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Emergency radiology cases 1st Edition Abujudeh Digital
Instant Download
Author(s): Abujudeh, Hani H
ISBN(s): 9780199941179, 0199941173
Edition: 1
File Details: PDF, 43.95 MB
Year: 2014
Language: english
EMERGENCY
RADIOLOGY CASES
Emergency Radiology Cases
Published and Forthcoming books in the Cases in Radiology series:
Body MRI Cases, William Brant and Eduard de Lange
Breast Imaging Cases, Catherine Appleton and Kimberly Wiele
Cardiac Imaging Cases, Charles White and Joseph Jen-Sho Chen
Chest Imaging Cases, Sanjeev Bhalla, Cylen Javidan-Nejad, Kristopher W. Cummings,
and Andrew Bierhals
Emergency Radiology Cases, Hani Abujudeh
Gastrointestinal Imaging Cases, Angela Levy, Koenraad Mortele, and Benjamin Yeh
Genitourinary Imaging Cases, Mark Lockhart and Rupan Sanyal
Musculoskeletal Imaging Cases, Mark Anderson and Stacy Smith
Neuroradiology Cases, Clifford Eskey, Clifford Belden, David Pastel,
Arastoo Vossough, and Albert Yoo
Nuclear Medicine Cases, Chun Kim
Pediatric Imaging Cases, Ellen Chung
Ultrasound Cases, Leslie Scoutt, Ulrike Hamper, and Teresita Angtuaco
Emergency Radiology Cases

Hani H. Abujudeh, MD, MBA, FSIR

Associate Professor of Radiology
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts

1
1
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© Oxford University Press 2014

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retrieval system, or transmitted, in any form or by any means, without the prior
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Inquiries concerning reproduction outside the scope of the above should be sent to the
Rights Department, Oxford University Press, at the address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-in-Publication Data

Abujudeh, Hani H., author.
Emergency radiology cases / Hani Abujudeh.
p. ; cm.—(Cases in radiology)
Includes bibliographical references and index.
ISBN 978–0–19–994117–9 (alk. paper)
I. Title. II. Series: Cases in radiology.
[DNLM: 1. Diagnostic Imaging—Case Reports. 2. Emergency Medicine—Case
Reports. 3. Radiology—Case Reports. WN 180]
RC78.7.D53
616.07′54—dc23 2013022349

This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent on the
individual circumstances. And, while this material is designed to offer accurate information with respect
to the subject matter covered and to be current as of the time it was written, research and knowledge
about medical and health issues is constantly evolving and dose schedules for medications are being
revised continually, with new side effects recognized and accounted for regularly. Readers must therefore
always check the product information and clinical procedures with the most up-to-date published
product information and data sheets provided by the manufacturers and the most recent codes of
conduct and safety regulation. The publisher and the authors make no representations or warranties to
readers, express or implied, as to the accuracy or completeness of this material. Without limiting the
foregoing, the publisher and the authors make no representations or warranties as to the accuracy or
efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and
expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a
consequence of the use and/or application of any of the contents of this material.

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
To my mentors, Stephen Baker, James Thrall, Robert Novelline.
To my aunts, Wissal Arnout and Badeea Arnout.
To my wife Shima.
Thank you so much for your support.
Acknowledgments

The Publisher thanks the following for their time and advice:

Mark Anderson, University of Virginia

Sanjeev Bhalla, Mallinckrodt Institute of Radiology, Washington University
Michael Bruno, Penn State Hershey Medical Center
Melissa Rosado de Christenson, St. Luke's Hospital of Kansas City
Rihan Khan, University of Arizona
Angela Levy, Georgetown University
Alexander Mamourian, University of Pennsylvania
Stacy Smith, Brigham and Women’s Hospital

vii
Preface

This book provides a concise, high-yield, imaging overview of the spectrum

Emergency and Trauma conditions. The cases are presented in an easy-to-read for-
mat, including the most recent information. Although the book is not intended to
be comprehensive it includes the most important presentations in the acute set-
tings. The images are of high quality and include the most recent technologies, such
as three-dimensional imaging. The book is divided into Trauma and Nontrauma
Emergencies, and it is further subdivided by body regions. There is an additional
section on Pediatric Emergency Cases. We hope this book will serve as a quick
reference, and assist you in mastering Emergency Radiology.

Hani H. Abujudeh, MD, MBA, FSIR

ix
Contents

Contributors xiii

Part I. Trauma

Section 1. Brain 3

Section 2. Spine 37

Section 3. Chest 63

Section 4. Abdomen 87

Section 5. Upper Extremity 121

Section 6. Lower Extremity 151

Part II. Nontrauma

Section 1. Brain 189

Section 2. Head, Neck, and Spine 219

Section 3. Chest 245

Section 4. Abdomen 269

Part III. Pediatric

Index of Cases 355

Index 359

xi
Contributors

Essmaeel Abdel-Dayem, MD Yolanda Bryce, MD

South Shore Radiology Associates Clinical Fellow in Radiology (EXT)
Weymouth, Massachusetts Department of Radiology
First Author: Cases 132, 136, 142, 146 Mount Auburn Hospital
Cambridge, Massachusetts
Hani H. Abujudeh, MD, MBA First Author: Cases 25, 47, 76, 125, 127, 129,
Associate Professor of Radiology 130, 133, 137, 153, 163, 164
Harvard Medical School
Massachusetts General Hospital Judah G. Burns, MD
Boston, Massachusetts Assistant Professor of Radiology
Book Editor: Emergency Radiology Cases Division of Neuroradiology
Senior Author: Cases 18, 21, 22, 24, 25 27, Albert Einstein College of Medicine
28, 30, 36, 38, 45, 46, 47, 49, 53, 54, 58, 59, Montefiore Medical Center
60, 64, 66, 67, 69, 76, 78, 83, 95, 101, 111, Bronx, New York
115, 121, 124, 123, 125, 126, 127, 128, 129, First Author: Cases 1, 2, 5
130, 131, 132, 133, 134, 136, 137, 142, 146,
149, 150, 151, 153, 155, 163, 164 Scott Cameron, MD
Department of Diagnostic Imaging
Tarik K. Alkasab, MD Newport Hospital
Instructor in Radiology Newport, Rhode Island
Department of Radiology First author: Case 53, 149
Massachusetts General Hospital
Boston, Massachusetts Carson Campe, MD
Section Editor: Trauma - Abdomen Clinical Fellow in Radiology (EXT)
First Author: Cases 17, 20, 147, 148 Department of Radiology
Massachusetts General Hospital
Shima Aran, MD Boston, Massachusetts
Research Fellow Section Editor: Trauma - Upper Extremity
Department of Radiology First Author: Cases 18, 22, 28, 58, 59, 60, 67
Massachusetts General Hospital Senior Author: Cases 61, 65
Boston, Massachusetts
First Author: Case 54 Enzo Cento, MD
Advanced Radiology Services
Laura L. Avery, MD Grand Rapids, Michigan
Assistant Professor of Radiology First Author: Cases 41, 44, 48, 96, 135, 138,
Massachusetts General Hospital 154, 161
Boston, Massachusetts
Part Editor: Nontrauma
First Author: Cases 13, 14, 15, 16

xiii
 Robert Chen, MD Andrew J. Gunn, MD
Instructor in Radiology Clinical Fellow in Radiology (EXT)
Department of Radiology Department of Radiology
Massachusetts General Hospital Mount Auburn Hospital
Boston, Massachusetts Boston, Massachusetts
First Author: Cases 68, 88, 97, 162 First Author: Cases 30, 36, 95, 115, 121, 128,
131, 134
Garry Choy, MD
Instructor in Radiology Harlan B. Harvey, MD
Department of Radiology Clinical Fellow in Radiology (EXT)
Massachusetts General Hospital Department of Radiology
Boston, Massachusetts Mount Auburn Hospital
Section Editor: Trauma - Chest Boston, Massachusetts
First Author: Cases 33, 34, 35, 37, 113, 114, First Author: Cases 21, 24, 49, 101, 151
118, 122, 123
Rania Hitto MD
Ryan M. Christie, MD Clinical Fellow
Assistant Professor of Radiology Division of Neuro-Radiology
Division of Emergency Radiology Massachusetts General Hospital
Emory University School of Medicine Boston, Massachusetts
Atlanta, Georgia First Author: Case 112
First Author: Cases 29, 31, 32
Luke F. M. Hoagland, MD
Laleh Daftari Besheli Clinical Fellow in Radiology (EXT)
Research Fellow Department of Radiology
Department of Radiology Mount Auburn Hospital
Massachusetts General Hospital Boston, Massachusetts
Boston Massachusetts First Author: Cases 46, 124, 155
First Author: Case 150
Jamlik O. Johnson, MD
Dameon Duncan, MD Assistant Professor of Radiology
Assistant Professor of Radiology Division Director for Emergency Radiology
Department of Radiology Emory University School of Medicine
Albert Einstein College of Medicine Atlanta, Georgia
Montefiore Medical Center Section Editor: Nontrauma - Abdomen
Bronx, New York First Author: Cases 42, 43, 117, 140
First Author: Case 116
Jason M. Johnson, MD
R. Joshua Dym, MD Instructor in Radiology
Assistant Professor of Radiology Department of Radiology
Department of Radiology Massachusetts General Hospital
Albert Einstein College of Medicine Boston, Massachusetts
Montefiore Medical Center Section Editor: Nontrauma - Head, Neck,
Bronx, New York and Spine
First Author: Cases 119, 120, 139, 141, 160 First Author: Cases 103, 104, 105, 106, 109, 110

Daniel T. Ginat, MD Rathachai Kaewlai, MD

Instructor in Radiology Department of Radiology
Department of Radiology Bumrungrad International Hospital
Massachusetts General Hospital Bangkok, Thailand
Boston, Massachusetts Part Editor: Trauma
First Author: 10, 100, 107, 108 First Author: Cases 92, 94
xiv Contributors
Christine Kassis, MD Parul Penkar, MD
Clinical Fellow in Radiology (EXT) Instructor in Radiology
Department of Radiology Department of Radiology
Mount Auburn Hospital Massachusetts General Hospital
Boston, Massachusetts Boston, Massachusetts
First Author: Case 126 First Author: Cases 70, 71, 72, 73, 74, 75,
84, 85
Taj Kattapuram, MD
Clinical Fellow in Radiology (EXT) Otto Rapalino, MD
Department of Radiology Instructor in Radiology
Mount Auburn Hospital Department of Radiology
Boston, Massachusetts Massachusetts General Hospital
First Author: Cases 27, 38, 66, 78, 111 Boston, Massachusetts
First Author: Cases 89, 91, 98
Faisal Khosa, MD
Assistant Professor of Radiology Marianne Reed, MD
Division of Emergency Radiology Diagnostic Radiology
Emory University School of Medicine Yale-New Haven Hospital
Atlanta, Georgia New Haven, Connecticut
Senior Author: Cases 39, 40, 55, 145 Senior Author: Cases 103, 105, 106, 109, 110

Mykol Larvie Javier M. Romero, MD

MDInstructor in Radiology Assistant Professor of Radiology
Department of Radiology Department of Radiology
Massachusetts General Hospital Massachusetts General Hospital
Boston, Massachusetts Boston, Massachusetts
Section Editor: Trauma - Brain First Author: Cases 6, 12, 93
First Author: Cases 3, 4, 7, 8, 9, 11, 87, 90,
99, 102 Pamela W. Schaefer, MD
Director, MR Imaging
Peter MacMahon, MD Associate Director, Neuroradiology
Department of Radiology Massachusetts General Hospital
Mater Misericordiae University Hospital Boston, Massachusetts
Dublin, Ireland Section Editor: Nontrauma - Brain
Section Editor: Trauma - Spine
First Author: Cases 56, 61, 62, 63, 65, 77, 79, Meir H. Scheinfeld, MD, PhD
80, 81, 82, 86 Assistant Professor, Department of Radiology
Albert Einstein College of Medicine
Louis Marone, MD Director, Division of Emergency Radiology
Clinical Fellow in Radiology (EXT) Montefiore Medical Center
Department of Radiology Bronx, New York
Massachusetts General Hospital First Author: Case 57
Boston, Massachusetts
Section Editor: Nontrauma - Chest J. Gabriel Schneider, MD
First Author: Cases 19, 26 Clinical Fellow in Radiology (EXT)
Department of Radiology
Timothy Meehan, MD Mount Auburn Hospital
Clinical Fellow in Radiology (EXT) Boston, Massachusetts
Department of Radiology Section Editor: Trauma–Lower Extremity
Mount Auburn Hospital First Author: Case 50
Boston, Massachusetts
First Author: Cases 45, 64, 69

Contributors xv
 Randheer Shailam, MD Adam Ulano, MD
Instructor in Radiology Resident in Radiology
Department of Radiology Mount Auburn Hospital
Massachusetts General Hospital Cambridge, Massachusetts
Boston, Massachusetts First Author: Case 83
Part Editor: Pediatric
First Author: Cases 152, 156, 157, 158, 159 Jason Weiden, MD
Assistant Professor of Radiology
Michael Spektor Division of Emergency Radiology
Assistant Professor in Radiology Emory University School of Medicine
Department of Radiology Atlanta, Georgia
Albert Einstein College of Medicine First Author: Cases 23, 51, 52, 143
Montefiore Medical Center
Bronx, New York
First Author: Case 144

Freddie Swain, MD
Assistant Professor of Radiology
Division of Emergency Radiology
Emory University School of Medicine
Atlanta, Georgia
First Author: Cases 39, 40, 55, 145

xvi Contributors
Part I Trauma
Section 1 Brain
 Case 1

History
▶ None

5
Case 1 Temporal Bone Fracture (Longitudinal)
Findings
▶ Imaging checklists
■ Fractures classified into three types: longitudinal, transverse, and mixed/oblique
■ Middle ear ossicles (most common ossicular injuries involve the incus and its articulations)
■ Otic capsule (involvement increases risk of SNHL, facial nerve injury, CSF leak)
■ Carotid canal (involvement should prompt evaluation for ICA dissection or occlusion)
▶ On MRI, T1W hyperintensity can be used to assess for middle ear or labyrinthine hemorrhage

Differential Diagnosis
▶ Pseudofracture: Multiple sutures, fissures, and aqueducts course through the temporal bone
■ Typically bilateral, symmetric, and corticated margins

Teaching Points
▶ Fracture through temporal bone, often with associated facial nerve injury or ossicular involvement
▶ Three types of fractures
■ Longitudinal: Parallels long axis of petrous bone; higher risk of ossicular dislocation
■ Transverse: Perpendicular to long axis of petrous bone; higher risk of facial nerve injury
■ Mixed/oblique type
▶ Communication between middle ear and membranous labyrinth caused by oval/round window rupture is
called perilymphatic fistula

Management
▶ Conservative management is usual first-line therapy. Many CSF leaks spontaneously resolve. Carefully
monitor for possible meningitis.

Further Readings
Dahiya R, Keller JD, Litofsky NS, Bankey PE, Bonassar LJ, Megerian CA. Temporal bone fractures: otic capsule sparing versus
otic capsule violating clinical and radiographic considerations. J Trauma. 1999;47(6):1079–1083.
Saraiya PV, Aygun N. Temporal bone fractures. Emerg Radiol. 2009;16(4):255–265.

6
 Case 2

History
▶ Fall at nursing home.

7
Case 2 Acute Subdural Hematoma

Findings
CT
▶ Crescentic, hyperdense collection within the extra-axial space that can cross suture lines but limited by dural
attachments
▶ Pitfalls on CT
■ Acute SDH may be heterogeneous or low in density
■ Mixed-density subdural can be seen with clot retraction or arachnoid tear
■ Isodense subdural may be present with anemia or subacute hemorrhage

MRI
▶ Variable signal intensity on T1W/T2W imaging; hyperintense on FLAIR
▶ Displaced bridging veins often visible with contrast

Differential Diagnosis
▶ Epidural hematoma: Lenticular (biconvex) extra-axial hemorrhage, limited by suture lines (may cross dural
attachments); associated skull fracture often seen on CT
▶ Hygroma: simple CSF collection in subdural space
▶ Empyema: Peripherally enhancing, infected collection of pus; restricted diffusion on DWI

Teaching Points
▶ Acute collection of blood products between the inner layer of the dura and arachnoid membranes
▶ Acute hemorrhage is usually as a result of severe head trauma, high-velocity acceleration, or deceleration head
injury. Chronic SHD is usually caused by more trivial trauma in patients with risk factors (chronic alcoholism,
epilepsy, coagulopathy).
▶ In children, neonatal hematomas may be related to delivery, and usually resolve. In infants and toddlers,
nonaccidental trauma must be considered.
▶ Typically overlies convexity, although posterior fossa hemorrhages can occur
▶ SDHs may be symptomatic even when small, especially in young patients
▶ Density characteristics are not an absolute indicator of relative timing of hemorrhage

Management
▶ Careful neurologic monitoring with expectant surgical management

Further Readings
Freeman WD, Aguilar MI. Intracranial hemorrhage: diagnosis and management. Neurol Clin. 2012;30(1):211–240.
Barnes PD. Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine.
Radiol Clin North Am. 2011;49(1):205–229.

8
 Case 3

History
▶ 46-year-old male who fell down stairs.

9
Case 3 Epidural Hematoma

Findings
CT
▶ A large right parietal epidural hematoma involving rupture of the right middle meningeal artery causes severe
mass effect, including leftward midline shift
▶ Heterogeneous density within the hematoma reflects recent and possibly active extravasation (arrow)
▶ There is a nondisplaced fracture in the right parietal bone (arrowhead)
▶ The anteroinferior margin of the right parietal epidural hematoma is bounded by the right temporoparietal suture
▶ There is a smaller left frontotemporal subdural hematoma

CTA (lower right image)

▶ Dural and superficial cortical vessels are displaced away from the calvarium by the epidural hematoma

Clinical Presentation
▶ Most commonly associated with major head trauma
▶ Epidural hematomas may develop over time, resulting in a lucid interval during which the patient is less
symptomatic followed by more profound impairment

Pathophysiology
▶ Intracranially, the dura is the periosteum and epidural hemorrhage requires the dissection of the dura away
from its calvarial attachment
▶ Epidural hematomas are most commonly related to arterial rupture and are frequently seen in the setting of
calvarial fractures, with increased frequency related to displaced fractures
▶ Epidural hematomas may also arise from venous disruption
▶ Middle meningeal artery branches in the temporal and parietal regions are vulnerable to injury, and most
epidural hematomas occur in these regions

Teaching Points
▶ Major head trauma, calvarial fracture, and a lucent interval followed by more profound impairment are
features concerning for epidural hematoma
▶ Epidural hematoma does not typically cross sutures unless there is severe fracture at the suture line
▶ Large epidural hematomas are typically lentiform in configuration, although small epidural hematomas may
conform to local boundaries
▶ Postcontrast images may show active extravasation

Management
▶ Patients with even small epidural hematomas must be carefully monitored, because progressive bleeding may
rapidly become life threatening
▶ Medical therapy should be directed toward maintaining cerebral perfusion pressure, and may include volume
resuscitation, osmotic diuretics, and hyperventilation
▶ Surgical drainage may be achieved with burr holes or craniectomy

10
 Case 4
History
▶ 72-year-old female in motor vehicle collision with closed head trauma.

11
Case 4 Subarachnoid Hemorrhage

Findings
▶ Hyperdensity consistent with subarachnoid hemorrhage (SAH) outlining the left precentral gyrus (upper left)
▶ SAH outlining the right sylvian fissure and infiltrating sulci in the right temporal lobe (upper right)
▶ Trace intraventricular hemorrhage layering in the occipital horn of the right lateral ventricle (lower left)
▶ SAH in the prepontine cistern (lower right)
▶ Subdural hematoma overlying the left temporal, parietal, and occipital lobes and extending along the falx and
left tentorial leaflet (multiple images)

Clinical Presentation
▶ Common symptoms include headache, nausea and vomiting, and decreased consciousness

Pathophysiology
▶ The arachnoid mater overlies the pia mater, which is the deepest layer of the meninges covering the brain and
spinal cord, and SAH expands the space between these coverings
▶ The pia mater is extensively innervated with nerve fibers that transmit pain and are irritated by blood,
resulting in severe headache, such as a thunderclap headache
▶ Intraventricular hemorrhage is a subtype of SAH

Teaching Points
▶ Head CT is the most appropriate first examination to evaluate for SAH
▶ Lumbar puncture is often more sensitive than CT for SAH, and may reveal evidence of chronic SAH, such as
xanthochromia
▶ MRI is relatively less sensitive for early SAH, although very sensitive for chronic SAH, which produces a
strong susceptibility signal
▶ Traumatic SAH is strongly associated with other forms of traumatic brain injury, including contusion and
diffuse axonal image

Management
▶ The diagnosis of traumatic SAH requires exclusion of nontraumatic SAH, which may precipitate subsequent
trauma (e.g., a fall or motor vehicle collision)
▶ When there is any consideration that nontraumatic SAH is present, vascular imaging with CT angiography is
indicated to evaluate for intracranial aneurysm, the leading cause of nontraumatic SAH
■ Complications of SAH that warrant close observation
■ SAH may impair CSF resorption and lead to increased intracranial pressure and hydrocephalus
■ SAH can cause vasospasm, typically within 4–10 days, that may result in territorial ischemia
■ Hunt & Hess classification grades the clinical presentation from 1 (mildest) to 5 (most severe)
■ Fischer grade classifies the quantity and location of SAH on CT from 1 (none evident) to 4 (diffuse or
intraventricular or intraparenchymal extension)

12
 Case 5

History
▶ Motor vehicle accident.

13
Case 5 Cerebral Contusion

Findings
CT
▶ Cortical hyperattenuation
▶ Subcortical white matter swelling that is progressive over time
MRI
▶ Cortical swelling
▶ Variable signal intensity of patchy hemorrhages, “blooming” on GRE sequences
▶ Bilateral, asymmetric injury is common
▶ May be accompanied by other forms of intracranial injury: subdural/epidural hematoma, fracture, contrecoup injury
▶ May result in chronic encephalomalacia
Differential Diagnosis
▶ Cerebral infarction
▶ Infiltrative tumor (usually low grade); distinguished by clinical history
▶ Early cerebritis
Teaching Points
▶ Posttraumatic brain injury with cortical and white matter injury often associated with coup-contrecoup injury
and may be found distant from the site of impact
▶ Edema and patchy hemorrhage are common
▶ Hemorrhagic progression of contusion after initial trauma can result in severe, long-term loss of function in
affected brain areas
▶ Characteristic locations adjacent to irregular skull surfaces
■ Anterior, inferior frontal lobes
■ Anterior temporal lobes
■ Parasagittal (interhemispheric falx)
▶ The characteristic location of cerebral contusion can often differentiate this lesion from other infectious or
neoplastic etiologies
Management
▶ Supportive ICU care is paramount, with efforts aimed to optimize cerebral perfusion pressure and prevent seizures
▶ Strategies include administration of mannitol, hyperventilation, and sedation
▶ The use of antiepileptic medications may prevent early onset seizures, which can cause irreversible status
epilepticus or increase intracranial pressure; however, may not prevent the later onset of epilepsy
Further Readings
Alahmadi H, Vachhrajani S, Cusimano MD. The natural history of brain contusion: an analysis of radiological and clinical
progression. J Neurosurg. 2010;112(5):1139–1145.
Kurland D, Hong C, Aarabi B, Gerzanich V, Simard JM. Hemorrhagic progression of a contusion after traumatic brain injury: a
review. J Neurotrauma. 2012;29(1):19–31.

14
 Case 6
History
▶ None

15
Case 6 Diffuse Axonal Injury

Findings
CT
▶ Multiple hyperattenuated foci measuring 1–15 mm, typically in the cortical-subcortical junction, corpus
callosum, and brainstem.
▶ These lesions may present a hypodense halo that likely represents peripheral edema.
▶ Sulci effacement may be present, with blurring of the gray and white matter interphase representing
brain edema.

MRI
▶ Multiple foci of blooming in GRE and SW images.
▶ Restricted diffusion in the cortical-subcortical junction, corpus callosum and brainstem.
▶ High T2/FLAIR signal in the areas of injury.
▶ The splenium is the segment most frequently involved of the corpus callosum.
▶ Brainstem involvement has a very poor clinical prognosis.

Teaching Points
▶ Patients usually lose conscience and likely persist with altered mental status when they suffer DAI.
▶ This lesion is the result of traumatic acceleration/deceleration or rotational injuries.
▶ The degree of DAI severity is associated with the location of the injury. In ascending order of severity: cortical
subcortical junction, corpus callosum, and brainstem.
▶ Brainstem DAI results in high mortality.
▶ Facial or skull fractures are not always associated with this type of trauma.

Management
▶ Supportive ICU care is paramount, with efforts aimed to optimize cerebral perfusion pressure and prevent
seizures.
▶ Strategies including administration of mannitol, hyperventilation, and sedation are important for the control
of brain edema.
▶ The use of antiepileptic medications may prevent early onset seizures.

16
 Case 7

History
▶ 52-year-old male with thrombocytopenia who fell from a bar stool.

17
Case 7 Intracranial Herniation

Findings
CT
▶ A large left cerebral subdural hematoma causes severe mass effect and brain herniation.
▶ The medial aspect of the left temporal lobe (the uncus) is displaced rightward across the tentorium, resulting
in left uncal herniation.
▶ Portions of the left cerebral hemisphere, principally the left cingulate gyrus and the corpus callosum, are
displaced to the right beneath the falx cerebri, resulting in subfalcine (or cingulate) herniation.
CTA
▶ Left uncal herniation results in compression of the posterior cerebral artery (PCA) and posterior
communicating artery (axial image, arrow). This may result in PCA territory infarction.
▶ Subfalcine herniation results in compression of the anterior cerebral arteries (ACAs). Normal right ACAs are
present, whereas the left the ACAs are highly attenuated (coronal image, arrowhead). This may result in ACA
territory infarction.
▶ Additional types of brain herniation (not depicted) include
■ Upward or downward transtentorial herniation of the thalami, brainstem, and medial temporal lobes
(central herniation)
■ Cerebellar tonsil herniation through the foramen magnum
■ Transcalvarial herniation, in which a portion of the brain protrudes through a defect in the calvarium that
may be congenital, traumatic, or postsurgical
Teaching Points
▶ Acute brain herniation requires emergent treatment
▶ May be caused by
■ Intrinsic processes: intra-axial hemorrhage, edema or tumor
■ Extrinsic processes: extra-axial hemorrhage, tumor, trauma
■ Hydrocephalus or ventricular entrapment
■ Compression of cerebral arteries may cause infarction
■ Subfalcine herniation: ACA territory infarction
■ Uncal herniation: PCA territory infarction
■ Uncal herniation may impinge cranial nerves, particularly the third cranial nerves
Management
▶ Intracranial pressure monitoring is indicated when there are signs, symptoms, or circumstances concerning
for elevated intracranial pressure
▶ Medical: hypertonic saline, mannitol
▶ Surgical: hemicraniectomy
Further Readings
Andrews BT. The recognition and management of cerebral herniation syndromes. In: Loftus CM, ed. Neurosurgical
Emergencies. 2nd ed. New York: Thieme; 2008:34–44.
Ropper AH. Hyperosmolar therapy for raised intracranial pressure. N Engl J Med. 2012;367:746–752.

18
 Case 8

History
▶ 51-year-old found down with ethanol intoxication.

19
Case 8 Spine Ligamentous Injury
Findings
▶ Subtle anterolisthesis of the C5 and C6 vertebrae
▶ Disruption of the anterior longitudinal ligament, posterior longitudinal ligament, and supraspinous ligament
(Figure 8.1; long, medium, and short arrows, respectively)
▶ Prevertebral soft tissue swelling from C6 through T3
▶ Extensive T2 hyperintensity consistent with edema in the posterior paraspinal muscles (Figure 8.2a;
arrowheads)
▶ Extensive edema in the posterior paraspinal soft tissues extending from the occiput superiorly through T2
inferiorly (Figure 8.2)
▶ T2 hyperintensity consistent with edema in the spinal cord at C6 through C7 reflecting spinal cord injury
(see Case 9)
▶ Signal hyperintensity between spinous processes from C4 through T1 indicates injury to the interspinous
ligamentous

Clinical Presentation
▶ Spine ligamentous injury may occur with relatively mild trauma, such as fall from standing height and low-
speed motor vehicle collisions
▶ Point tenderness may relate to spine ligamentous injury, although this is not a sensitive or specific finding
for such

Spectrum of Imaging Findings

▶ Alignment abnormality
■ Anterior, posterior, and lateral spondylolisthesis
■ Widening of spinous processes
▶ Intervertebral disk disruption
▶ Frank disruption of ligaments
▶ Edema in paraspinal soft tissues
▶ Epidural hematoma, particularly in relation to disruption of the posterior longitudinal ligament
▶ Craniocervical junction injuries
■ Apical ligament
■ Alar ligaments
■ Cruciate ligaments
■ Tectorial membrane
■ Anterior and posterior atlantooccipital membranes
■ Posterior atlantoaxial membrane

Teaching Points
▶ Spine ligamentous injury is more apparent when imaged early, such as within 72 hours of injury, before edema
begins to resolve
▶ In the cervical (C3-C7), thoracic and lumbar spine, two of three columns intact (anterior, posterior, and
middle) is generally regarded as mechanically stable

Management
▶ Immobilization of the entire spinal column is essential until spine is cleared
▶ Immobilization with braces is the mainstay of therapy for spine ligamentous injury without accompanying
bone or spinal cord injury
▶ Nonsteroidal anti-inflammatory drugs are useful for pain control
▶ Surgery reserved to restore mechanical instability

20
 Case 9

History
▶ 36-year-old male who fell two stories.

21
Case 9 Spinal Cord Injury

Findings
CT
▶ Comminuted fractures of the T11 and T12 vertebral bodies resulting in retropulsion of bone fragments into
the spinal canal and loss of vertebral body height
MRI
▶ Vertebral body fractures with bone marrow edema
▶ Abnormal expansion and edema in the inferior spinal cord consistent with acute contusion, prominently
involving the conus medullaris (Figure 9.1a; arrow)
▶ Edema in the central spinal cord and posterior columns (Figure 9.2a; arrowhead)
Clinical Presentation
▶ Symptoms are proportional to the severity of injury and level of spinal cord involvement
▶ High cervical SCI may cause coma and death because of brainstem injury
▶ Spinal cord injury without radiographic abnormality (SCIWORA): SCI occurring in the absence of
abnormality detectable on plain radiographs or CT imaging
▶ SCIWORA most commonly occurs in children and frequently results in delayed presentation of even severe
symptoms, such as paralysis
Pathophysiology
▶ Acute SCI most commonly arises from trauma and involves intramedullary edema and often hemorrhage
▶ Nonacute SCI may arise from chronic trauma, most frequently in the setting of degenerative disk changes,
resulting in spondylomyelopathy
Teaching Points
▶ The degree of SCI may be disproportionate to spinal canal narrowing, because cord injury may result from
transient deformations, as with SCIWORA
▶ Both acute and nonacute SCI may be present, especially in patients with significant degenerative changes
▶ Spinal cord edema may increase substantially in SCI, whereas hemorrhage generally does not
Management
▶ Immobilization of the entire spinal column is essential until spine is cleared
▶ Prompt glucocorticoid administration reduces injury
▶ Loss of motor function is an indication for urgent surgical decompression
▶ Spine MRI is indicated in patients with neurologic deficits and for evaluation of obtunded patients
Further Readings
Chandra J, Sheerin F, Lopez de Heredia L, Meagher T, King D, Belci M, Hughes RJ. MRI in acute and subacute post-traumatic
spinal cord injury: pictorial review. Spinal Cord. 2012;50:2–7.
Chittiboina P, Cuellar-Saenz H, Notarianni C, Cardenas R, Guthikonda B. Head and spinal cord injury: diagnosis and
management. Neurol Clin. 2012;30:241–276–ix.

22
 Case 10

History
▶ None

23
Case 10 Ossicular Dislocation

Findings
▶ Figure 10.1a is an axial CT image of the right temporal bone that shows that the head of the malleus (arrow) is
completely dissociated from the body of the incus (arrowhead).
▶ Figure 10.2a is an axial CT image of the corresponding normal left temporal bone that shows the intact
ice-cream cone configuration of the incudomalleal joint (arrow).

Differential Diagnosis
▶ Malleoincudal subluxation
▶ Incus interposition surgery
Teaching Points
▶ Ossicular injury can lead to conductive hearing loss.
▶ The main types of ossicular disruption include incudomalleolar joint separation, incudostapedial joint
separation, dislocation of the incus, dislocation of the malleoincudal complex, and stapediovestibular dislocation.
▶ Incudostapedial joint separation is the most common posttraumatic ossicular derangement, followed by
complete incus dislocation from both its incudomalleolar and incudostapedial articulations.
▶ The incudomalleolar joint normally has an ice-cream cone configuration on axial CT images, in which the head of
the malleus is seated in a groove (facet for the malleus) within the body of the incus. This arrangement is disrupted
with incudomalleolar joint subluxation or dislocation and is therefore best appreciated on axial CT sections.

Management
▶ Careful search for associated injuries on temporal bone CT, including temporal bone and ossicular fractures,
perilymphatic fistula, and facial nerve injury.
▶ Ossiculoplasty.
Further Readings
Meriot P, Veillon F, Garcia JF, Nonent M, Jezequel J, Bourjat P, Bellet M. CT appearances of ossicular injuries. RadioGraphics.
1997;17(6):1445–1454.
Yetiser S, Hidir Y, Birkent H, Satar B, Durmaz A. Traumatic ossicular dislocations: etiology and management. Am J
Otolaryngol. 2008;29(1):31–36.
Zayas JO, Feliciano YZ, Hadley CR, Gomez AA, Vidal JA. Temporal bone trauma and the role of multidetector CT in the
emergency department. RadioGraphics. 2011;31(6):1741–1755.

24
 Case 11

History
▶ 86-year-old female who fell and injured her left face.

25
Case 11 Orbital Hematoma

Findings
CT
▶ Preseptal, intraorbital density representing hematoma extending along the lateral orbital wall, with a convex
margin projecting intraorbitally
▶ Mildly displaced fracture of the lateral orbital wall
▶ Marked mass effect contributing to mild proptosis
▶ Mild stretching of the optic nerve caused by proptosis
▶ Extensive preseptal periorbital soft tissue swelling
CTA
▶ Punctate focus of contrast within the hematoma concerning for pseudoaneurysm or possibly active
extravasation (Figure 11.1a)
▶ Intraorbital displacement of the lateral rectus muscle (Figure 11.2a)
Clinical Presentation
▶ Commonly associated with trauma, especially blunt injury
▶ Clinical signs may include proptosis and decreased range of motion of the ipsilateral globe
▶ Clinical symptoms may include pain, decreased visual acuity, and diplopia resulting from decreased range of motion
▶ An afferent pupillary defect reflects nerve injury
▶ Surgical procedures that may cause orbital hematoma include endoscopic sinus surgery, blepharoplasty, and
orbital reconstruction
Pathophysiology
▶ In trauma, hemorrhage is most frequently subperiosteal related to disruption of small vessels in the periosteum
▶ Orbital hematomas may arise from extension of infection, particularly sinusitis, into the subperiosteal intraorbital space
▶ Less common causes of orbital hematoma include ruptured vascular malformation and hemorrhagic neoplasm
▶ Postseptal hemorrhage (posterior to the orbital septum) is more likely to cause injury to the globe, optic nerve,
and other orbital structures than preseptal hematoma (anterior to the orbital septum)
▶ May cause an acute orbital compartment syndrome, which may lead to vision-threatening compressive optic
neuropathy, which requires emergent management
Teaching Points
▶ Traumatic and nontraumatic orbital hematomas most commonly occur in the subperiosteal space
▶ Active extravasation on postcontrast imaging is concerning for rapid expansion of the hematoma
Management
▶ Conservative therapy may include glucocorticoids for anti-inflammatory effect, especially with delayed presentations
▶ Surgical treatment may involve hematoma evacuation and orbit reconstruction
▶ Hematoma evacuation may also be performed with needle aspiration
Further Reading
Ramakrishnan VR, Palmer JN. Prevention and management of orbital hematoma. Otolaryngol Clin North Am.
2010;43:789–800.

26
 Case 12

History
▶ None

27
Exploring the Variety of Random
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from afar, and realizing how the little puny efforts of a handful of
men could hold in check such a devastating force. Only country
dwellers could appreciate the peril of having all one owned in the
world, all that was dear and precious, and comprised in the word
“home,” swept away in the path of the flames.
“Poor old Cynthy,” said Jean. “I’m so glad she has her cats. I shall
never forget her face when she looked back. Just think of losing all
the little keepsakes of a lifetime.”
It was nearly five o’clock when Shad returned. He was grimy and
smoky, but exuberant.
“By jiminitty, we’ve got her under control,” he cried, executing a
little jig on the side steps. “Got some hot coffee and doughnuts for a
fellow? Who do you suppose worked better than anybody? Gave us
all cards and spades on how to manage a fire. He says this is just a
little flea bite compared with the ones he has up home. He says he’s
seen a forest fire twenty miles wide, sweeping over the mountains
up yonder.”
“Who do you mean, Shad,” asked Jean. “For goodness’ sake tell
us who it is, and stop spouting.”
“Who do you suppose I mean?” asked Shad, reproachfully.
“Honey Hancock’s cousin, Ralph McRae, from Saskatoon.”
Jean blushed prettily, as she always did when Ralph’s name was
mentioned. She had hardly seen him since his arrival, owing to
Billie’s illness, and Carlota’s visit with her. Still, oddly enough, even
Shad’s high praise of him, made her feel shyly happy.
The fire burned fitfully for three days, breaking out unexpectedly
in new spots, and keeping everyone excited and busy. The old Ames
barn went up in smoke, and Mr. Rudemeir’s saw mill caught fire
three times.
“By gum!” he said, jubilantly, “I guess I sit out on that roof all
night long, slapping sparks with a wet mop, but it didn’t get ahead
of me.”
 Sally and Kit ran a sort of pony express, riding horseback from
house to house, carrying food and coffee over to the men who were
scattered nearly four miles around the fire-swept area. Ralph and
Piney ran their own rescue work at the north end of town. Honey
had been put on the mail team with Mr. Ricketts’ eldest boy, while
the former gave his services on the volunteer fire corps. The end of
the third day Jean was driving back from Nantic station, after she
had taken Carlota down to catch the local train to Providence. The
Contessa had sent her maid to meet her there, and take her on to
Boston. It had been a wonderful visit, Carlota said, and already she
was planning for Jean’s promised trip to the home villa in Italy.
Visions of that visit were flitting through Jean’s mind as she drove
along the old river road, and she hardly noticed the beat of hoofs
behind her, until Ralph drew rein on Mollie beside her. They had
hardly seen each other to talk to, since her return from Boston.
“The fire’s all out,” he said. “We have left some of the boys on
guard yet, in case it may be smouldering in the underbrush. I have
just been telling Rudemeir and the other men, if they’d learn to pile
their brush the way we do up home, they would be able to control
these little fires in no time. You girls must be awfully tired out. You
did splendid work.”
“Kit and Sally did, you mean,” answered Jean. “All I did was to
help cook.” She laughed. “I never dreamt that men and boys could
eat so many doughnuts and cup cakes. Cousin Roxy says she sent
over twenty-two loaves of gingerbread, not counting all the other
stuff. Was any one hurt, at all?”
“You mean eating too much?” asked Ralph, teasingly. Then more
seriously, he added, “A few of the men were burnt a little bit, but
nothing to speak of. How beautiful your springtime is down here in
New England. It makes me want to take off my coat and go to work
right here, reclaiming some of these old worked out acres, and
making them show the good that still lies in them if they are plowed
deep enough.”
 Jean sighed, quickly.
“Do you really think one could ever make any money here?” she
asked. “Sometimes I get awfully discouraged, Mr. McRae. Of course,
we didn’t come up here with the idea of being farmers. It was Dad’s
health that brought us, but once we were here, we couldn’t help but
see the chance of making Greenacres pay our way a little. Cousin
Roxy has told us we’re in mighty good luck to even get our
vegetables and fruit out of it this last year, and it isn’t the past year I
am thinking of; it’s the next year, and the next one and the next.
One of the most appalling things about Gilead is, that you get
absolutely contented up here, and you go around singing blissfully,
‘I’ve reached the land of corn and wine, and all its blessings freely
mine.’ Old Daddy Higginson who taught our art class down in New
York always said that contentment was fatal to progress, and I
believe it. Father is really a brilliant man, and he’s getting his full
strength back. And while I have a full sense of gratitude towards the
healing powers of these old green hills, still I have a horror of Dad
stagnating here.”
Ralph turned his head to watch her face, giving Mollie her own
way, with slack rein.
“Has he said anything himself about wanting to go back to his
work?” he asked.
“Not yet. I suppose that is what we really must wait for. His own
confidence returning. You see, what I’m afraid of is this: Dad was
born and brought up right here, and the granite of these old hills is
in his system. He loves every square foot of land around here. Just
supposing he should be contented to settle down, like old Judge
Ellis, and turn into a sort of Connecticut country squire.”
“There are worse things than that in the world,” Ralph replied.
“Too many of our best men forget the land that gave them birth, and
pour the full strength of their mature powers and capabilities into
the city mart. You speak of Judge Ellis. Look at what that old fellow’s
mind has done for his home community. He has literally brought
modern improvements into Gilead. He has represented her up at
Hartford off and on for years, when he was not sitting in judgment
here.”
“You mean, that you think Dad ought not to go back?” asked
Jean almost resentfully. “That just because he happened to have
been born here, he owes it to Gilead to stay here now, and give it
the best he has?”
Ralph laughed, good naturedly.
“We’re getting into rather deep water, Miss Jean,” he answered.
“I can see that you don’t like the country, and I do. I love it down
east here where all of my folks came from originally, and I’m mighty
fond of the west.”
“Oh, I’m sure I’d like that too,” broke in Jean, eagerly. “Mother’s
from the west, you know. From California, and I’d love to go out
there. I would love the wide scope and freedom I am sure. What
bothers me here, are those rock walls, for instance.” She pointed at
the old one along the road, uneven, half tumbling down, and
overgrown with gray moss; the standing symbol of the infinite
patience and labor of a bygone generation. “Just think of all the
people who spent their lives carrying those stones, and cutting up all
this beautiful land into these little shut-in pastures.”
“Yes, but those rocks represent the clearing of fields for tillage. If
they hadn’t dug them out of the ground, they wouldn’t have had any
cause for Thanksgiving dinners. I’m mighty proud of my New
England blood, and I want to tell you right now, if it wasn’t for the
New England blood that went out to conquer the West, where would
the West be today?”
“That’s all right,” said Jean, a bit crossly for her, “but if they had
pioneered a little bit right around here, there wouldn’t be so many
run down farms. What I would like to do, now that Dad is getting
well, is make Greenacres our playground in summertime, and go
back home in the winter.”
“Home,” he repeated, curiously.
 “Yes, we were all born down in New York,” answered Jean,
looking south over the country landscape, as though she could see
Manhattan’s panoramic skyline rising like a mirage of beckoning
promises. “I am afraid that is home to me.”
 CHAPTER XX
OPEN WINDOWS

“It always seems to me,” said Cousin Roxy, the first time she
drove down with Billie to spend the day, “as if Maytime is a sort of
fulfilled promise to us, after the winter and spring. When I was a
girl, spring up here behaved itself. It was sweet and balmy and
gentle, and now it’s turned into an uncertain young tomboy. The
weather doesn’t really begin to settle until the middle of May, but
when it does—” She drew in a deep breath, and smiled. “Just look
around you at the beauty it gives us.”
She sat out on the tree seat in the big old-fashioned garden that
sloped from the south side of the house to what Jean called “the
close.” The terraces were a riot of spring bloom; tall gold and purple
flag lilies grew side by side with dainty columbine and poet’s
narcissus. Along the stone walls white and purple lilacs flung their
delicious perfume to every passing breeze. The old apple trees that
straggled in uneven rows up through the hill pasture behind the
barn, had been transformed into gorgeous splashy masses of pink
bloom against the tender green of young foliage.
“What’s Jean doing over there in the orchard?” Kit rose from her
knees, her fingers grimy with the soil, her face flushed and warm
from her labors, and answered her own query.
“She’s wooing the muse of Art. What was her name? Euterpe or
Merope? Well, anyway that’s who she’s wooing, while we, her
humble sisters, who toil and delve after cut worms—Cousin Roxy,
why are there any cut worms? Why are there fretful midges? Or any
of those things?”
 “Land, child, just as home exercises for our patience,” laughed
Mrs. Ellis, happily.
Jean was out of their hearing. Frowning slightly, with compressed
lips, she bent over her work. With Shad’s help she had rigged up a
home-made easel of birchwood, and a little three legged camp stool.
As Shad himself would have said, she was going to it with a will. The
week before she had sent off five studies to Cousin Beth, and two of
her very best ones, down to Mr. Higginson. Answers had come back
from both, full of criticism, but with plenty of encouragement, too.
Mrs. Robbins had read the two letters and given her eldest the quick
impulsive embrace which ever since her babyhood had been to Jean
her highest reward of merit. But it was from her father, perhaps, that
she derived the greatest happiness. He laid one arm around her
shoulders, smiling at her with a certain whimsical speculation, in his
keen, hazel eyes.
“Well, girlie, if you will persist in developing such talent, we can’t
afford to hide this candle light under a bushel. Bethiah has written
also, insisting that you are given your chance to go abroad with her
later on.”
“What does Mother say?” asked Jean, quickly. She knew that the
only thing that might possibly hold her back from the trip abroad
would be her mother’s solicitude and loving fears for her welfare.
“She’s perfectly willing to let you go as long as Cousin Beth goes
with you. It would only be for three months.”
“But when?” interrupted Jean. “It isn’t that I want to know for
my own pleasure, but you don’t know how fearfully precious these
last years in the ’teens seem to me. There’s such a terrible lot of
things to learn before I can really say I’ve finished.”
“And one of the first things you have to learn is just that you
never stop learning. That you never really start to learn until you
attain the humility of knowing your own limitations. So don’t you
worry, Jeanie, you can’t possibly go over to Europe and swallow its
Art Galleries in three months. By the way, if you are really going, you
had better start in learning some of the guide posts.”
He crossed over to one of his book cases, and picked out an old
well-worn Baedeker bound in red morocco, “Northern Italy.” He
opened it lovingly, and its passages were well underlined and
marked in pencil all the way through. There were tiny sprays of
pressed flowers and four leaved clovers, a five pointed fig leaf, and
some pale silver gray olive ones. “Leaves from Vallambrosa,” he
quoted, softly. “Your mother and I followed those old world trails all
through our honeymoon, my dear.”
Jean leaned over his shoulder, eagerly, her arms clasped around
his neck, her cheek pressed to his.
“You dear,” she said, fervently. “Do you know what I’m going to
do with the very first five thousand dollars I receive for a
masterpiece? I shall send you and the Motherbird flying back to visit
every single one of those places. Won’t you love it, though?”
“I’d rather take all you kiddies with us. You gain so much more
when you share your knowledge with others. Do you know what this
west window makes me think of, Jean?” He pointed one hand to the
small side window that looked far down the valley. “Somewhere over
yonder lies New York. Often times through the past year, I have
stood there, and felt like Dante at his tower window, in old Guido Di
Rimini’s castle at Ravenna. Joe’s pigeons circling around down there
make me think of the doves which he called ‘Hope’s messengers’
bringing him memories in his exile from his beloved Florence.”
Jean slipped down on her knees beside him, her face alight with
gladness.
“Oh, Dad, Dad, you do want to go back,” she cried. “You don’t
know how afraid I’ve been that you’d take root up here and stay
forever. I know it’s perfectly splendid, and it has been a place of
refuge for us all, but now that you are getting to be just like your old
self—”
Her father’s hand checked her.
 “Steady, girlie, steady,” he warned. “Not quite so fast. I am still a
little bit uncertain when I try to speed up. We’ve got to be patient a
little while longer.”
Jean pressed his hand in hers, and understood. If it had been
hard for them to be patient, it had been doubly so for him, groping
his way back slowly, the past year, on the upgrade to health.
Softly she repeated a poem that was a favorite of Cousin Roxy’s,
and which he had liked to hear.
 THE HILLS OF REST

Beyond the last horizon’s rim,

Beyond adventure’s farthest quest,
Somewhere they rise, serene and dim,
The happy, happy Hills of Rest.

Upon their sunlit slopes uplift

The castles we have built in Spain—
While fair amid the summer drift
Our faded gardens flower again.

Sweet hours we did not live go by

To soothing note on scented wing;
In golden lettered volume lie
The songs we tried in vain to sing.

They all are there: the days of dream

That built the inner lives of men!
The silent, sacred years we deem
The might be and the might have been.

Some evening when the sky is gold,

I’ll follow day into the west;
Nor pause, nor heed, till I behold
The happy, happy Hills of Rest.

Jean was thinking of their talk as she sat out in the orchard
today, trying to catch some of the fleeting beauty of its blossom
laden trees. It was an accepted fact now, her trip abroad with Mrs.
Newell, and they planned to sail the first week in September, so as
to catch the Fall Academy and Exhibitions, all the way from London
south to Rome. A letter from Bab had told her of the Phelps boy’s
success; after fighting for it a year he had taken the Prix de Rome.
This would give him a residence abroad, three years with all
expenses paid, full art tuition and one thousand dollars in cash.
Babbie had written:
“I am teasing Mother to trot over there once again, and am
pretty sure she will have to give in. The poor old dear, if only she
would be contented to let me ramble around with Hedda, we would
be absolutely safe, but she always acts as if she were the goose who
had not only laid a golden egg, but had hatched it. And behold me
as the resultant genius. Anyway we’ll all hope to meet you down at
Campodino. I hear the Contessa’s villa there is perfectly wonderful.
Mother says it’s just exactly like the one that Browning rented during
his honeymoon. He tells about it in ‘DeGustibus.’ I believe most of
the rooms have been Americanized since the Contessa married
Carlota’s father, and you don’t have to go down to the seashore
when you want to take a bath. But the walls are lovely and crumbly
with plenty of old lizards running in and out of the mold. I envy you
like sixty. I wish I had a Contessa to tuck me under her wing like
that.”

“How are you getting along, girlie?” asked a well known voice
behind her.
“I don’t know, Dad,” said Jean, leaning back with her head on
one side, looking for all the world, as Kit would have said, like a
meditative brown thrush. “I can’t seem to get that queer silver gray
effect. You take a day like this, just before a rain, and it seems to
underlie everything. I’ve tried dark green and gray and sienna, and it
doesn’t do a bit of good.”
“Mix a little Chinese black with every color you use,” said her
father, closing one eye to look at her painting. “It is the old masters’
trick. You’ll find it in the Flemish school, and the Veronese. It gives
you the atmospheric gray quality in everything. Hello, here come
Ralph and Piney.”
Piney waved her hand in salutation, but joined Kit and Helen in
the lower garden at their grubbing for cut worms.
 “If you put plenty of salt in the water when you sprinkle those,
it’ll help a lot,” she told them.
“Oh, we’ve salted them. Shad told us that. We each took a bag of
salt and went out sprinkling one night, and then it rained, and I
honestly believe it was a tonic to the cut worm colony. The only
thing to do, is go after them and annihilate them.”
Ralph lifted his cap in greeting to the group on the terrace, but
went on up to the orchard. Kit watched him with speculative eyes
and spoke in her usual impulsive fashion.
“Do you suppose for one moment that the prince of Saskatoon is
coming wooing my fair sister? Because if he has any such notions at
all, I’d like to tell him she’s not for him,” she said, emphatically. “Now
I believe that I’m a genius, but I have resources. I can do
housework, and be the castle maid of all work, and smile and be a
genius still, but Jean needs nourishing. If he thinks for one moment
he’s going to throw her across his saddle bow and carry her off to
Saskatoon, he’s very much mistaken.”
Piney glanced up at the figures in the orchard, before she
answered in her slow, deliberate fashion,
“I’m sure, I don’t know, but Ralph said he was coming back here
every spring, so he can’t expect to take her away this year.”
Up in the orchard Mr. Robbins talked of apple culture, of the
comparative virtues of Peck’s Pleasants and Shepherd Sweetings,
and whether peaches would grow in Gilead’s climate. From the birch
woods across the road there came the clinking of a cow bell where
Buttercup led some young stock in search of good pasturage. Shad
was busy mending the cultivator that had balked that morning, as he
was weeding out the rows of June peas. He called over to Mr.
Robbins for some advice, and the latter joined him.
Ralph threw himself down in the grass beside the little birch
easel. Jean bent over her canvas, touching in some shadows on the
trunks of the trees, absently. Her thoughts had wandered from the
old orchard, as they did so often these days. It was the future that
seemed more real to her, with its hopes and ambitions, than the
present. Gilead was not one half so tangible as Campodino perched
on the Campagna hills with the blue of the Mediterranean lapping at
its feet.
“Aren’t you afraid you’ll miss it all?” asked Ralph, suddenly.
“Perhaps,” she glanced down at him in Jean’s own peculiar,
impersonal way. To Ralph, she had always been the little princess
royal, ever since he had first met her, that night a year ago, in the
spring gloaming. Dorrie and Kit had met the stranger more than half
way, and even Helen, the fastidious, had liked him at first sight, but
with Jean, there had always been a certain amount of reserve, her
absorption in her work always had hedged her around with thorns of
aloofness and apparent shyness. “But you see after all, no matter
how far one goes, one always comes back, if there are those you
love best waiting for you.”
“You’ll only be gone three months, won’t you?”
Jean shook her head.
“It depends on how I’m getting on. Cousin Beth says I can find
out in that time whether I am just a plain barnyard chicken, or a real
wild swan. Did you ever hear of how the islanders around Nantucket
catch the young wild geese, and clip their wings? They keep them
then as decoys, until there comes a day when the wings are full
grown again, and the geese escape. Wouldn’t it be awful to imagine
one were a captive wild goose, and then try to fly and discover you
were just a nice little home bred White Leghorn pullet.”
“Oh, Jean,” called Kit. “Cousin Roxy’s going, now.”
Ralph rose, and extended his hand.
“I hope your wings carry you far, Jean,” he said earnestly. “We’re
leaving for Saskatoon Monday morning and I’ll hardly get over again
as Honey and I are doing all the packing and crating, but you’ll see
me again next spring, won’t you?”
Jean laid her hand in his, frankly.
 “Why, I didn’t know you were going so soon,” she said. “Of
course, I’ll see you if you come back east.”
“I’ll come,” Ralph promised, and he stood where she left him,
under the blossoming apple trees, watching the princess royal of
Greenacres join her family circle.

THE END

TRANSCRIBER NOTES

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 *** END OF THE PROJECT GUTENBERG EBOOK JEAN OF
GREENACRES ***

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