Resident on call CMH cases

Collected by: Lisa H. Lowe, MD

History: Not waking up for night time feeding & hypotonia

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Findings:

•Lens shaped hyperdense area indicates epidural hematoma

•Midline shift

•Some dark non-clotted blood is seen also

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Dx: Epidural hematoma

•Nonaccidental trauma

•Surgically evacuated

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Hx: 8y male s/p MVA not waking

Findings:

•Hyperdense perimesencephalic cisterns indicate subarachnoid blood

•Narrowed midbrain worrisome for diffuse cerebral edema

Dx: Subarachnoid hemorrhage

•Hyperdense perimesencephalic cisterns indicate subarachnoid blood

•Narrowed midbrain worrisome for diffuse cerebral edema

Hx: 6y female severe headache & past hx of arachnoid cyst

Findings:

•Subdural fluid, hypodense bilateral (flattened gyri and no crossing vessels seen)

•Not subarachnoid fluid

•Arachnoid cyst seen at lower level in temporal fossa

Dx: Subdural effusion due to arachnoid cyst rupture

Hx: 1 yr female seizures

Findings

•Square shape frontal horns is seen with absent septum pellucidum

•Clefts in the brain bilateral, left > right indicates schizencephaly

Dx: Septooptic dysplasia

Hx: 3 yr near drowning

Findings

•Diffuse loss of gray white differentiation

•Bilateral foci of low density in the thalami

Dx: Profound hypoxic ischemic injury in a child

•With not so severe HIE, there is often watershed injury with preservation of thalami (due to preferential shunting of oxygenated blood to thalami)

•With total anoxia or prolonged hypoxia, the shunting does not work and the thalami may take the biggest hit

•This worst situation is with both involved as in this child

Hx: Premature infant with drop in hematocrit

Findings:

•Heterogeneous lesion in the posterior fossa with high and low density indicating partially clotted blood

•Linear periventricular high density and at the caudothalamic grooves indicates germinal matrix still present (arrowhead)

•Cortex also high density due

to extreme prematurity

Dx: Posterior fossa hemorrhage

Hx: Macrocephaly

Findings

•Prominence of the CSF spaces around the brain

•There is no flattening of the gyri and there are tiny vessels in the CSF indicating it is the subarachnoid, not subdural space

Dx: Benign enlarged subarachnoid spaces

•Seen most 3m - 3yrs

•Presents with macrocephaly in an otherwise healthy child

•Resolves spontaneously

•Associated with slight increased risk of subdural bleed

Hx: Apnea in a 2 week old

Findings

•Prominent venous structures, including the internal cerebral veins & straight sinus

Dx: Normal prominent venous sinuses

•Can mimic venous sinus thrombosus

•Should do contrasted exam if unsure and if not thrombus will see enhancement

Hx: Persistent vomiting in 4-yr-old male

Findings:

•Posterior fossa low density mass with peripheral calcification

Dx: Ependymoma

DDx:

•Medulloblastoma

•Juvenile pilocytic astrocytoma

•PNET

Hx: Baby fell of couch

Hx: Baby fell of couch

•Hyperdense subdural blood on left side indicates recent trauma

•Loss of left side sulci due to subdural fluid

Dx: Nonaccidental injury

•Hyperdense subdural blood on left side indicates recent trauma

Hx: Child stopped breathing

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Findings:

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Mixed density left subdural blood with left to right shift

Left loss of gray white differentiation and shift left to right of midline

Dx: Hyperacute subdural hematoma

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Mixed density indicates blood has not had time to clot yet

Must distinguish from acute on chronic SDH, in which there is there is not acute mass effect

Requires urgent surgical intervention

Hx: Seizure in 8 day old

Findings:•Bilateral high density in the thalami

•Prominent internal cerebral veins (arrowhead)

•Focus of right frontal horn intraventricular blood (arrow)

Dx: Venous hemorrhage due to venous sinus thrombosis

•Internal cerebral vein thrombus, most common in babies, classically causes bilateral thalamic ischemia/hemorrhage

Hx: Newborn with CHF and head bruit

Findings:

•Hydrocephalus from obstruction of 4th

•Enlarged Vein of Galen and transverse sinuses

Dx: Vein of Galen varix

•Treated with intravenous coils

Hx: Newborn with in utero hydrocephalus

Findings

•CSF space that connects with 4th ventricle (arrow)

•Hypoplastic cerebellum and large retrocerebellar fluid collection

•Hyrocephalus

•Macrocephaly

Dx: Dandy Walker malformation

•DW cyst has NO cerebellar vermis

•DW variant has some vermis

•DW malformation includes DW cyst and variant

•On CT hard to know if there may be a little vermis, so just say DWM and leave specifics to MRI reports

Hx: Seizure and headache 15yf

Findings

•Hypodense area left frontal lobe

•Vague

•No contrast given

•MRI planned

Hx: Multiple sclerosis

•Multiple foci in white matter on FLAIR MRI