Question

A 10-year-old female patient arrives in the emergency department after falling from a playground slide and injuring her head. She lost consciousness at the scene but is awake on arrival to the ED. She complains of nausea and left-sided headache but responds to verbal commands appropriately. The neurosurgeon is called in to examine the patient. During the examination she loses consciousness again, becomes hypertensive and bradycardic. Her left pupil is now fixed and dilated. The surgeon calls the OR to set up for an emergency procedure.

1. What is the suspected diagnosis?

2. Why was an emergency procedure ordered?

3. What is the procedure that will be performed?

4. What is the long-term prognosis for the patient?

5. What is the difference between a subdural and an epidural hematoma?

Answer 1

Answer 1:

The suspected diagnosis is epidural hematoma:

The clues to the diagnosis are:

1. History of head trauma
2. Lucid interval - loss of consciousness followed by improvement and then later the patient lost consciousness again.
3. Loss of consciousness
4. Headache and nausea ( due to an increase in  intracranial pressure)
5. Bradycardia and hypertension - suggestive of increase intracranial pressure. Ipsilateral dilatation of the pupil ( due to uncal herniation with compression of the oculomotor nerve)( uncus is the innermost part of the parahippocampal gyrus) [ the combination of bradycardia, hypertension, and irregular breathing = Cushing reflex

Epidural space is the space between the dura mater and the skull. The subdural space is the space between dura mater and arachnoid matter.

Answer 2:

The patient has the following signs:

• Hypertension
• Bradycardia
• Ipsilateral pupillary dilation

These features suggest the patient has increase intracranial pressure. If left untreated the patient may develop central nervous depression and eventually death.

Answer 3:

The Burr hole procedure ( trephination ) helps to evacuate the blood. An alternative procedure is a craniotomy. This procedure will allow a more adequate evacuation of the hematoma

Answer 4:

Long term prognosis for a patient with purely epidural hematoma is excellent.

Presence of the following factors is associated with poor prognosis

1. Epidural hematoma > 50 cm
2. A low Glasgow coma scale before surgery / on arrival
3. Abnormal pupillary examination
4. Advanced age
5. Elevated intracranial pressure in the post-operative period
6. Hematoma volume more than 30 - 150 ml
7. Midline shift > 10 -12 ml

Answer 5:

Epidural hematoma	Subdural hematoma
Bleed between the skull and dura mater	Bleed between the dura mater and arachnoid mater
rupture of the middle meningeal artery	rupture of the bridging veins
Doesn't cross the suture lines	Crosses the suture lines
It is biconvex in appearance	It is crescentic in appearance
Lucid interval is present	Gradual increase in headache annd confusion