Presentation
High-speed motor vehicle accident.
Patient Data
Subgaleal hematoma overlying the left coronal suture multifocal hyperdensities in keeping with debris.
Numerous small hemorrhagic contusions are noted in a coup-contrecoup pattern (left temporal pole and right posterior temporal/parietal lobe) with an associated small volume of sulcal subarachnoid hemorrhage at the vertex and in the interventricular cistern and a thin parafalcine subdural hematoma.
Left frontal bone minimally displaced fracture line extends through the roof of the orbit, left frontal sinus to involve the medial wall of the orbit. Opacification of the ethmoid and maxillary sinuses is consistent with blood. Normal opacification of the mastoid air cells and middle ears. No skull base fracture.
Additionally, numerous grey-white matter junction parenchymal hemorrhages are noted, along with a solitary hemorrhage in the left side of the pons. These are suggestive of diffuse axonal injury.
Extensive traumatic brain injury with persistent subdural hematoma overlying the left parieto-occipital convexity. In addition to a number of superficial hemorrhagic contusions there are numerous petechial hemorrhages (best seen on SWI) at the cortical grey-white matter junction as well as white matter tracts particularly of the splenium of the corpus callosum and within the brainstem. These are associated with edema.
The pattern is characteristic of severe (grade 3) diffuse axonal injury.
Case Discussion
This case is a good illustration of how much more sensitive MRI (particularly SWI) is in the detection of small hemorrhages compared to CT. It is important to remember that even SWI is only demonstrating a minority of the actual injury present.
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