What study would you recommend next, and why?
CT angiogram of the circle of Willis. The presence of fractures that extend into the left carotid canal, jugular bulb and transverse sinus increase risk of vascular injury. The CTA (not provided here) in fact showed thrombosis of the left transverse sinus.
There are multiple acute intracranial haemorrhages, includingthe right dorso-lateral midbrain, left thalamus and scattered subcortical petechial haemorrhages predominantly in the right frontal and temporal lobes.There is also moderate volume traumatic subarachnoid haemorrhage, maximal over the right frontal convexity, and a thin right cerebral convexity subdural haematoma There is no midline shift or herniation. Multiple small locules of intracranial gas associated with the left petrous temporal bone fracture (see bone windows). There is also gas within the left transverse sinus. The lateral portion of the transverse sinus is relatively hyperdense compared to the remainder of the dural sinuses.
Multiple skull fractures, including a complex left petrous temporal bone fracture with transverse and longitudinal components occipital fracture with associated widening of the left parieto-occipital suture, left parietal bone and extensive sphenoid sinus fractures. Fractures involve walls of both the left jugular foramen and the left carotid canal.