Presentation
Head trauma. Taking anticoagulants.
Patient Data
Large acute subdural hemorrhage over the left frontoparietal lobes with active bleeding.
Cerebral contusions in the right frontal lobe.
Intraventricular hemorrhage in both lateral ventricles.
Midline shift.
Basal cistern effacement.
Hemorrhagic at pontomesencephalic junction consistent with a Duret hemorrhage.
No skull fractures.
Case Discussion
Duret hemorrhages are most commonly seen at ventral and paramedian aspects of the upper brainstem, involving medulla and pons.
In this case, head trauma resulted in subdural and intraventricular hemorrhage raising intracranial pressure. There is subfalcine and uncal herniation. The connection between the sudden increase in intracranial pressure and the development of Duret hemorrhages has two main hypotheses:
arterial origin with compromise of the perforator arteries that arise from the basilar artery
venous origin