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Difficulty: MediumNeurosurgery

A 22-year-old man is brought to the emergency department via ambulance 45 minutes after being struck on the right side of his head with a baseball bat during an altercation. Witnesses report that he briefly lost consciousness for about one minute but then awoke and was conversing normally. During transport, he became increasingly somnolent and is now unarousable with a Glasgow Coma Scale (GCS) score of 5 (Eyes: 1, Verbal: 1, Motor: 3). His temperature is 37.0°C (98.6°F), blood pressure is 165/95 mm Hg, pulse is 52/min, and respirations are 10/min and irregular. Physical examination reveals a right-sided fixed and dilated pupil, and he exhibits decorticate posturing on the left side in response to painful stimuli. A non-contrast computed tomography (CT) scan of the head demonstrates a 3.5-cm biconvex, hyperdense collection in the right temporal region with 11 mm of midline shift. Which of the following is the next best step in management?

  1. Emergent craniotomy and hematoma evacuationAnswer
  2. B
    Serial neurological examinations in the intensive care unit
  3. C
    Delaying the procedure until next-of-kin provides informed consent
  4. D
    Transport for magnetic resonance imaging of the brain
  5. E
    Initiation of broad-spectrum intravenous antibiotics

Answer

Emergent craniotomy and hematoma evacuation
The correct answer addresses the acute uncal herniation caused by a rapidly expanding epidural hematoma. The classic presentation includes a lucid interval followed by rapid neurological decline, an ipsilateral blown pupil (due to compression of the oculomotor nerve), and contralateral hemiparesis. The non-contrast CT finding of a biconvex, hyperdense collection is diagnostic. With significant midline shift and clinical signs of herniation, emergent craniotomy and hematoma evacuation is the definitive and necessary life-saving intervention.

Step-by-Step Solution

1
Analyze the patient's history and timeline.
The patient suffered head trauma followed by a brief loss of consciousness, a classic 'lucid interval', and subsequent rapid neurological deterioration.
This specific temporal pattern is highly characteristic of an expanding arterial bleed, specifically an epidural hematoma.
2
Evaluate the vital signs and physical examination findings.
The patient exhibits hypertension, bradycardia, and irregular respirations (Cushing triad) along with an ipsilateral blown pupil and contralateral posturing.
These findings indicate massively elevated intracranial pressure leading to uncal (transtentorial) herniation, a life-threatening neurosurgical emergency.
3
Interpret the neuroimaging data.
The non-contrast CT scan shows a large biconvex (lens-shaped) hyperdensity with midline shift.
This definitively confirms the diagnosis of an epidural hematoma with significant mass effect.
4
Determine the most appropriate definitive management.
Immediate surgical decompression via craniotomy is required.
Because the patient is actively herniating, any delay for observation, consent, or further imaging is contraindicated.

Key Concept

Epidural hematoma presentation and emergent neurosurgical management
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Topics

Neurosurgery

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