Author: Florian T. Schmid, MD, Björn Stinn, MD, Jörg-Thomas Kluckert, MD,
Thomas Chlibec, MD, and Simon Wildermuth, MD, PhD,
Institute of Radiology, Kantonsspital St. Gallen, Switzerland

History

A 52 year old male fell off a 7 m high roof during maintenance work. After the arrival of the med-evac helicopter, the emergency physician diagnosed an initial Glasgow-Coma- Score (GCS) of 3, hypotonia and tachycardia. The left pupil was fixed under direct light. An asymmetric mydriasis existed in both eyes. A periorbital hematoma developed quickly on the left side and there was visible blood flow out of the nose and left ear. The patient was hemodynamically stabilized by transfusion, intubated on site and afterwards airlifted to our clinic. At the emergency room the patient received a rightsided pleural drain (Buelau) and a CT examination of the head and body was performed as per standard trauma protocol.

Diagnosis

The initial native CCT-scan showed frontobasal contusions on both sides and in the right basal ganglias. A mixed subarachnoid and subdural bleeding in the left hemisphere lead to a consecutive shift of the centerline and to an initial, tentorial herniation. The aqueduct was free. The thin-slice reconstruction showed singular, pontine and cerebellar shear-lesions. The frontal base was ambilaterally fractured and emanated into the right temporal bone and pneumencaphalon. A hematotympanon on the left was probably caused by a longitudinal fracture of the petrous bone which sphenoidally emanated. The viscerogenic cranium endured a tripoidal fracture on the right and an ipsilateral blow-out fracture of the orbital base without herniation of orbital soft tissue. The diagnosis was a consecutive hematosinus. A ventral right pneumothorax without relevant collapse of lung tissue could be found after insertion of the “Buelau”- drainage. The bilateral postobasal lung contusions were corresponding with the costal fractures of ribs three and four on the right. According to the trauma mechanism, a liver laceration of segment five and six could also be found, with a large hematoma and active, portal-venous hemorrhage. Little perihepatic and interenteric liquid with an attenuation of 40 HU correlatewith a caudal liver capsule lesion. Mesenteric, hepatic and gastric edema matched the patient’s initial shock state. Despite a small, v-shaped perfusion defect of the left kidney, there were no further abdominal pathologies. An arterial injury as a cause of the perfusion defect could be reliably excluded. The spine did not show any injuries – only degenerations. A little Pipkin 3 impact fracture of the right femur was detected. Together with a non-dislocated fracture of the frontal pelvic ring, including the advocated anterior acetabulum, it marked the power vectors. A fracture of the right dorsal pelvic ring caused instability while striding the right iliosacral joint.

Fig. 1: Frontobasal contusions on both sides and mixed subarachnoid and subdural bleeding in the left hemisphere (arrows).
Fig. 2: The viscerogenic cranium endured a tripoidal fracture on the right and an ipsilateral blow-out fracture of the orbital base.

Fig. 3: A liver laceration was found with a hematoma and active portal-venous hemorrhage.
Fig. 4: Fractures of the right femur (red) and of the frontal pelvic ring (orange) were detected.

Comments

Already in 1976, Cowley influenced the concept of “golden hour”¹ and illustrated that trauma management always means time management. The mortality of traumatized patients increases significantly after the first hour, and includes not only first aid and quick transport. The time before therapy is essential. A fast and comprehensive diagnosis became the solution for a successful triage and therapy.² Today’s multislice CT with slice configurations of 40 and more slices, short rotation times and high-performance tubes allow a diagnosis with detailed information about the neurosurgical, traumatological, thoracic- and abdominal surgical state of the patient. In this case, the initial prognostic detection of shear lesions in brainstem and cerebellum already indicated a possible lethal outcome. Nevertheless, the perceptibility of such minimal changes of the modern spiral CT of the brain indicates a huge progress in technology. The findings were not only quantitative, in terms of short examination times of large volumes, but also qualitative with continuously better spatial resolutions down to 0.33 mm in isotropic voxels. A modern dose modulation method like Care Dose 4D considerably reduces the necessary dose exposure.

¹ Cowley RA (1976) The resuscitation and stabilization of major multiple trauma patients in a trauma center environment. Clin Med 83: 14.
² A.Beck, F.Gebhard, Th. Fleiter, E. Pfenninger, L.Kinzl: [Time optimized modern shock room management using digital techniques]; Unfallchirurg. 2002 Mar; 105(3): 292–6.