Presentation
A 30 year old male, driver, restrained in a motor vehicle accident presented by ambulance from the scene to a regional ED with a GCS of 14/15, and promptly dropped his GCS after CT.
Patient Data
Right sided extradural hematoma measuring up to 16 mm in thickness with associated right cerebral sulcal effacement, right lateral ventricular effacement and 4 mm of midline shift to the left. Impending right uncal herniation. Swirling low density within the hematoma (swirl sign) consistent with ongoing active bleeding from the middle meningeal artery. The hematoma crosses the coronal suture which is unusual for extra-dural hematomas but can occur in the setting of skull fracture or suture diastasis. Right frontal scalp laceration and mildly depressed right frontal skull fracture. There is involvement of the right frontal sinus with an additional small volume of extra-axial hemorrhage underlying this.
Follow-up CT study shows excellent outcome with no brain injury evident.
Case Discussion
This was an interesting case of traumatic right sided extradural hematoma, presenting to a regional hospital.
The patient was intubated immediately after CT after a drop in conscious state and associated right sided blown pupil (3rd cranial nerve impingement), with aggressive medical management of his ICP, and transferred by road to a tertiary hospital with neurosurgical capabilities. Given the swift deterioration, and prolonged time of road transport, a decision was made by the tertiary trauma and neurosurgical team to meet the ambulance transport en route and perform a pre-hospital burr hole in the back of the ambulance.
The patient was then transferred to definitive care at the tertiary hospital for decompressive craniotomy.
He went on to make a full neurological recovery.
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