermis of the cerebellum localized hemorrhagic contusion or focal hematoma involving the anterior aspect of the genu of the splenium of corpus callosum also present. Additional scattered hemorrhagic foci in the bilateral frontal and left parietal lobes also present in the gray-white matter junction. FLAIR sequence demonstrate also increased signal intensity involving the splenium of the corpus callosum. Those findings are compatible with diffuse axonal injury.   
Diffusion is scan demonstrate no evidence of territorial cerebral infarction, noting signal changes associated with the blood products.    
There is generalized cerebral edema with sweating of the cortex, for example in the right to frontal superior frontal gyrus. There is no midline shift or hydrocephalus. Ventricular size within normal range for patient's age. Edema which could represent contusion also involving the posterior mid brain bilaterally more on the left side. The central aquduct of Sylvius is patent. The postcontrast images demonstrate no enhancing mass. Mild linear meningeal enhancement in the cerebral convexity noted which could be related to the subarachnoid hemorrhage.   
     
The cervicocranial junction is anatomic. There is no evidence of transtentorial or tonsillar herniation. Slight prominent bilateral frontal subdural CSF signal is seen measuring up to 4 mm, a nonspecific finding. However, this is within normal range. Mucoperiosteal thickening and minimal fluid in the ethmoid and sphenoid sinuses could represent underlying sinus inflammatory disease but could also be related to intubation. Mastoid air cells junction no significant fluid opacification. Multiple area of the scalp edema from the trauma present without harsh hematoma.   
        
 IMPRESSION:     
 1. There is stable appearance of intracranial hemorrhages when compared to the CT exam including small subdural hematoma, subarachnoid hemorrhage, intraventricular blood product, and possible hemorrhagic contusion to the posterior corpus callosum. The involvement of the corpus callosum and multiple hemorrhagic foci at the gray-white matter junction is compatible with diffuse axonal injury. Please correlate with clinical presentation.   
 2. Mild generalized cerebral edema present with no evidence of herniation or midline shift. No evidence of hydrocephalus. No evidence of acute territorial cerebral infarction.   

CT:

RESULT:   

CT head without contrast   
INDICATION:  Trauma with concern for cervical spine fracture on the comparison CT study.   
TECHNIQUE:  CT images through the brain were acquired without intravenous contrast material.   
 COMPARISON:  Same day at 0711 hours.   
 FINDINGS:   
 There are layering hyperdensities in the dependent portions of the occipital horns of the lateral ventricles. These are not apparent on the previous examination, though comparison is limited. Additionally, there is suggestion of increased density along sulci in the left frontal lobe, seen for instance on slices 23-26 from series 6, which raises concern for minimal subarachnoid blood. Overall, however, there is slightly better visualization of the extra-axial spaces along the frontal lobes, which could be related to some degree of edema on the prior study or technical differences. No evidence of new or significant increase in mass effect.   
The basal cisterns remain patent.   
 Partially seen probable C1 fracture. No skull fractures are identified.   
The orbits are within normal limits. There are small fluid levels in the visualized sphenoid sinuses which could be related to intubation.   
     
 IMPRESSION:   
 Findings suggestive of intraventricular blood as above. There is also suggestion of minimal subarachnoid blood products along the left frontal lobe. These can be monitored on follow up exam if clinically indicated.