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Med-Challenger PEDS
Comprehensive Review and Assessment for Pediatricians
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Issue: January 1, 2008
Case: Trauma: Facial, Head, and Neck
Taken from
Med-Challenger PEDS
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Question:
A five-month-old male presents with fever, irritability, and vomiting over the past eight hours. His temperature at home was 38.0 rectally. He vomited five times. Past medical history is unremarkable.
Exam: T 38.0C (rectal), P 150, R 40 (crying). He is pale and fussy, though consolable at times. He doesn't focus or interact well. Anterior fontanelle is full. Pupils reactive. The tympanic membranes are pearly-pink. Oral mucosa moist.
Heart regular, without murmur. Lungs clear. Abdomen soft on inspiration without detectable tenderness. Testes not enlarged. Capillary refill time is two to three seconds. Muscle tone is good.
A lumbar puncture returns CSF that is homogeneously bloody (blood mixed with CSF). All three tubes appear to be equally bloody. CSF, blood, and urine samples are sent to the lab for culture. The child is given IV antibiotics.
A CT scan of the head without contrast is performed and is seen to the right.
Based on your interpretation of the CT scan, what is your presumptive diagnosis?
- The CT scan reveals multiple cerebral calcifications. The patient most likely has a congenital CNS infection.
- The CT scan is normal. The patient most likely has meningitis.
- The CT scan reveals a subarachnoid hemorrhage. The patient most likely has an arteriovenous malformation.
- The CT scan reveals a midline partially-calcified mass posteriorly. The patient most likely has a malignant neoplasm of the CNS.
- The CT scan reveals a posterior inter-hemispheric subdural hematoma. The patient has most likely been abused.
Answer:
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About the Image:
Brain contusions appear as focal regions of low CT density, reflecting edema in an area of macerated brain. Contusions may be found subjacent to a skull fracture or in the region of maximal impact of the brain against the skull or skull base. Hemorrhagic contusions appear as patchy areas of low and high density in the brain parenchyma. The nonvascular distribution of most contusions and the associated overlying skull and scalp injury distinguish them from brain infarctions. Contusions opposite the site of skull and scalp injury are consistent with a contrecoup mechanism of brain injury.
Acute intraparenchymal hematomas appear on head CT as rounded high density regions within the brain parenchyma. They tend to be of more uniform high attenuation and more sharply marginated than blood associated with hemorrhagic contusions. A small rim of surrounding low density around hematomas reflects associated edema and macerated tissue.
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