Intermediary injury

Case contributed by Dr Henry Knipe

Presentation

High-energy trauma. GCS 3.

Patient Data

Age: 25 years
Gender: Male
CT

Small volume of traumatic subarachnoid at the vertex and in the prepontine cistern. Small volume of intraventricular haemorrhage. Sulcal effacement but with preserved grey white matter differentiation. Hyperdensity at the left basal ganglia is suspicious for a petechial haemorrhage. 

CT

24 hours later

At the site of a petechial haemorrhage in the left basal ganglia there is now a large intraparenchymal haemorrhage. New mass effect with midline shift toward the right.

New left mesial temporal subcortical haemorrhage. Left midbrain and left parietal lobe hyperdense foci are suspicious for petechial haemorrhages. 

Stable intraventricular haemorrhage. Right frontal ICP monitor. 

Annotated image

Blue arrows demonstrate left basal ganglia petechial haemorrhages on the initial study, which has progressed into a large haemorrhage on the 24 hour follow-up study with new midline shift (green arrow).

Yellow arrows indicate small intraventricular haemorrhage, layering in the trigone. 

Case Discussion

Intermediary injuries are shearing haemorrhagic contusions from disruption of the lenticulostriate injuries affecting the basal ganglia or thalami. They are associated with diffuse axonal injury (DAI), which is almost certain in this case.

This case illustrates that the initial CT brain can have a collection of apparently minor/subtle injuries that evolve into more severe injuries. Also, DAI can often be occult or under called on CT. It should be remembered that CT provides only a "snapshot" in time. 

PlayAdd to Share

Case information

rID: 47379
Case created: 13th Aug 2016
Last edited: 19th Aug 2016
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.