J Korean Neurosurg Soc.  2013 Jun;53(6):380-382. 10.3340/jkns.2013.53.6.380.

Precedence of Parenchymal Enhancement on CT Angiography to a Fatal Duret Hemorrhage

• Sim KB
• Na DG
• Park JK

• KMID: 2190830
• DOI: http://doi.org/10.3340/jkns.2013.53.6.380

Abstract

We report a case of fatal duret hemorrhage (DH) in a patient with acute tentorial subdural hematoma and bilateral chronic subdural hematoma along the cerebral hemispheres. Preoperative CT angiography (CTA) revealed prominent parenchymal enhancement in the ventral pontomesencephalic area. After burr-hole drainage, a large hemorrhage developed in this area. The parenchymal enhancement in the CTA may reflect the pontomensencephalic perforating vessel injury, and may be a sign of impending DH of acute transtentorial downward herniation. Previous use of aspirin and warfarin might have potentiated the process of DH and increase the extent of the bleed.

Keyword

Duret hemorrhage; CT

MeSH Terms

Angiography
Aspirin
Cerebrum
Drainage
Glycosaminoglycans
Hematoma, Subdural
Hematoma, Subdural, Chronic
Hemorrhage
Humans
Warfarin
Aspirin
Glycosaminoglycans
Warfarin

Figure

• 

  Fig. 1 Initial precontrast brain CT reveals left-side subacute tentorial subdural hematoma and bilateral subacute subdural hematoma with gyral displacement (A and B). No significant abnormal density is seen in the ponto-mesencephalic junction (C) and a bilateral transtentorial downward uncal herniation is seen. Preoperative CTA was done and an enhanced axial CT and sagittal multiplanar reformatted image at the arterial phase reveals abnormal wedge-shaped enhancement in the midline pontomesencephalic junction (D and E). The 1-day follow-up CT just prior to the operation reveals newly developed a scanty amount of hemorrhage in the midline tegmentum of the rostral pons (F). Postoperative CT after burr-hole drainage reveals a large amount of ICH centered on the pontomesencephalic brain stem (G and H).

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