Cerebral haemorrhagic contusions: temporal evolution

Case contributed by Dr Bruno Di Muzio

Presentation

Bicycle vs. car.

Patient Data

Age: 28
Gender: Male

CT Brain - First exam

Modality: CT

Bilateral frontal contusions, worse on the right.

Subarachnoid haemorrhage over the right frontal lobe are noted in the sylvian fissures bilaterally.

There is midline shift to the left of 3 mm.

The basal cisterns are effaced.

Left posterior fossa haemorrhage is probably extra-axial.

Bilateral subtle skull base bone fractures which do not extend to the occipital condyles.

On the right, the occipital fracture extends into the right jugular foramen through the vestibular apparatus across the facial nerve canal and in the right temporomandibular joint.

The fracture also involves the right carotid canal.

There are locules of gas seen within the semi circular canals.

Blood fills the right middle ear cleft.

CT Brain - Day 1

Modality: CT

Non contrast study. Comparison made to the study from earlier in the day.Numerous, multifocal bifrontal parenchymal haematomas, more marked on the right and more prominent than scan earlier today. Right anterior and lateral temporal and left cerebellar parenchymal haematomas. Stable mass effect with effacement of the right lateral ventricle and midline shift to the left when compared to the earlier scan today . Further dilatation of the temporal horn of the left lateral ventricle.The ventricles are otherwise unchanged in size but slightly increased when compared. Loss of gray /white differentiation of right lentifrom nuclei and inferio temporal lobe The basal cisterns are effaced. Skull fractures previously described.

 

CT Brain - Day 3

Modality: CT

Direct comparison has been made with the previous study:

Temporal evolution of the extensive right orbitofrontal, dorsal and mesial frontal, and right temporal pole, as well as left cerebellar hemisphere haemorrhagic contusions. The temporal horn of the left lateral ventricle has decreased in size.

In addition there is less effacement of the ambient cisterns.

There is a newly inserted right frontal ICP monitor.

CT Brain - Day 7

Modality: CT

Bifrontal craniectomy performed in the interval since the previous scan.

Bifrontal scalp high density which may represent surgical material or haematoma.

Right frontal EVD tip abuts the right foramen of Monro.

The extensive right frontal and anterior temporal contusions are unchanged in size with slightly more surrounding hypodensity on today's study.

Degree of midline shift to the left is approximately 10 mm (previously 8mm).

Left cerebellar hemisphere contusion unchanged.

Surface CSF spaces are moderately more effaced than on the previous study.

Ventricular size is unchanged, with the right ventricle being more effaced than the left.

The basal cisterns the patent.

Conclusion:

Overally, marginal increase in midline shift and diffuse sulcal effacement since the previous study. No new hemorrhage or infarction.​

CT Brain - 1 month later

Modality: CT

Non-contrast axial scanning has been performed, with comparison made CT brain obtained late last month.

Bifrontal craniectomies are again noted, with prior EVD removal.

There has been further resolution of inferior left frontal hypodensity, with extensive inferior right frontal hypodensity (consistent with established gliosis/encephalomalacia) remaining.

Small frontal convexity subdural collections have resolved.

MRI Brain - Epilepsy protocol (3 years later)

Modality: MRI

 

No previous MRIs available for comparison. Review is made with the preceding CT scans.

Previous bifrontal craniectomy and previous bilateral drain tubes placement is noted.

Extensive regions of encephalomalacia are present at the sites of the previous shearing injuries in both frontal lobes.

This involves the anterior and inferior aspect of the right frontal lobe with less severe encephalomalacia involving the anterior aspect of the left frontal lobe as well as around the line of the previously placed left drain tube.

Less severe changes affect the right temporal lobe.

A small focus of signal change is noted within the left thalamus.

Further regions of encephalomalacia and haemosiderin staining are noted within the left cerebellar hemisphere with extension into the vermis.

Volume loss companies the regions of encephalomalacia and is reflected in volume loss within the anterior aspect of the corpus callosum.

No abnormality of the parietal lobes is identified.

The hippocampi remain of good volume

Conclusion:

Previous severe head trauma.

Extensive bifrontal regions of encephalomalacia with further involvement of the temporal lobes and left cerebellar hemisphere.

No abnormality of the parietal lobe is identified​

Case Discussion

This case demonstrates the evolution of a severe head trauma with multiple cerebral haemorrhagic contusions that led to progressive increased intracranial pressure in the first days after the accident. A decompressive craniotomy was performed. Three years later the patient started to present seizures, probably due to cerebral contusions. The last MRI showed extensive encephalomalacia as the contusions sequelae. 

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Case Information

rID: 40224
Case created: 13th Oct 2015
Last edited: 20th Oct 2015
Inclusion in quiz mode: Included

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