CT of brainstem injury

We present a case of 80-year-old man who had headache of 1 day duration and gross subdural haemorrhage in the absence of any history of noticeable trauma, leading to descending transtentorial herniation and secondary brain stem haemorrhages called Duret haemorrhages. It is rare to find a Duret haemorrhage on imaging. This case has been presented to highlight the rarity of the condition and the unusual posterior location of the bleed and also the universally fatal nature of these haemorrhages. Relevant literature is reviewed.

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“…Mortality rate for brainstem injuries in those with transtentorial herniation is 2–3 times greater than that in those without it 9 …”

Section: Discussionmentioning

confidence: 93%

Atypical Duret haemorrhages seen on computed tomography

Marupaka

Sood

2008

Emerg Medicine Australasia

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“…After CT era, due to its ability to demonstrate the nature, sites, and multiplicity of traumatic brain injury, CT is now the primary diagnostic method for head injury. It is also very useful to elucidate classical DAI and posterior fossa lesions based on direct and indirect signs which include focal hemorrhage, significant contrast enhancement, hemorrhagic contusion, and edema of brain stem33), appearing as areas of high-, mixed-, and low density on the scan. Indirect signs are obliteration of the pontine, cerebello-pontine angle, and perimesencephalic cisterns.…”

Section: Discussionmentioning

confidence: 99%

“…The second hypothesis is that TBSI may occur alone or in association with other cranial injuries. Head injury carries a much graver prognosis when brain stem is involved33). Since severe head injury is often characterized by injury to several sites, both intra-and extra-axial, there may be no clear-cut clinical evidence of a specific brain stem lesion.…”

Section: Discussionmentioning

confidence: 99%

“…Since severe head injury is often characterized by injury to several sites, both intra-and extra-axial, there may be no clear-cut clinical evidence of a specific brain stem lesion. The most significant lesion may not be suspected until the patient fails to exhibit normal signs of recovery or it may be an unexpected autopsy findings33). Relating the location of the lesions and outcome, the death appeared to be closely linked to the phenomenon of bilateral pontine lesions, especially if bilateral upper pontine lesions are involved.…”

Section: Discussionmentioning

confidence: 99%

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The Prognostic Factors Related to Traumatic Brain Stem Injury

Kim

2012

J Korean Neurosurg Soc

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ObjectiveThis study was conducted to assess the clinical significance of traumatic brain stem injury (TBSI) reflected on Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) by various clinical variables.MethodsA total of 136 TBSI patients were selected out of 2695 head-injured patients. All initial computerized tomography and/or magnetic resonance imaging studies were retrospectively analyzed according to demographic- and injury variables which result in GCS and GOS.ResultsIn univariate analysis, mode of injury showed a significant effect on combined injury (p<0.001), as were the cases with skull fracture on radiologic finding (p<0.000). The GCS showed a various correlation with radiologic finding (p<0.000), mode of injury (p<0.002), but less favorably with impact site (p<0.052), age (p<0.054) and skull fracture (p<0.057), in order of statistical significances. However, only GOS showed a definite correlation to radiologic finding (p<0.000). In multivariate analysis, the individual variables to enhance an unfavorable effect on GCS were radiologic finding [odds ratio (OR) 7.327, 95% confidence interval (CI)], mode of injury (OR; 4.499, 95% CI) and age (OR; 3.141, 95% CI). Those which influence an unfavorable effect on GOS were radiologic finding (OR; 25.420, 95% CI) and age (OR; 2.674, 95% CI).ConclusionIn evaluation of TBSI on outcome, the variables such as radiological finding, mode of injury, and age were revealed as three important ones to have an unfavorable effect on early stage outcome expressed as GCS. However, mode of injury was shown not to have an unfavorable effect on late stage outcome as GOS. Among all unfavorable variables, radiological finding was confirmed as the only powerful prognostic variable both on GCS and GOS.

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“…Since pupillary function was impaired from the time of injury, the bleeding may have been superimposed on ischemic damage 111, 351. Some investigators have interpreted CT lesions that require contrast infusion for visualization as contusions, but there was difficulty in distinguishing such lesions from damage due to herniation and brainstem compression {9, 30, 311. Four of our patients had small putaminal hemorrhages that were also delayed in appearance.…”

Section: Discussionmentioning

confidence: 99%

Acute traumatic midbrain hemorrhage

Ropper

Miller

1985

Annals of Neurology

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A syndrome resulting from traumatic midbrain hemorrhage is described in 5 patients, 3 of whom had intracranial pressure measurements and 2 of whom had pathological examinations. The major clinical signs, evident immediately after injury, are coma, dilated (4 to 8 mm diameter) pupils that are fixed to light and dark, diminished limb tone, and impaired horizontal eye movements. The hemorrhages are single and linear or oval-shaped in the midsagittal rostral midbrain, extending several millimeters bilaterally. The appearance of the hematoma may be delayed on computed tomographic scanning, but early abnormalities of wave V of the brainstem auditory evoked potentials aid in diagnosis. Pathological features suggest that secondary brainstem distortion occurred soon after injury, perhaps resulting from a transiently raised intracranial pressure, but shearing injuries caused by acceleration-deceleration forces were also found.

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CT of brainstem injury

Cited by 21 publications

References 13 publications

Atypical Duret haemorrhages seen on computed tomography

Atypical Duret haemorrhages seen on computed tomography

The Prognostic Factors Related to Traumatic Brain Stem Injury

Acute traumatic midbrain hemorrhage

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