Posterior transphenoidal fracture

Subarachnoid hemorrhage overlying the bilateral frontal, temporal and left occipital lobes.

Bilateral thin subdural hematomas with no significant mass effect. No facial bone fracture. Paranasal sinuses are unremarkable. 

Obliquely oriented biparietal and left occipital fractures.

On the left, fracture lines extend to a comminuted minimally displaced left squamous temporal bone fracture that extends through the petrous temporal bone, involving the middle and inner ear and left mandibular fossa. The left TMJ remains enlocated. Opacification of the mastoid air cells. The left carotid canal is not involved. The fracture extends into the underlying dural venous sinus and locules of gas are seen within the diminutive anterior transverse sinus.

On the right, fracture lines extend to the squamous temporal bone. No fracture line through the petrous temporal bone, however, there is opacification of the mastoid air cells. The right sided temporal bone fracture also extends into the underlying dural venous sinus, with focal thrombus seen at the junction of the right transverse and sigmoid sinus.

The two fractures are presumable joined in the midline through the pituitary fossa and sphenoid with air seen in the left cavernous sinus (posterior transverse transsphenoidal fracture). 

The ossicular chains appear intact. Large left pre-septal periorbital soft tissue swelling noted. 

Extensive subarachnoid and intraventricular blood is noted. The left occipital horn blood has slightly increased. Bilateral convexity subdural collections (hygromas) are more prominent.

Cerebral venogram demonstrates a right dominant dural venous draining system. There is non-occlusive thrombus at the distal transverse sinus, which does not extend into the sigmoid sinus or IJV. The left transverse sinus is diminutive in caliber, with no sigmoid sinus visualized. The left IJV drains from the inferior petrosal sinus. 

CTA COW (not shown) The vertebral arteries and internal carotid arteries are unremarkable.