Brief Answer:
Need films to really be able to see what you're referring to

Detailed Answer:
Good afternoon and thank you for your question.

In response to question (a) I understand that a patient suffered multiple blows to the head. Can you tell me the nature of these blows? Was this an assault using fists or being struck by blunt objects or was it a fall down several flights of stairs? He has headaches at 3 hrs. post incident while at the doctor's with a near tachycardic presentation (HR- 93-97). Swelling (likely subcutaneous) is palpably fluctuant from your description and painful. You are asking whether any swelling can be seen on the scan. Please understand that I am not a radiologist but as a neurologist who does look at a number of CT scans along with bone window sequences I cannot see anything that really pops out at me in terms of EDEMA OR SWELLING over the left temporal area. I also cannot see the presence of blood but I would really need to be at the scanning machine to be able to read what are called Hounsfield units that can help us distinguish blood from bone and normal vs. swollen tissue with blood intermixed. Again, I do not see anything that is "knock your socks off...swollen."

(b) You mention a "permanent indentation" on the top center back of the head which is palpable and you say is from another traumatic injury 1.5 years ago.

Unfortunately, I cannot seem to get the DICOM viewer to do much...perhaps because it is a ZIP file and my computer doesn't have an unzipping program? Not sure.

However, I do believe that from the raw images I can detect on the sagittal films several views where there is a discontinuity in the mid occipital region. Whether or not there is a real time fracture, I cannot tell because the resolution of the images on my screen is not very good and magnification only seems to make things worse because I'm actually magnifying the PIXELS of my computer screen which does nothing for improving the viewing of details on the film. I either need the viewer or the actual films to see anything more.

Is your concern that they are calling for an ACTUAL fracture in the same place where he suffered a severe blow 18 months ago or are they trying to call the presence of an OLD fracture?

Clinically speaking....if the area of discontinuity that I'm seeing in fact, represents the same area of "indentations" that the radiologist is seeing then, if this were a fracture I would expect to see some bleeding intracranially or other extravasations into the subcutaneous tissues which I can't make out. Of course, as I just said my perspective is compromised because I have very small images, no access to the viewer, and any magnification of the images is pointless.

Can you upload the actual radiology report?

If I've satisfactorily addressed your question then, could you do me the kindest of favors by CLOSING THIS QUERY and be sure to include some fine words of feedback and a 5 STAR rating to our transaction if you feel the response has helped you? Again, many thanks for posing your question.

Do not forget to recontact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 53 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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Brief Answer:
Confirmation of swelling and prior fracture

Detailed Answer:
Good morning.

After revamping the system a bit I was successful at looking at the Dicom images in their entirety. I viewed 329 images several times carefully paying attention to your question of left sided temporal swelling about 1" above the ear from an incident recorded as XXXXXXX 2016. I also looked carefully every image (not just the bone windows) to see if I could convince myself of any evidence that there is a previously healed fracture (partial depressed fracture) at the top center back of the head (superior mid-occipital) region. I reviewed images 26 and 27 in detail compared to the other images.

I am unable to confirm the presence of any significant edema or swelling in the soft subcutaneous tissues over the left temporal area approximately 1" above the ear. However, be aware that CT scan is not the best modality for observing soft tissue pathology and therefore, its absence on the scan must be correlated with clinical examination as well. Also, be aware that the patient appears to be slightly rotated in the scanner with respect to the head and therefore, this must be taken into account when making any calls of swelling/edema of tissues since symmetry is not perfect anymore for comparative purposes.

I cannot see any radiographic evidence of a partially or otherwise depressed skull fracture in the superior mid-occipital region either. The periosteal surface of the calvarium (skull) appears continuous and though there are minor irregularities seen these are more likely than not consistent with the bumps that are felt on the skull due to development growth and not as a result of bony scarring or cicatrization following traumatic fracture of the skull plate itself.

Though 3D reconstruction of these images may offer a slightly improved view of the bumps and so forth I don't think it would add much to the bone window data which fails to reveal, in my opinion, evidence of either a prior or real time fracture.

If I've satisfactorily addressed your question then, could you do me the kindest of favors by CLOSING THIS QUERY and be sure to include some fine words of feedback and a 5 STAR rating to our transaction if you feel the response has helped you? Again, many thanks for posing your question.

Do not forget to recontact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 125 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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Brief Answer:
As a neurologist my knowledge of advanced radiographic forensics is limited

Detailed Answer:
Good morning and thank you for your questions.

Though I am happy to give as best an answer I can to these questions please understand that neurologists are well trained in reading CT and MRI sequences of the brain, spinal cord, and the nervous system in general. However, when it comes to forensically identifying old skull table fractures or even soft tissue swelling involving head/neck structures....then, expertise by most neurologists will drop off quite dramatically. Your best bet would be to seek out radiologists or even better yet, NEUROradiologists when it comes to this sort of case where head/neck related structures are in question.

In general, MRI's are held to be superior to CT scans when there are questions of soft tissue injury or pathology. So in the case of swelling if it were subtle in a patient as far as the scan is concerned then, study such as MRI would better detect the defect as well as be able to possibly components of the swelling in terms of bleeding, straight water, pus, fragments of bone or other foreign bodies (so long as they were radio-opaque to MR energy).

CT scans are particularly sensitive and considered best when looking for bony abnormalities or anything with a component of calcification (e.g. teeth). And so in this example any fracture (old or new) of the skull would best be looked at by CT scan. You seem to be already familiar CT reconstruction planar imaging which can even lend more sensitivity (but not necessarily SPECIFICITY) in detecting things that are subtle in terms of normal topographic landmarks vs. pathological.

Modalities such as ULTRASOUND for orthopedic purposes has been gaining popularity in the last 5 years and even though many people wouldn't consider using it since it doesn't "penetrate" bone to any extent...experienced technicians and radiologist know how to read the echoreflection in order to detect even things as small as STRESS FRACTURES which are often times missed by both plain X-RAY as well as CT scans...even spiral CT's.....so I might suggest ORTHOPEDIC ULTRASOUND technology applied to the skull could yield similar results if looking for very subtle lesions. I don't know how successful it could be in detecting healed lesions from the past but that would be a matter of asking the testing doctor.

Also, another interesting but INDIRECT way of looking at damage to bony structures is to use MRI to look at what is BELOW the bony or periosteal/osteal layers to see if any subtle changes locally can be detected in the BONE MARROW signals for which MRI is very sensitive. The theory being that any isolated and local change in marrow signal intensity can be correlated with a trauma (either past or present..depending upon the severity) of the bony tissue ABOVE the area where the marrow were "malfunctioning" as it were. That's a pretty cool indirect way I'm aware of in using MRI to look for subtle damage or INvisible damage to a bone....even long after it's healed over.

I am aware of some cases in my patients where we've used NUCLEAR CISTERNOGRAPHY procedures because a patient had leakage of what appears to be CSF..either through an orifice of the body such as the ear or nose...or a routine MRI of the brain shows their MENINGES "lighting up" and so nuclear imaging was used to track fluid through abnormal openings in bony tables and plates (fine fracture lines) which were so small that they were missed by CT/X-ray films. But nuclear medicine techniques to directly look at present or old fractures would not really be an option.

Finally, densitometry testing and the corollary to that would be perhaps something like GALLIUM bone scanning in order to detect places where bone is thinned out or THICKENED again looking for places where a bone may have been traumatized and then, either HEALED the way bone should heal with a nice protective and thick scar....or it may be osteopenic or porotic compared to the adjoining areas which would then, suggest a failure for proper healing to take place and this can persist for a very long time...perhaps, for the patient's life. These modalities are often used forensically when looking at pediatric abuse cases.

As far as the second question is concerned....my PREFERENCE in looking at films is is to use the Real McCoy's....and if possible in concert with the radiology report. In other words, nowadays, the physical films are not around much anymore but most facilities will provide a CD ROM or DVD with the proper readers. I'm always using discs in my office to read studies for patients viewing pleasure. Another way, I've found helpful to obtain fairly high quality images for viewing and magnification is by having patients transfer the contents of their CD/DVD to a DROPBOX account which can be password protected and by the method I can look at things. I suppose that's similar to the Google Drive approach.

If I've satisfactorily addressed your question then, could you do me the kindest of favors by CLOSING THIS QUERY and be sure to include some fine words of feedback and a 5 STAR rating to our transaction if you feel the response has helped you? Again, many thanks for posing your questions and all the best to you in the future.

Do not forget to recontact me at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 174 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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Brief Answer:
All the best to you

Detailed Answer:
Many thanks for your explanation on the DICOM archive and all the best to you.

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