PMC5096764_01
The findings of the serial brain CT examinations. An urgent study (A) just after the blow to the right occipital area of her head (arrowhead) shows subarachnoid hemorrhaging with left frontal subdural hematoma (arrow). The following studies 6 hours (B) and 24 hours later (C) demonstrate exaggeration of the left frontal contusion (arrow) and further expansion of the contusion into the intraparenchymal hematoma (arrowhead), respectively. Thereafter, gradual improvements in the size of the hematoma (arrowhead) are noticed on clinical days 5 (D) and 11 (E). Disappearance of the hemorrhagic lesion marked by an area of hypodensity (arrowhead) is shown on clinical day 33 (F), indicating the resolution of the contusion.
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Urgent brain computed tomography (CT) showed subarachnoid hemorrhaging with a left frontal subdural hematoma (Fig. 1A), and subsequent contrast-enhanced diagnostic CT revealed bilateral thrombosis of the pulmonary arteries (Fig. 2A and B), despite the absence of venous filling defects in the abdominal veins and the lower limbs. Despite the expansions of the left frontal contusion demonstrated by repeat brain CT examinations 6 and 24 hours later (Fig. 1B and C), the patient did not manifest any neurological deficits. The heparinization was switched to warfarin (3 mg/day) on clinical day 8, delivering a PT-international normalized ratio of 1.7 to 2.5, and subsequent brain CT examinations performed on clinical days 11 (Fig. 1D) and 17 (Fig. 1E) showed gradual improvement in the intracranial lesion. Repeat brain CT performed on clinical day 33 showed the resolution of the contusion (Fig. 1F), while at 1 month of follow-up, she was still being treated with oral PSL (30 mg/day) combined with the warfarinization, having reached partial remission with a 24-hour urine protein level of 1.3 g and marginal improvement in the serum Alb level to 2.2 g/dL.
The findings of chest CT angiogram. An initial study (A and B) shows intraluminal thrombi in the main pulmonary arteries (arrows), while no filling defects are demonstrated in the repeat study (C and D).
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Another session of contrast-enhanced CT performed on clinical day 18 revealed the disappearance of the thromboses (Fig. 2C and D), and thus, oral prednisolone (PSL) at 40 mg/day was commenced 2 days later when she was no longer dependent on the oxygen administration.