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Case 287

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A 76-year-old male patient admitted to the Emergency Room with headache and mental confusion, after 24 hours of falling from approximately 6 meters of height. Computed tomography (CT) of the head was performed for diagnostic elucidation.

Given the clinical case and the images provided, what is the most likely diagnosis?

a) Cerebral contusion

25%

b) Subdural hematoma

25%

c) Epidural hematoma

25%

d) Brain concussion

25%
   

Image analysis

Image 1: non-contrastedaxial computed tomography (CT) scan of the head in third ventricle level. Hypodense area presents in the right temporal lobe (suggestive of edema). This area is also permeated from foci with the blood density, compatible with cerebral contusion (in yellow). Intraventricular hemorrhage (red arrow) and subarachnoid (blue arrow) are also evidenced. Soft tissue density material is presented in the maxillary sinuses and in some ethmoidal cells. It suggests inflammatory sinus process.

 

Image 2: non-contrastedaxial computed tomography (CT) scan of the head in the pontine level. Hyperdensal area presents in the right temporal lobe (suggestive of hemorrhage), with surrounding hypodense halo (compatible with edema) - in yellow. Intraventricular hemorrhage (red arrow), subarachnoid hemorrhage (blue arrows) and hyperdensal focus, suggestive of pontine intraparenchymal hemorrhage (yellow arrow) are also evidenced. Presence of soft tissue density material is presented in the maxillary sinuses and in some ethmoidal cells, compatible with inflammatory sinus process.

Relevant aspects

- Brain contusions are quite common and are presented in 20-30% of serious traumatic brain injuries;

- Non-contrasted CT of the head is the first investigation for diagnosis and follow-up;

- Heterogeneous encephalic areas are presented in CT, with hyperdensities interspersed by hypodense zones in relation to the cerebral cortex;

- Frontal and temporal lobes are the most affected;

- Treatment may be conservative or surgical, according to the patient`s evolution.

References

- Hemphill JC, Aminoff MJ, Wilterdink JL. Traumatic brain injury: Epidemiology, classification, and pathophysiology. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. [09/07/2017].

- Mendonça RA, Rossi MD, Neto HM. Cranioencephalic injury. In: Silva CIS, D’Ippolito G, Rocha AJd, Vedolin L, Mendonça RA. Encéfalo. Rio de Janeiro: Elsevier; 2010 (Brazilian College of Radiology and Diagnostic Imaging). p. 565 – 594.

- Alvis-Miranda H, Alcala-Cerra G, Moscote-Salazar LR. Traumatic cerebral contusion: pathobiology and critical aspects. Cartagena: Universidad de Cartagena; 2013.

- American College of Surgeons - Advanced Trauma Life Support - ATLS:student course manual. 9ª ed. 2012.

Author

André Dias Nassar Naback, 5th year medical student of the Federal University of Minas Gerais.

E-mail: andrenaback[arroba]gmail.com

Victor Teatini Ribeiro, 5th year medical student of the Federal University of Minas Gerais.

E-mail: victorteatini[arroba]hotmail.com

Orientation

José Nelson Mendes Vieira. Professor of the Anatomy and Medical Imaging Department of the Medical School of Federal Unversity of Minas Gerais. 

E-mail: zenelson.vieira[arroba]gmail.com

Reviewers

Laio Paiva, Juliana Albano, Luísa Bernardino, Rafael Valério, Profa. Viviane Parisotto.

Translation

Joice Carneiro Dias Prodígios.

Test question

(HUAC - Federal University of Campina Grande / 2015) A 24-year-old patient entered the ER with a history of cranial trauma 4 hours ago during a football match (he collided with another player). At the time of the trauma, the patient did not lose consciousness and continued to play. After 20 minutes of the trauma, he progressed with headache and asked to be replaced. After 45 minutes, he presented worsening of the headache and started vomiting. After 2 hours of trauma, he evolves with drowsiness and progressive lowering of the level of consciousness. On admission in trauma’s hospital Glasgow coma scale was 7 with anisocoria on the right. What is the probable diagnosis?

a) Diffuse axonal injury

25%

b) Acute extradural hematoma

25%

c) Acute subdural hematoma

25%

d) Brain contusion

25%

e) Brain concussion

25%
   

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