Subdural hemorrhages on sinus CT

Case contributed by Dr Derek Smith

Presentation

Investigations for worsening frontal headaches. Seen by ENT and sinus CT requested.

Patient Data

Age: 60 years
Gender: Male

CT sinuses

CT

No significant sinus opacification.

Leftward septal deviation with a bone spur.

Normal ostiomeatal complexes.

Intact laminae papyrcea.

Symmetrical cribriform plates.

Right Onodi cell.

No neurovascular exposure.

CT sinuses: soft tissues windowed for brain

CT

When windowed for better brain interpretation, there is mass effect on the lateral ventricles with bilateral predominantly iso- to hyperdense subdural hematomas, larger on the right.

The patient had a history of falls, and before the routine sinus CT was reported the patient attended ED following another fall with reduced consciousness.

CT head

CT

Large subdural hematomas - right larger than left - approximate coronal depth 20 mm.

Mixed density and some septations but acute blood components evident, with bilateral middle cranial fossa subarachnoid blood, likely traumatic.

Early hydrocephalus with sulcal effacement with temporal horn enlargement and ambient cistern effacement.

The patient was transferred to a neurosurgical center and underwent bilateral burr hole decompression. Sluggish recovery, with deterioration in GCS and left motor function led to repeat imaging.

CT head: five days postoperative

CT

Bilateral burr hole placement and interval drainage of subdurals, with postoperative pneumocephalus.

The left side has improved but there is acute rebleeding into the right extra-axial space with worsened mass effect; right uncal and leftward subfalcine herniation. Focal mixed density in the pons, even allowing for beam hardening, is concerning for Duret hemorrhage.

MRI head: 10 days postoperative

MRI

Signal abnormality with T1w hyperintensity compatible with right Duret hemorrhage and associated infarct on ADC.

Mixed signal bilateral subdurals, reduced from the previous CT.

Case Discussion

The sinus CT is a useful operative planning guide, with plenty to remember and comment on. The radiologist has to remember their role includes identifying and reporting findings and processes that may be outwith the surgeons' focus; for example intracranial abnormalities such as hemorrhages.

This case also demonstrates Duret hemorrhages which are compressive pontine injuries seen in downward herniation.

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