Presentation
Assaulted; bruising to right head, neck, chest and upper back. Blood from right ear and right scalp. Reduced left sided movement. GCS 8 at best.
Patient Data
Several scattered contusions; right frontal, left parasagittal, right angular gyrus, and right periventricular. Hemorrhage in the splenium. Thin subdural parafalcine hematomas.
Intraventricular hemorrhage and mild ventricular dilatation. Patent basal cisterns and foramen magnum, unremarkable posterior fossa.
Extensive extracranial soft tissue swelling/hematoma. Of note, the right helix is expanded by hematoma with a fluid level and the external auditory meatus is narrowed compared with the left. Unremarkable included paranasal sinuses and mastoid air spaces (partial fluid opacification of the anterior sinuses) and orbits. No skull fracture.
Case Discussion
A number of findings associated with head trauma are evident including intraventricular and subdural hemorrhages, although the most concerning findings are the scattered contusions at the grey-white matter junction and within the corpus callosum compatible with diffuse axonal injury.
From being previously independent, this patient is now in long term residential care.
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