Case 16 - Herniations: 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.

INDICATION: Head trauma. Known intraventricular hemorrhage. 

COMPARISON: Head CT performed earlier the same day at 1053 

TECHNIQUE: Axial CT images of the intracranial compartment was performed without the administration of intravenous contrast. Multiplanar reconstructions in the coronal and sagittal plane were generated and reviewed. 

FINDINGS: 

Redemonstration of small volume layering hemorrhage in the occipital horn of the left lateral ventricle. No new intracranial hemorrhage. Previously described tiny left frontal subarachnoid hemorrhage is not definitively seen on this examination. No new intracranial hemorrhage. 

Basal cisterns are preserved. Gray-white matter differentiation is intact. 

Biparietal scalp contusions and right greater than left temporal scalp edema. Calvarium is intact. Intraorbital compartments are normal bilaterally. Paranasal sinuses and mastoid air cells are clear. 

IMPRESSION: 

Stable left intraventricular hemorrhage. 

No new hemorrhage or progressive abnormality.

INDICATION: pedestrian struck. known IVH. continued AMS, assess IVH 

TECHNIQUE: Axial CT scan images were performed from the foramen magnum to the vertex without administration of intravenous contrast. 

COMPARISON: CT head done on 8/20/2017 

FINDINGS: 

Small amount of layering blood is noted within the occipital horn of left lateral ventricle which is unchanged compared to prior examination. There is probable tiny amount of subarachnoid hemorrhage is seen overlying the left frontal convexity, new compared to prior examination (series 2, image 21) 

Bilateral temporoparietal scalp hematomas in soft tissue collections are seen, not significantly changed compared to prior examination with skin laceration and surgical sutures in place on left side. 

There is sliver of fluid seen overlying right frontal lobe with minimal underlying mass effect, slightly more prominent compared to prior study 

Ventricles, sulci and cisterns are normal in shape, size and position. No mass effect or midline shift is noted. No extra-axial fluid collections are seen. 

Ventricles are symmetric without any evidence of hydrocephalus. No transtentorial or transforaminal herniation is noted. Gray-white differentiation is well-maintained. 

Posterior fossa is unremarkable. Cisterns are well visualized. 

Visualized orbits are unremarkable. Paranasal sinuses are unremarkable. Bony calvarium is unremarkable with normal appearance of the craniovertebral junction. 

IMPRESSION: 

Minimal amount of intraventricular hemorrhage is unchanged compared to prior examination with probable minimal focal subarachnoid hemorrhage overlying the frontal lobe. 

No hydrocephalus/herniation.

EXAM: MRI brain, with and without IV contrast; MRA head; MRA neck. 

INDICATION: 52-year-old male who struck by truck, CT demonstrated intraventricular hemorrhage. 

TECHNIQUE: Multiplanar multisequence MR images of the brain were obtained with the administration of IV gadolinium based contrast. 

COMPARISON: CT 8/22/2017 

FINDINGS: 

MRI Brain: 

There is restricted diffusion seen in the splenium of the corpus callosum with extension to the body of the corpus callosum. This is associated with multiple areas of microhemorrhage to the left of midline affecting the top of the corpus callosum and the adjacent cortex.. Microhemorrhages are present in the medial aspect of the left frontal lobe extensively as well. This includes involvement of the cingulum and supplemental motor area. Microhemorrhages are also seen in the subcortical white matter of the right frontal lobe, left parietal-occipital junction, right parietal-occipital junction. A focus along the posterior lateral left thalamus is also present. 

Study is limited secondary to motion artifact. 

Redemonstration of layering blood product within the left lateral ventricle, not significantly changed when compared to CT 8/22/2017. No evidence of extra axial fluid collection. 

Ventricles normal in size and shape for patient's age. Patent basal cisterns. Orbits and paranasal sinuses unremarkable. 

MRA head: 

Significant motion artifact severely limits visualization of the intracranial arteries above the level of the circle of Willis. 

The intracranial carotid arteries, M1 segment of the middle cerebral arteries, A1 segment of the anterior cerebral arteries, and posterior cerebral arteries appear patent. 

Codominant vertebrobasilar system which appears patent. SCAs and AICAs appear patent. 

No evidence of dissection or aneurysm as best as can be determined given limitations described above. 

MRA Neck: 

Study is limited secondary to motion artifact. 

Normal three-vessel aortic arch. The vertebral arteries arise from the subclavian arteries. 

No significant stenosis of the common or internal carotid arteries. No significant stenosis of the vertebral arteries, which appear patent along their course. 

IMPRESSION: 

1. Discrete focus of restricted diffusion in the splenium of the corpus callosum. Because of the absence of hemorrhage associated with this I think it is more likely to be secondary to the institution of Keppra drug rather than secondary to non-hemorrhagic shearing injury. 

2. Multifocal areas of susceptibility deposition bilaterally in the hemispheres and most affecting the cingulum and supraventricular medial left frontal lobe compatible with hemorrhagic shearing injuries at the gray-white junction also affecting the posterior lateral left thalamus. 

3. Redemonstration of layering blood products within the left lateral ventricle, not significantly change from previous CT. 

4. Severely limited MRA head and neck secondary to motion artifact. Nonetheless no abnormalities are appreciated.