0:01

This is one of those classic stories that

0:03

we sometimes talk about in neuroradiology.

0:07

This was a patient who was evaluated for trauma,

0:11

and as you can see from the CT scan, he's got

0:15

bilateral subdural hematomas along the tentorium,

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as well as a subdural hematoma that is

0:23

along the frontal convexities, extending to

0:26

the temporal convexities and parietal convexities.

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And you also see that there's midline shift here.

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There's a lot of damage going on,

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as well as a parenchymal hemorrhage.

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In the medial left temporal lobe, there is

0:42

subarachnoid hemorrhage in the basal cisterns.

0:46

Well, when you look at the clinical history on this

0:50

patient by going into the electronic medical record,

0:53

what happened was that this patient had sudden

0:56

onset of the worst headache of life while driving

1:00

a car, and with that headache, crashed the car.

1:06

So the headache preceded the motor vehicle

1:10

accident, and this is that scenario

1:13

where you're scratching your head—Is

1:15

all this from trauma, or is it something

1:18

related to that initial headache?

1:21

In this particular instance, the patient's

1:25

subarachnoid hemorrhage indicated that the

1:27

patient probably had an aneurysm that bled, leading

1:32

to that worst headache of life and crashing

1:36

the car off the side of the road. Without that

1:40

clinical history of the headache preceding

1:43

the trauma,

1:44

you would never know that.

1:45

So, let's go and look at the associated angiogram.

1:50

Here is the angiogram, and I'm just

1:53

going to go to the money images here.

1:56

You can see what's being measured is this very

1:59

large posterior communicating artery aneurysm.

2:03

Here's, um, a little bit more of a

2:06

scene from the coiling of the aneurysm,

2:09

but here is the very large aneurysm.

2:11

Here's a posterior

2:12

cerebral branch posterior communicating artery aneurysm.

2:16

This aneurysm burst into the medial left temporal lobe,

2:24

as well as the subarachnoid space, leading to the patient

2:28

having that severe headache and crashing the car.

2:31

So the primary problem is the aneurysm rather than the

2:40

trauma.

2:41

I just wanna go back and make a few

2:43

comments about aneurysms and head trauma.

2:48

So, it is true that sometimes the trauma itself

2:54

can lead to dissection of an intracranial vessel.

2:59

The most common intracranial vessel to be

3:01

dissected is the middle cerebral artery

3:04

because of its length and its, um,

3:08

pathway in a transverse dimension.

3:12

When the middle cerebral artery is dissected,

3:15

it may have a focal weakness in the blood

3:18

vessel that can lead to a dissecting aneurysm.

3:23

So, if you see a patient who has trauma and also has

3:28

a middle cerebral artery distribution stroke, again—

3:32

did the stroke lead to the trauma, or did the

3:36

trauma lead to a dissection of the middle

3:41

cerebral artery, either occluding it or leading to an

3:45

aneurysm, which may be a setup for embolic phenomenon?

3:50

So, this is another scenario where you may see a CTA

3:55

performed even in the setting of clear head trauma.