e-CASES: Severe cranioencephalic injuries, Carotid artery dissection, Aspiration pneumonia, Pelvic fracture
41-year old patient, with previous history of a first suicide attempt in June 2009; he was admitted following a second suicide attempt by defenestration, on August 19, 2009.
The patient was admitted to the emergency room for polytrauma with severe cranioencephalic trauma with fracture and a depressed fronto-orbital fracture with external communication. The patient was intubated and ventilated, no pupillary asymmetry.
The body scan is provided.
- Right frontal hemorrhagic contusions.
- Diffuse axonal lesions of the corpus callosum, internal temporal lobe, and mesencephalus.
- Acute subdural hematoma of the right convexity (9 mm thick) and 6 mm thick right temporopolar extradural hematoma.
- Moderate volume subarachnoid hemorrhage and intraventricular hemorrhage.
- Right-left subfalcine herniation and onset of right medial temporal herniation.
- Vascular aspects: aneurysmal dissection of the right internal carotid in its subpetrous portion, additional image on left lateral face of the left internal carotid in its intracavernous portion, strongly suggestive of posttraumatic pseudoaneurysm (contact fracture of carotid canal).
- Bony aspects: right frontal depression fracture with pneumocephalus. This fracture extends forwards to the orbit with displaced comminuted fracture of the roof, inducing grade II exophthalmos. It extends at the middle stage of the base of the skull with fracture of the right temporal condylar fossa, the greater wing of the right sphenoid bone, the walls of the sphenoid canal and the left carotid canal and finally with an extralabyrinthic fracture of the left petrous bone with no damage to the ossicular chain.
With respect to the face, Hemi-Lefort III on right (fracture of right pterygoid bone, fracture of the maxillonasal suture, and lamina papyracea, following by the frontozygomatic suture and zygomatic arch) with fracture line on the anterior and posterior walls of the maxillary sinus and fracture of the orbital floor with no incarceration. Fracture of the coronoid apophysis of the right mandible.
No posttraumatic spinal lesions.
Parenchymatous opacification of almost the entire left inferior lobe, with atelectatic component due to bronchial obstruction, all strongly suggestive of inhalation pneumopathy.
Non-displaced fracture of the middle arch of the 2nd right rib.
No other traumatic lesions (centro-lobular emphysema).
No lesions of the intra-abdominal solid organs.
Hemoretroperitoneum following fracture of the pelvic girdle at 4 points:
- Separation fracture of the pubic symphysis
- Fracture of the right obturator frame
- Fracture of both sacral wings, vertical on the right passing through the sacral foramens, and transverse on the left.
Fracture of the right transverse process of L5.
No urological or vascular complications but very strong suspicion of urethral injury given the significant displacement of the symphyseal separation.
Comminuted fracture of the right greater trochanter.
Severe cranioencephalic injuries, Carotid artery dissection, Aspiration pneumonia, Pelvic fracture
- Transfer to the neurosurgical emergency department for surgical debridement of the craniocerebral wound and right frontal "contusectomy".
- Followed by administration of a curative dose anticoagulant treatment.
- Conservative treatment of the pelvic fracture.
The patient is still hospitalized in intensive care.
- A cranioencephalic arterial angioCT scan must be performed in the event of any fracture of the base of the skull and in the event of any severe facial injury. The subpetrous portion of the internal carotid and its intracavernous portion are the most vulnerable sites.
- Inhalation pneumopathy is systematized and predominantly affects the inferior lobes (frequently occurs following severe facial injury due to blood inhalation++).
- Suspect urethral injury in the event of a significantly displaced symphyseal separation, particularly in the presence of associated pre-prostate fat filling and/or an ischiocavernous muscle hematoma.