Presentation
Passenger in a road traffic accident. In CT (not available) reported contusion of the left frontal lobe. Coma, clinical status inadequate to CT findings.
Patient Data
Cerebral haemorrhagic contusions in the left frontal lobe and mild contra-coup injuries in the right frontoparietal region, with a very thin small subacute subdural haematoma in this location.
On SWI sequence, multiple punctate susceptibility artifacts are visible, located at the grey-white matter junction, in the corpus callosum, cerebellum, and in the midbrain tegmentum (including substantia nigra on the left), indicating microhaemorrhages.
Fluid (possibly blood) in the left maxillary sinus and in the air cells of the right temporal bone.
Incidental high-signal T2/FLAIR lesion high in the left frontotemporal region.
Case Discussion
A constellation of MRI appearance (multiple punctate microhaemorrhages, not visible on CT) and clinical status (inadequately poor in relation to CT scan findings) indicate diffuse axonal injury (DAI). Considering the location of the microhaemorrhages, this is a grade III injury. The involvement of rostral midbrain (tegmentum and substantia nigra) has been shown to be a poor prognostic factor 1.
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