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Special Feature
November 1, 2004

Image of the Month—Quiz Case

Author Affiliations

From the Department of Surgery, Division of Trauma and Critical Care, Los Angeles County-University of Southern California Trauma Center.


Grace S.RozyckiMD

Arch Surg. 2004;139(11):1257. doi:10.1001/archsurg.139.11.1257

A 34-year-old male was involved in a motor vehicle crash. On admission to the trauma center, he was alert, his Glasgow Coma Score was 15, his blood pressure was 130/85 mm Hg, and his heart rate was 104 beats per minute. The patient had a closed midshaft fracture of the left femur, an open comminuted fracture of the right tibia and fibula, and an open comminuted fracture of the right elbow. His admission hemoglobin level was 11.7 g/dL and his platelet count was 230 000/mm3. The initial chest radiograph and computer tomographic (CT) scan of the chest were all normal. The CT scan of the head was reported as a normal CT scan with no evidence of intracranial pathology, brain edema, or increased intracranial pressure. The patient was resuscitated and monitored for 8 hours and subsequently taken to the operating room where he underwent internal fixation of the femur and external fixation of the tibia and the elbow.

During the operation he remained hemodynamically stable and his arterial oxygen saturation remained greater than 97%. The patient’s estimated blood loss was 800 mL and he received 2 units of blood. Postoperatively the patient could not be awakened. A new head CT and chest radiograph were normal. Carotid color flow studies were normal. The blood gases were within normal limits. His hemoglobin level was 8.6/dL, white blood cell count was 10.1/mm3, and his platelet count was 73 000/mm3. A third head CT scan 48 hours after operation was normal and magnetic resonance imaging was performed (Figure).

What Is the Diagnosis?

  • Diffuse axonal injury.

  • Delayed intracerebral hemorrhagic lesions.

  • Diffuse brain edema.

  • Cerebral fat embolism.