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Question1of150Neurology80
A44yearoldmanisevaluatedintheemergencydepartmentforasevereglobalheadacheandblurred
vision.Twohoursago,hewasstruckwithapipeintherightfrontotemporalregionandanteriorneck
andknockedtothegroundbutdidnotloseconsciousness.Whiledescribingtheassault,thepatient
becomesstuporous.
Onphysicalexamination,bloodpressureis150/100mmHg,pulserateis50/min,andrespirationrate
is10/min.Continuedstuporisnoted,asarerightpupillarydilation,palsyoftheoculomotornerve
(cranialnerveIII),andanextensorplantarresponseontheleft.Thepatientwithdrawsfrompainmore
weaklyontheleftthantheright.Noothercranialnerveabnormalitiesaredetected.

Whichofthefollowingisthemostlikelydiagnosis?
74%
A
Epiduralhematoma
18%
B
Leftinternalcarotidarterydissection
7%
C
Postconcussionsyndrome
0%
D
Posttraumaticseizure

ChooseanAnswerAbove
Answer&Critique
CorrectAnswer:A
EducationalObjective:Diagnoseaposttraumaticepiduralhematoma.
KeyPoint
Traumaticepiduralhematomaclassicallypresentswithprecipitousneurologicdeclineafterhead

traumacommonsymptomsaresevereheadacheandvomiting,withpossibleimpairmentof
consciousnessdevelopingimmediatelyorafteralucidinterval.
Thispatientmostlikelyhasanepiduralhematoma.Traumaticepiduralhematomaclassicallypresents
withprecipitousneurologicdeclineafterheadtrauma.Mostpatientswiththisdiagnosishaveaskull
fracturewithassociatedruptureofanunderlyingartery,typicallythemiddlemeningealartery.Blood
underarterialpressureaccumulatesbetweentheinnertableoftheskullandtheduralmembranes.The
mostcommonsymptomsaresevereheadacheandvomiting.Impairmentofconsciousnessmay
developimmediatelyorafteralucidinterval.Uncalorsubfalcinebrainherniationcanoccurandis
characterizedbyipsilateralocculomotornerve(cranialnerveIII)palsy,contralateralparesis,and
stupororcoma.Hypertensionwithbradycardia(theCushingresponse)canbeanothersignof
increasedintracranialpressure.ACTscanoftheheadconfirmsthediagnosis,andimmediatesurgical
evacuationisrequired.Mortalityratesarecommonlyreportedtobe10%to20%.
DissectionoftheleftinternalcarotidarterytypicallyresultsinipsilateralHornersyndromewith
ptosis,miosis,andanhidrosisbutnotoculomotornerve(cranialnerveIII)palsy.Contralateral
hemiparesiscouldresultifasecondarystrokeweretooccurintheleftfrontallobeafterthedissection,
butrapidlydecliningconsciousnesswouldbeunexpected.
Postconcussionsyndromeisdefinedbyaconstellationofneurologic,psychological,and
constitutionalsymptomswithoutsignificantabnormalitiesonphysicalexamination.Minorneurologic
findingsnotedontheexaminationofapatientwithmildtraumaticbraininjurymayincludeocular
convergenceinsufficiencyormildataxia,buttypicallyexaminationfindingsarenormal.Thispatient's
clinicalfindingsdonotfitthispattern.
Seizuresoccurinapproximately5%ofpersonshospitalizedforacuteheadtrauma.Theymaybe
classifiedasimmediateifoccurringwithinthefirst24hours,earlyifnotedwithinthefirstweek,
orlateifoccurringmorethan1weekaftertheinjury.Halfoftheseizuresoccurringwithinthefirst
weekwilloccurinthefirst24hours,andtheriskdecreaseswithtime.Somecorrelationbetweenthe
severityofinjuryandtheriskofposttraumaticseizuresexists.Thispatientshowsnosignsof
involuntarymotoractivity,soconvulsivestatusepilepticusisnotpresent.Nonconvulsivestatus
epilepticusmightmanifestasstupor,butthepresenceoffocalcranialnerveandmotordeficitsinthis
patientismoreindicativeofaprogressivestructurallesion.

Bibliography
ZammitC,KnightWA.Severetraumaticbraininjuryinadults.EmergMedPract.2013Mar15(3):1
28.PMID:23452439
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