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During a robbery, a 34-year-old local shopkeeper was hit on the head with a wooden bat and he lost consciousness.

On arrival to the ED, he was awake but oriented only to person.

There were multiple contusions on the right side of his head and blood draining from his nose, but he had no difficulty maintaining his airway. His pupils were equal and he was able to move all four extremities. The initial Glasgow coma scale (GCS) score was 14. His vital signs were normal and, aside from the head injury, there was no other evident trauma.

After initial stabilization, a head CT was performed (Figure 1).

  • What are the findings on his head CT?
  • (There are six abnormalities)

The primary goal of emergency CT scanning in a patient with head trauma is rapid identification of a surgically correctable lesion such as large subdural, epidural, or intracerebral hematoma. Clinical outcome can be substantially improved with prompt surgical treatment.

Many patients, however, do not have such lesions despite significant head injury. Lesions that cannot be surgically corrected include nonhemorrhagic cerebral contusions, diffuse axonal injury (DAI), and smaller intracranial hemorrhages. The clinical status of patient with these injuries can range from minor concussion to coma. Patients with these injuries are at risk for delayed development of intracranial hematomas or cerebral edema. These are known as secondary injuries.

Although this patient’s CT does not show lesions requiring immediate surgical intervention, there are several findings of significant head injury.

On CT image 5 (Figure 2), the ventricles appear small. Such slit-like ventricles are a sign of diffuse cerebral edema due to the traumatic brain injury. Another sign of diffuse cerebral edema is effacement (thinning or obliteration) of the cortical sulci.

Figure 2

Image 5—Brain window.

  • 1. Slit-like ventricles; effacement of cortical sulci.
  • 2. Slight midline shift.
  • 3. Skull appears thick left parietal region.
  • 4. Calcified choroid plexus (arrowhead).
  • 5. Normal venous sinuses in posterior falx (arrows).

On this and the adjacent images (Figure 2 and Figure 1, images 5, 6, and 7), slight midline shift to the right can be seen. This is ...

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