Clinical question: Intracranial hemorrhage. Signs and symptoms: Intracranial hemorrhage. CT brain without infusion:Images through posterior fossa are unremarkable.Images through the supratentorial space demonstrate massive left frontal contusion with significant amount of hemorrhage. Two lesser degree extensive areas of contusion and hemorrhage in the right frontal lobe is also noted. Compared to prior suboptimal CT of brain there is a slight interval increase in the amount of hemorrhage in the right frontal lobe.Extensive bilateral anterior temporal lobe contusions are again identified. Slight increase in the hemorrhage in the left temporal lobe is suspected, however note should be made that the quality of the exam on the prior study is very poor due to extensive motion.Vasogenic edema surrounding all areas of the above described hemorrhage. Extensive subarachnoid hemorrhage is again identified. There is evidence of bilateral subdurals along the leaves of tentorium which is better appreciated on the current exam than prior. The subdurals extend dorsal to the occipital lobes (left greater than right). The thickest measurable portion of the larger left subdural measures only 3.7 mm on axial image 17. There is mass effect on the left frontal horn secondary to hematoma in the left frontal lobe. The degree of mass-effect remains identical to prior study. Residual blood within the bilateral dependent portion of the lateral ventricles remain similar to prior study. No change in the size of normal appearing ventricle or system.Calvarium is intact, mastoid air cells and middle ear cavities are unremarkable. Opacification of bilateral ethmoid air cells and otherwise well pneumatized paranasal sinuses.Images through orbits demonstrate severely enlarged superior ophthalmic veins which are abnormal and are concerning for increased flow secondary to carotid cavernous fistula. Recommend auscultation and bilateral orbit for detection of bruit and further evaluation with a dedicated MRI, MRA, MRV examination is recommended.
1.Extensive bifrontal and temporal contusion with surrounding vasogenic edema.2.Suggestion of slight increase in the amount of hemorrhage as detailed above.3.Extensive subarachnoid hemorrhage with no appreciable interval change.4.No appreciable interval increase in the degree of mass effect or size of ventricular system.5.Better visualization of blood in the subdural space overlapping bilateral tentorial leafs as detailed.6.Calvarium remains intact.7.Significantly enlarged and bilateral superior ophthalmic veins is concerning for a carotid cavernous fistula considering patient's history of trauma and extensive intracranial hemorrhage. Above findings were discussed with neural ICU fellow pager number 6228.