A 65-year-old man comes to the emergency department due to sudden-onset headache. The patient has had no recent falls or head trauma. Medical history includes hypertension and lung adenocarcinoma with abdominal metastasis. Initial noncontrast CT scan of the head reveals a small temporal lobe hemorrhage. Over the next 24 hours, the patient becomes progressively obtunded and develops generalized tonic-clonic seizures. Blood pressure is 190/96 mm Hg, pulse is 38/min, and respirations are 10/min with brief episodes of apnea. A repeat noncontrast CT scan of the head reveals acute hemorrhage expansion with brain herniation. Which of the following findings is most likely to be observed on this patient's repeat neurologic examination?

Question

A 65-year-old man comes to the emergency department due to sudden-onset headache.  The patient has had no recent falls or head trauma.  Medical history includes hypertension and lung adenocarcinoma with abdominal metastasis.  Initial noncontrast CT scan of the head reveals a small temporal lobe hemorrhage.  Over the next 24 hours, the patient becomes progressively obtunded and develops generalized tonic-clonic seizures.  Blood pressure is 190/96 mm Hg, pulse is 38/min, and respirations are 10/min with brief episodes of apnea.  A repeat noncontrast CT scan of the head reveals acute hemorrhage expansion with brain herniation.  Which of the following findings is most likely to be observed on this patient's repeat neurologic examination?

Quizplus · Accepted Answer

11ec160b_359b_3c4e_9249_0bcb3c8837c2_MD0001_00 This patient developed a spontaneous intracerebral hemorrhage with subsequent clinical deterioration due to ongoing bleeding and hemorrhage expansion. Expanding space-occupying lesions (eg, hemorrhage, hematoma) increase intracranial pressure, which can manifest with headache, vomiting, impaired consciousness, and ultimately Cushing triad (eg, hypertension, bradycardia, irregular respirations) when brain herniation is imminent. Herniation can occur in different portions of the brain depending on the location of the initial lesion. Lesions in the temporal lobe tend to cause transtentorial herniation of the uncus, which can compress the ipsilateral oculomotor nerve (CN III) as it exits the midbrain at the same level. Patients often develop ipsilateral CN III palsy with a fixed dilated pupil due to preganglionic parasympathetic nerve fiber damage. If intracranial pressure continues to increase, the herniation can progress to involve the uncus bilaterally, ultimately causing downward displacement of the brainstem (ie, central herniation). This results in brainstem hemorrhages (ie, from rupture of paramedian basilar artery branches), continued clinical deterioration from damage to medullary cardiac and respiratory centers, abnormal posturing, and ultimately death. (Choice B) Horner syndrome (ie, ptosis, miosis, anhidrosis) is associated with lesions affecting the posterolateral hypothalamus or sympathetic tracts in the brainstem (eg, lateral medulla). (Choice C) Uncal herniation can compress the cerebral peduncles, resulting in corticospinal tract injury with contralateral hemiparesis. However, patients initially have flaccid paralysis with hyporeflexia (ie, spinal shock); spasticity/hyperreflexia develops days to weeks following acute upper motor neuron injury and would not yet be present in this patient. (Choice D) Nystagmus is generally seen with lesions to the pons, medulla, or cerebellum due to disruption of vestibular pathways. (Choice E) Hydrocephalus can cause upward gaze palsy due to dilation of the third ventricle with compression of the dorsal midbrain (eg, superior colliculus, pretectal area). Educational objective: Expanding space-occupying lesions can increase intracranial pressure, causing transtentorial herniation of the uncus. Uncal herniation often compresses the ipsilateral oculomotor nerve (CN III) as it exits the midbrain, resulting in CN III palsy with a fixed dilated pupil (due to preganglionic parasympathetic nerve fiber damage). __________ References: Types of cerebral herniation and their imaging features. (http://www.ncbi.nlm.nih.gov/pubmed/31589570)

A 65-Year-Old Man Comes to the Emergency Department Due to Sudden-Onset