Neuro_MR_Brain: 38 M, MVA, GCS 3.

MRI BRAIN WITH AND WITHOUT CONTRAST:

CLINICAL HISTORY: Concern for traumatic brain injury or stroke. Reviewed the medical record reveals motor vehicle accident versus tree, ejected from vehicle with GCS 3.

FINDINGS:

BRAIN:

Parenchyma: Scattered cerebral parenchymal restricted diffusion, FLAIR hyperintensity, and susceptibility indicates moderate grade diffuse axonal injury. Blood is also seen along the posterior body and splenium the corpus callosum.

Restricted diffusion within the bifrontal and biparietal lobes at the middle and anterior cerebral artery territory borderzone.

Restricted diffusion within the paramedian and posterior aspects of both thalami. A moderate amount of blood pools around the supravermian cistern, thalami, and midbrain.

Extra-axial spaces: Subarachnoid blood layers within the superior cerebral sulci convexities. Right hemispheric subdural collection measuring 6 mm, previously 3 mm 48 hours ago. Left anterior frontal subdural collection measuring 4 mm.

Ventricles: Left frontal approach external ventricular drain terminates at the foramen of Monro. No ventriculomegaly or midline shift. Small amount of blood layers within the occipital horns of the lateral ventricles. Cavum septum pellucidum.

Orbits: Small preseptal hematoma about the left globe. The right orbit is normal.

Visualized paranasal sinuses: Blood layers within the ethmoid and sphenoid sinuses. Moderate paranasal sinus mucosal thickening.

Mastoid air cells: Bilateral effusions, larger on the left.

Bones: Normal.

Soft tissues: Right frontal, parietal, and temporal scalp hematoma measuring 1.8 cm.

Additional comment: None.

INTRACRANIAL ANGIOGRAM:

Anterior circulation: No flow-limiting stenosis or aneurysm. The circle of Willis is complete.

Posterior circulation: Diminutive vertebrobasilar system, presumably related to prominent bilateral PCOMs. No artery of Percheron identified. No flow-limiting stenosis or aneurysm.

Dural venous sinuses: Patent.

Additional comment: None.

EXTRACRANIAL ANGIOGRAM:

Proximal great vessels: No flow-limiting stenosis or dissection.

Cervical vessels: No flow-limiting stenosis or dissection.

Additional comment: None.

PERFUSION:

ASL shows increased cerebral blood flow to the border zone MCA - ACA territory infarcts. Contrast enhanced bolus perfusion is normal.

IMPRESSION:

1. Extensive traumatic brain injury with multiple hemorrhagic lesions of diffuse axonal injury, diffuse intracranial hemorrhage (including subdural, subarachnoid, and intraventricular hemorrhages),and bifrontal and left temporal parenchymal contusions.

2. Acute infarcts in the bilateral frontal and parietal lobes in a borderzone distribution, suggesting superimposed hypoperfusion or embolic injury. Some associated luxury perfusion.

3. Acute infarcts in the paramedian and posterior aspects of the thalami, presumably related to deep internal cerebral vein injury given marked blood products in this region. Of note, the internal cerebral veins are patent on this exam. Another possibility is shear/stretch injury of small posterior cerebral artery branches although no abnormality is identified on angiographic images. Occlusion of an artery of Percheron is unlikely given nonvisualization of this variant on angiography and involvement of the posterior aspect of the thalami which is typically in the territory supplied by the posterior choroidal arteries and not in the normal vascular territory of the artery of Percheron.

4. No obvious herniation or significant mass effect.

(DAI)