CLINICAL HISTORY: 43-year-old male status post motorcycle crash with cervical spine injury, traumatic subarachnoid hemorrhage, and possible cerebral contusion seen on prior CT.
Parenchyma: Findings consistent with diffuse axonal injury (DAI) with multiple foci of GRE hypointensity/DWI hyperintensity left greater than right parasagittal white matter, splenium of corpus callosum, extensively throughout the subcortical white matter, and the right posterolateral pons with some probable surrounding edema. More diffuse area of injury is present in the left anterior temporal lobe. There is restricted diffusion in the bilateral fornices and the left greater than right hippocampi, consistent with infarct is probably related to the patient's DAI.
Diffuse subarachnoid hemorrhage appears grossly stable to the prior CTs and is best expected on the FLAIR sequences.
Right frontal approach ventricular catheter with the tip just to the right of midline in the right lateral ventricle. A second catheter tract is present anteriorly along the course of the EVD.
Ventricles and extra-axial spaces: The ventricles and sulci are stable in size. Similar-appearing intraventricular hemorrhage is again noted. Subarachnoid hemorrhage appears grossly stable.
Visualized paranasal sinuses: Opacification of the paranasal sinuses with fluid levels in the bilateral maxillary, sphenoid, and posterior ethmoid sinuses.
Mastoid air cells: Bilateral mastoid effusions.
Anterior circulation: No flow-limiting stenosis or aneurysm.
Posterior circulation: The vertebral arteries are not well-visualized. No flow-limiting stenosis in the basilar or PCAs.
Normal perfusion on ASL.
Vertebrae: STIR hyperintense edema is seen associated with the right C2 facet fracture and the C7 right lateral mass fracture. At the C7 fracture site hyperintense signal is present within the C7-T1 neural foramen (series 18 image 42) which is concerning for C8 nerve root avulsion. A ventral epidural hematoma is present which appears to extend from this fracture site into the anterior spinal canal resulting in displacement and mild compression of the left ventral cord. This measures approximately 6 mm in maximum AP dimension (series 1801 image 82) and extends superiorly to the level of C3 where it measures approximately 2 mm in maximum AP dimension. The inferior extent of the hematoma is not fully included in this study, though the hematoma does taper somewhat inferiorly.
Edema seen along the anterior and right aspect of the dens (series 18 images 3 through 5) with adjacent prevertebral edema is suspicious for ligamentous injury. The anterior longitudinal ligament, posterior longitudinal ligament, and posterior element ligamentous structures appear grossly intact. Subtle T2 hyperintensity is also present within the C2-3 neural foramen on the left (series 18 image 14) and nerve root injury at this location is not excluded.
Cord: Displacement and mild compression of the left ventral cord greatest from C5 through C7 T1 as above, without gross cord signal abnormality.
Extra-vertebral soft tissues: Diffuse edema is present throughout the right greater than left paraspinal soft tissues.
Additional comment: The patient is intubated.
1. Extensive diffuse axonal injury involving much of the supratentorial white matter, corpus callosum, and right posterior upper pons as described above. Acute infarcts involving the bilateral hippocampi and fornices is probably related to the patient's DAI.
2. Large ventral spinal epidural hematoma which results in displacement and mild compression of the spinal cord. This appears most prominent in the region of the C7 right lateral mass fracture and extends superiorly to the level of C3 as described above. The inferior extent of the hematoma is not imaged on this study. No evidence of cord cord signal abnormality. Thereis likelyavulsion of the right C8 nerve root within the C7-T1 neural foramen. Subtle highsignal may be present at the left C2-3 foramen, it is difficult to ascertain if this isnormal variant or indicates avulsion injury.
3. Similar appearance of subarachnoid and intraventricular hemorrhage. Stable ventricles, cisterns, and position of right frontal EVD.
4. Edema along the anterior and right lateral dens with a small amount of prevertebral edemais suspected to reflect ligamentous injury. Fluid is present in the right C2-3 joint.