A 27 Year Old Woman Involved In A Car Crash

A 27 year old woman is brought to an emergency department by an ambulance after being involved in a single car collision , when her car slipped off on a wet road and hit a telephone pole. The patient is conscious now but says she thinks she lost consciousness for sometime after the accident. She complains of some mild neck and upper back soreness but denies any pain elsewhere in her body. She has no numbness or weakness of her extremities , no history of nausea or vomiting or loss of bladder or bowel control. She had a laceration about 4 cm length on her scalp that was covered with a bandage in the emergency department.
On her initial examination she is found to be alert and conscious with no neurological abnormalities. On her second survey she seems to be disoriented not knowing her name and location and is also complaining of a severe headache.
A CT scan Is done and shows the following findings:

This is a sagittal head CT scan without contrast demonstrating a large epidural hematoma with right to left shift and ventricular narrowing.

The patient was diagnosed as a case of
Epidural hematoma and was taken to neurosurgery operating room for drainage of the hematoma and placement of  an intracranial pressure monitor.

Case Discussion:
Epidural hematoma:
It is the collection of blood between the dura matter and the skull due to an arterial hemorrhage. The most common cause of arterial bleeding is an injury to the middle meningeal artery following blunt head trauma.

Clinical features: Patients usually have an initial lucid interval after the trauma in which they show no neurological signs of the injury , followed later by severe headache, confusion, nausea and possible seizures. On physical examination the patient may have altered mental status, possible hemiparesis or hemiplegia and pupil abnormalities.

Diagnosis: CT scan without contrast shows a convex, hyperdensity compressing the brain at the site of injury and a possible adjacent skull fracture.

Treatment: Is emergent drainage of the hematoma either via burr hole or craniotomy, stabilization of the blood pressure and the intra cranial pressure to reduce the risk of herniation.