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e-CASES: Craniocerebral trauma, Carotid artery injury with dissection, traumatic perforation of GI tract, pulmonary artery injury, Chance fracture

病史

Female patient victim of a high-speed car accident (rear passenger with belt). At start of care by emergency services, she was found in a coma, Glasgow of 5, with anisocoria (right > left) and a frontal deteriorating scalp wound (15-20 cm) with extensive bleeding. She was intubated prior to transfer to the university hospital.

 

The body scan is provided.

檢查結果

My report:

 

Cranioencephalic space:

 

Left acute subdural hematoma with a maximum thickness of 3 mm with no mass effect.
Moderate volume subarachnoid hemorrhage (bilateral in the cortical sulci of the vertex and interpeduncular cistern).
Left occipital cortical hemorrhagic petechiae.
No median line structure deviation.
Bilateral frontal skin wound.
Bone aspects: fracture of the left tympanic bone and fracture of the walls of the sphenoid sinus with hemosinus.
Vascular aspects: dissection of the subpetrous portion of both internal carotids (left aneurysmal dissection).

 

(N.B.: calcification of the lentiform nuclei and degenerative cervical spine)

 

No posttraumatic cervical spine lesions.

 

Thoracic space:
Biapical layer of pneumothorax.
Foci of middle lobar and left superior lobar contusions.
Hemomediastinum with probably posttraumatic dissecting pseudoaneurysm of the right branch of the pulmonary artery, with no active bleeding.
A few pockets of posterosuperior pneumomediastinum with no indication of a tracheobronchial tract wound.
Fracture of the anterior arch of the 2nd and 3rd right ribs with extrapleural contact hematoma.
Non-displaced fractures of the anterior arch of the 2nd, 8th, 9th and 10th left ribs.

 

Abdominopelvic space
Presence of some pockets of perihepatic air, but which appear to be in the preperitoneal space.
However, extra-intestinal pneumoperitoneal air pockets dorsal to the umbilicus with marked parietal contact thickening of the jejunal loops (and transmural enhancement defect of one jejunal loop in the left flank suggestive of gastrointestinal perforation).
Inter-loop and Douglas pouch hemoperitoneum.
No posttraumatic lesions of the intra-abdominal solid organs.
Small volume of hemoretroperitoneum related to distraction-flexion Chance type fracture, combining:
- an "open" transverse fracture of the spinous apophysis of L3,
- a fracture of the right superior joint of L4 with no dislocation,
- a fracture of the right and left transverse processes of L3 and L4,
- an anterior comminuted fracture of the vertebral body of L4 with compression but no posterior wall recession.

 

All these elements and the fracture mechanism are suggestive of damage to the disks and yellow and inter-spinous ligaments: unstable fracture.

 

Note: gastric filling despite the presence of a nasogastric tube and the fortuitous discovery of an 8 mm cystic lesion of the head of the pancreas and a lipoma of the small intestine.

 

N.B.: visualization of an articular fracture of the left wrist on the abdominopelvic acquisition (arm left along the body).


診斷

Craniocerebral trauma, Carotid artery injury with dissection, traumatic perforation of GI tract, pulmonary artery injury, Chance fracture


討論

FOLLOW-UP:

 

- Emergency gastrointestinal surgery with, during the laparotomy: left transverse colon contusion with serous wound, cecal contusion and presence of a sutured jejunal anti-mesenteric centimetric wound.
- Semi-emergency lumbar spine surgery: percutaneous posterior osteosynthesis.
- Basic monitoring, without curative anticoagulation, of the bilateral carotid dissection; discuss the possibility of endovascular treatment (angioplasty).
- Clinical monitoring and transesophageal ultrasonography of the pulmonary arterial pseudoaneurysm in the near future.
- Screw-plate osteosynthesis of the external cuneal fracture of the left wrist.


重點

Important points:

 

- "Seat belt syndrome" comprises Chance type fractures of the lumbar spin, intestinal and mesenteric injuries, and vascular lesions of the large abdominal vessels, which should be investigated systematically.
- The best sign of posttraumatic intestinal perforation is the visualization of a break in the continuity of an intestinal loop (or a lack of focal enhancement) associated with extra-intestinal contact air pockets.
- Pulmonary artery injuries are exceptionally reported in CT analysis; they are indicative of a violent mechanism.


參考資料

IM13



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