WIDI - N1) Lucid interval following head injury

N1) Lucid interval following head injury

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with altered mental status.
Review the DDx considerations in a patient with altered mental status.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with altered mental status.

History

A 50-year-old woman presents to the ED with altered mental status. Five hours ago, she fell off a golf cart and struck her head. She initially lost consciousness but then quickly recovered and was alert for several hours. Afterwards, she developed a headache, vomiting, and confusion, prompting her daughter to bring her to the ED.

Physical Exam

BP: 190/115, HR 45, RR 8, Temp 98.6 F, O2 saturation 98%. Neuro: altered mental status with a GCS of 9 (E2V3M4).

Labs

None

Provisional Diagnosis

Select the Dx you believe is most appropriate

Stroke

Epidural Hematoma

Hypoglycemia

This patient most likely has an epidural hematoma considering the history of head trauma and clinical history as suggested by the ‘lucid interval’ following the fall from the golf cart. The patient also exhibits signs of elevated intracranial pressure as demonstrated by the ‘Cushing Triad’ (hypertension, bradycardia, bradypnea) secondary to a space occupying lesion.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient will require emergent workup and management.

First Imaging Study

What is the first imaging study you will order?

MRI with susceptibility-weighted imaging

CT Head without IV contrast

CT head with IV contrast

The CT Head without contrast is the best initial imaging modality to evaluate for epidural hematoma. CT Head is quicker to obtain than MRI and is the superior imaging choice to assess for bone fractures and bleeding. It is important to omit contrast to assess bleeding.

View ACR Appropriateness Criteria

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

CT Head without IV Contrast

There is a subdural hematoma

Yes

This represents an epidural hematoma, which overlies the left parietal temporal lobe. The hematoma is lens shaped and remains within the suture lines. Depending on the location, a subdural hematoma classically crosses suture lines, resulting in a crescent shaped hematoma.

There is midline shift.

Yes

There is a 5mm midline shift secondary to the mass effect epidural hematoma.

There is a skull fracture.

Yes

The fracture of the left parietal bone likely led to tearing of the posterior branch of the middle meningeal artery and the formation of the epidural hematoma.

View Report

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Second Imaging Study

What is the next imaging study you will order?

CT with contrast

MRI with susceptibility weighted imaging

MRI with contrast

None

The non-contrast CT confirms the diagnosis of epidural hematoma and further imaging is not indicated.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Subdural hematoma

Epidural hematoma

Stroke

This patient has an epidural hematoma secondary to head trauma and rupture of the posterior branch of the middle meningeal artery.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

An epidural hematoma is a medical emergency due to its potentially devastating neurological sequalae.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 50-year-old female presenting to the ED with an epidural hematoma with 5mm of midline shift resulting in focal neurologic deficits. An emergent neurosurgical consultation is indicated for evaluation of surgical intervention.

Lessons Learned:
- Epidural hematoma often occurs secondary to head trauma and is typically a result of a rupture of the middle meningeal artery due to skull fracture. Blood accumulates between the skull and the dura mater, which leads to the characteristic lens-shaped hemorrhage, which respects the suture lines because the dura mater tightly adheres to the skull at the sutures. By contrast, depending on the location, a subdural hemorrhage classically crosses suture lines.
- Patients with epidural hematoma often experience a “lucid interval”, which is the period of alertness that occurs after losing consciousness and is followed by subsequent mental status decline. This clinical trajectory is explained by the accumulation of blood gradually increasing in size, which results in mass effect and neurological deficits.
- The first best diagnostic modality is the CT scan, which can detect intracranial bleeding as well as skull fracture.

Socioeconomic Factors:
- Mortality is highest in elderly patients and those with prolonged time between clinical intervention/surgery.
- Incidence of epidural hematoma is higher among males and adolescents.
- Uninsured patients, minority patients, and patients with more severe brain injuries face disproportionate treatment outcomes.
- Uninsured patients are less likely to be discharged to inpatient rehabilitation.

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Contributors:
Thomas Kent, MS2 - Content Contributor
Alexandria Hotop - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator