A 21-year-old man sustained a fall, hitting the left side of his head on a rock. He did not lose consciousness, but during the next 30 minutes, he developed a headache and vomited twice. The patient has no chronic medical conditions and takes no medication. Blood pressure is 136/90 mm Hg and pulse is 68/min. On examination, he is drowsy but otherwise well oriented. Swelling and tenderness are noted over the left frontoparietal region. CT scan of the head will most likely reveal which of the following?

Question

A 21-year-old man sustained a fall, hitting the left side of his head on a rock.  He did not lose consciousness, but during the next 30 minutes, he developed a headache and vomited twice.  The patient has no chronic medical conditions and takes no medication.  Blood pressure is 136/90 mm Hg and pulse is 68/min.  On examination, he is drowsy but otherwise well oriented.  Swelling and tenderness are noted over the left frontoparietal region.  CT scan of the head will most likely reveal which of the following?

Quizplus · Accepted Answer

This patient with a traumatic head injury has worsening mental status that developed over a matter of minutes. In association with the swelling over the left frontoparietal region, this presentation suggests an epidural hematoma. Epidural hematomas most commonly occur due to tearing of the middle meningeal artery, resulting in accumulation of blood between the dura matter and the skull. They often occur with fracture in the pterion region (the junction of the frontal, parietal, temporal, and sphenoid bones) and most commonly affect young adults. Although patients classically present with loss of consciousness followed by a lucid interval, only 20%-50% of patients develop this characteristic presentation and some initially remain alert. However, rapid hematoma expansion soon results in neurologic decompensation with signs of elevated intracranial pressure (eg, headache, nausea/vomiting, altered mental status); symptoms typically develop within minutes to hours. CT scan of the head typically reveals a hyperdense biconvex lesion that does not cross suture lines. hyperdense biconvex lesion (Choice A) Diffuse axonal injury (DAI) can occur from blunt force injury but typically results in immediate coma. In addition, DAI is usually diagnosed with MRI; CT scan has low sensitivity and is often normal. (Choice C) Although an intracerebral hemorrhage causes neurologic decline, it typically occurs in older patients in the setting of severe hypertension, cerebral amyloid angiopathy, or anticoagulant/antiplatelet use. It is not typically associated with trauma and would be unexpected in this young patient. (Choice D) Subarachnoid hemorrhage typically causes a sudden, severe "thunderclap" headache, often associated with loss of consciousness and meningismus. It usually occurs due to rupture of an intracranial aneurysm. (Choice E) Subdural hematoma (SDH) is a common result of traumatic head injury but occurs due to tearing of the bridging veins, resulting in venous bleeding. This typically occurs in older adults and in those on antithrombotic agents. In addition, many patients develop coma from the time of onset in acute SDH, whereas chronic SDH results in the insidious onset of confusion, headache, and somnolence over a period of days to weeks. Educational objective: Epidural hematomas occur due to tearing of the middle meningeal artery and typically occur with skull fracture. Although patients classically present with loss of consciousness followed by a lucid interval, many initially remain alert. However, hematoma expansion results in neurologic decompensation with signs of elevated intracranial pressure (eg, headache, nausea/vomiting, altered mental status) within minutes to hours.

A 21-Year-Old Man Sustained a Fall, Hitting the Left Side