case files neurology
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case files neurology

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evacuation of an
epidural hematoma are the initial GCS, pupillary response, motor examina-
tion, and associated intracranial injuries seen on the CT scan. In noncomatose
individuals, a favorable outcome occurs in 90\u2013100% of patients whereas mor-
tality ranges from 0\u20135%. For patients in coma, a favorable outcome occurs
between 35 and 75% of the time with a mortality rate of between 10 and 40%.
Of interest, normally reacting pupils prior to surgery result in a favorable out-
come in 84\u2013100% of patients, although the great majority of individuals with
bilaterally abnormal pupillary reactions have a poor outcome or death.
Associated intracranial injuries such as cerebral contusions also impact
adversely on outcome. Rapid diagnosis and timely evacuation of the hematoma
are crucial in optimizing outcome.
Comprehension Questions
[8.1] Blunt trauma to the skull followed by brief loss of consciousness, then
a period of relative normalcy, then a cranial to caudal pattern of deteri-
oration without stiff neck is most characteristic of which clinical entity?
A. Acute epidural hematoma
B. Chronic subarachnoid hemorrhage
C. Bacterial meningitis
D. Cerebral contusion
[8.2] Homogeneous high density throughout the ventricular system on an
unenhanced CT scan is most characteristic of which clinical entity?
A. Acute epidural hematoma
B. Subarachnoid hemorrhage because of a burst proximal middle
cerebral artery aneurysm
C. Basal ganglia hematoma
D. Ruptured cavernous angioma
[8.3] Select T (true) or F (false) for the following statement. A normal brain
CT scan performed 1 hour after a closed head injury in the context of
a relatively normal neurologic examination precludes development of
epidural hematoma.
[8.1] A
[8.2] B
[8.3] False. An evolving epidural hematoma can occur any time after the
immediate injury. Repeat CT brain imaging is indicated if there is any
change in the neurologic status of the patient.
\u2756 The historical hallmark of epidural hematomas is injury followed by
a lucent relatively asymptomatic period, followed by deteriora-
tion, although the lack of this clinical history is by no means
\u2756 With suspected epidural hematoma, deterioration can be quite rapid
so close observation is necessary.
\u2756 Epidural hematomas require urgent surgical intervention a large
percentage of the time, so neurosurgical consultation early is
\u2756 Noncontrast CT scan of the cranium is the recommended radiologic
test for initial evaluation.
Bullock MR, Chesnut R, Ghajar J, et al. Surgical Management of Traumatic Brain
Injury Author Group. Surgical management of acute epidural hematomas.
Neurosurgery 2006 Mar;58(3 suppl):S7\u201315; discussion Si-iv.
Lee EJ, Hung YC, Wang LC, et al. Factors influencing the functional outcome of
patients with acute epidural hematomas: analysis of 200 patients undergoing
surgery. J Trauma 1998;45:946\u2013952.
Liebeskind DS. Epidural hematoma. Available at:
topic574.htm. Accessed April 17, 2006. 
Offner PJ, Pham B, Hawkes A. Nonoperative management of acute epidural
hematomas: a \u201cno-brainer.\u201d Am J Surg 2006;192:801\u2013805.
Toyama Y, Kobayashi T, Nishiyama Y, et al. CT for acute stage of closed head
injury. Radiat Med 2005 Aug;23(5):309\u2013316.
\u2756 CASE 9
A 23-year-old female construction worker is brought in to the emergency room
(ER) after falling off a beam at work 24 hours ago. The beam was approximately
10 feet off the ground and slippery. Witnesses who reported the fall saw the patient
land on her back, hit her head, and sustain a brief period of loss of consciousness.
However, within a minute or so the patient was back to her baseline and refused
medical evaluation. Today when she showed up at work she didn\u2019t \u201cseem right\u201d at
times, whereas at other times, she seemed herself. For instance, her coworkers
report that she is having difficulty performing simple tasks at work, and she
responds slowly and at times inappropriately when answering questions. On inter-
view, the patient answers most questions angrily and inappropriately, although at
times, she answers lucidly. She denies experiencing headache, neck pain, visual
symptoms, or loss of balance. She is not known to have any medical illnesses. On
examination, she is afebrile, her blood pressure is 110/68 mmHg, and her pulse is
100 beats/min. She is awake but inattentive easily losing her focus. Her general
examination is notable for the absence of nuchal rigidity and no obvious head
trauma. Her Mini Mental State Examination (MMSE) is 24/30 having difficulty
with orientation, concentration, and recall. She fluctuates throughout the examina-
tion at times being more appropriate than others. Her Glasgow Coma Scale is 14
broken down as E4 V4 M6 the only deficiency being verbal as she is disoriented.
She does not have aphasia or dysarthria but does ramble and is tangential. Her neu-
rologic examination shows intact cranial nerves and intact pinprick. The sensory,
motor, and cerebellar examination cannot be adequately assessed because she is
uncooperative, although her movements appear symmetric. The deep tendon
reflexes are hyperreflexic throughout with bilateral Babinski signs present.
\u25c6 What is the most likely diagnosis?
\u25c6 What is the next diagnostic step?
ANSWERS TO CASE 9: Delirium from Head Trauma
Summary: A 23-year-old woman without medical illnesses presents with acute
alteration in mental status 24 hours after sustaining head trauma with brief loss
of consciousness. Her examination shows attentional deficits, disorganized
thinking, altered psychomotor activity, difficulty focusing, memory deficits,
and disorientation. Additionally, it seems that there has been some fluctuation
to her symptoms. The examination is notable for absent nuchal rigidity and
generalized hyperreflexia with bilateral Babinski signs.
\u25c6 Most likely diagnosis: Delirium from subarachnoid hemorrhage.
\u25c6 Next Diagnostic Step: CT scan of the head, complete blood count
(CBC), comprehensive metabolic panel, and urine toxicology screen.
1. Be familiar with the clinical presentation of delirium.
2. Learn the differential diagnosis of delirium including medical and
trauma related causes.
3. Describe how to evaluate a patient with delirium.
This 23-year-old woman presents with acute fluctuating levels of attention,
confusion, and altered psychomotor activity following head trauma associ-
ated with loss of consciousness (concussion). Her examination shows an altered
MMSE and Glasgow Coma Scale with generalized hyperreflexia and bilateral
Babinski sign. The findings of attentional deficits, disorganized thinking,
altered psychomotor activity, difficulty focusing, memory deficits, and dis-
orientation are characteristic for delirium. Importantly, not all patients with
altered mental status have delirium. The hallmarks of delirium are cogni-
tive impairment, impaired attention, and fluctuating course. Altered men-
tal status can be from coma, stupor, and so forth. Given the history of trauma
and signs of central nervous system dysfunction (inattention, confusion, and
generalized hyperreflexia) the diagnosis of delirium from trauma related head
injuries needs to be entertained. This can include epidural hematoma, sub-
dural hematoma, or intracerebral hemorrhage besides subarachnoid hemor-
rhage. The lack of symptoms such as vomiting, headache, seizures, and the
fact that she was lucid for at least the day of the trauma makes it highly
unlikely to be an epidural hematoma or intracerebral hemorrhage. The lack of
focal neurological findings argues against an acute subdural hematoma or
intracerebral hemorrhage. The most likely diagnosis is thus subarachnoid