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Difficulty: EasyNeurosurgery

A 25-year-old man is transported to the trauma center after being struck on the right side of the head with a heavy metal wrench during an altercation. He experienced a brief loss of consciousness lasting approximately one minute at the scene, but was subsequently awake, alert, and answering questions appropriately during transport. Three hours after arrival, he becomes acutely lethargic and stops following commands. His blood pressure is 165/95 mmHg, and his heart rate is 55/min. Neurological examination reveals a Glasgow Coma Scale score of 6 and a right pupil that is 7 mm and unresponsive to light. A non-contrast head computed tomography scan demonstrates a hyperdense, lens-shaped collection over the right frontotemporal convexity that does not cross cranial suture lines. Which of the following is the most appropriate next step in management?

  1. Urgent craniotomy and hematoma evacuationAnswer
  2. B
    Immediate transfer for a cranial magnetic resonance imaging study
  3. C
    Admission to the surgical intensive care unit for hourly neurological observation
  4. D
    Administration of broad-spectrum intravenous antimicrobials
  5. E
    Cerebrospinal fluid analysis via spinal tap

Answer

Urgent craniotomy and hematoma evacuation
The correct choice identifies the definitive management for an acute epidural hematoma causing uncal herniation. The patient's lucid interval followed by rapid neurological deterioration, Cushing reflex (hypertension and bradycardia), fixed/dilated pupil, and biconvex hyperdensity on CT confirm a life-threatening expanding hematoma. The only appropriate intervention is emergent surgical decompression (craniotomy) to evacuate the clot and relieve the pressure on the brainstem.

Step-by-Step Solution

1
Analyze the patient's mechanism of injury and symptom timeline.
Blunt trauma to the temporal region followed by a brief loss of consciousness, a 'lucid interval', and subsequent rapid neurological decline.
This timeline is the classic presentation for an epidural hematoma, typically caused by a rupture of the middle meningeal artery.
2
Interpret the physical exam findings and vital signs.
The patient has bradycardia and hypertension (Cushing reflex), a Glasgow Coma Scale score of 6, and a blown (fixed and dilated) right pupil.
These findings strongly indicate elevated intracranial pressure and active right-sided uncal herniation compressing the ipsilateral oculomotor nerve (CN III).
3
Correlate clinical findings with the imaging results.
The head CT shows a hyperdense, lens-shaped (biconvex) mass limited by cranial sutures.
This radiologic finding definitively confirms the diagnosis of an epidural hematoma.
4
Determine the next best step in management.
The patient requires immediate surgical intervention.
Active brain herniation from an expanding epidural hematoma is a surgical emergency. Delaying for further imaging or pursuing conservative therapy will result in death or permanent severe disability.

Key Concept

Epidural hematomas classically present with a lucid interval and a biconvex hyperdensity on CT. When accompanied by signs of brain herniation (e.g., blown pupil, Cushing reflex), immediate surgical evacuation is the required life-saving intervention.
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Topics

Neurosurgery

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