• Describe the pathophysiology of extradural and subdural hematomas.
• Identify the surgical emergency and provided rationale for the choice.
• Describe the most likely type of head injury and outline an appropriate treatment plan.
• Your answer must follow APA 7th edition format.
• Submit the answer to this assignment area.
Patient 1 – Two individuals come to the emergency department with head injuries. One, 25 years old, has just been in a motor vehicle accident (MVA) and has a temporal lobe injury. The other, 65 years old, has increasing confusion after a fall that happened earlier in the week.
a. Differentiate the pathophysiology of extradural hematoma and subdural hematoma.
b. Identify the patient in the above scenario requiring immediate emergency surgical intervention and provide rationale for your choice.
Patient 2 – An 38 year old was driving his 1970 Chevy Corvette to a Milwaukee Brewers baseball game when a deer jumped out in front of him on the highway. He swerved his car and hit a telephone pole instead. His head hit the windshield and he suffered severe head trauma.
a. Describe the most likely specific type of head injury he suffered.
b. Outline the treatment plan for this patient.
Estimated time to complete: 6 hours
Answers
Head Injury Case Studies
Brain injury affects many people, whether from trauma, masses, strokes, or other means.
This brief paper will cover the brain injuries of extradural hematomas, subdural hematomas, and
contusions along with treatment options. If treated correctly, these tragic injuries can have a
better prognosis.
Case Study 1
Two individuals come to the emergency department with head injuries. One, 25 years old,
has just been in a motor vehicle accident (MVA) and has a temporal lobe injury. The other, 65
years old, has increasing confusion after a fall that happened earlier in the week.
Pathophysiology of Extradural Hematoma and Subdural Hematoma
Extradural hematomas (EH), also known as epidural hematomas, are when there is a bleed
between the dura mater and the skull and make up 1-2% of traumatic brain injuries (TBI). The
most common mechanism is motor vehicle crashes (MVCs) and they rarely occur in those over
50 (<10%) due to the dura being strongly adhered to the skull in older persons (Price, et al.,
2016). Temporal epidural hematomas make up 70-80% of all EH as seen in the 25 year old
patient. The bulk of these are due to temporal fractures. The majority of EH are from arterial
bleeds. In this case, it is probably attributed to damage to the middle meningeal artery or vein. It
can cause a medial shift in the temporal lobe which can give rise to herniation of uncal and
hippocampal gyrus through the tentorial notch. Those with classic symptoms of temporal EHinitially lose consciousness and then are lucid for a few hours to a few days before neurological
deterioration. During this lucid period, the hematoma is growing in size. This leads to an
increasingly severe headache, nausea, vomiting, drowsiness, confusion, contralateral hemiparesis
and possibly seizures. This patient would also possibly exhibit ipsilateral pupillary dilation. EH
can lead to herniation and death if not treated in time[McC13].
Subdural hematomas (SH) make up 10-20% of traumatic brain injuries (TBI)[McC13]. They
are a collection of blood between the dura mater and the arachnoid mater. In contrast to EH, SH
usually is seen in the elderly due to atrophy of the brain creating more space for movement and
shear[Mea16]. There are different types of subdural hematomas. Acute SH develop quickly
within 48 hours and are usually located in the top portion of the skull. Sub-acute SH develop in
a slower fashion, over 2 days to 2 weeks. Then there are chronic SH which develop over weeks
to months and are usually seen in the elderly and alcoholics[McC13]. Acute and sub-acute SH
are caused by a tearing of the bridging veins (veins that connect the dural sinus to the cortical
surface) usually as a result of high-speed impact to the skull, but can also happen in the elderly
more easily as a result of more minor accidents such as falls (like in the case of the 65 year old
patient) which, along with assaults, cause around 72% of SH. As the venous blood leaks from
the torn vessel, it separates the dura mater from the arachnoid mater allowing the blood to pool
out along the cerebral convexity. This pressure from the bleed causes injury to the brain and
increases intracranial pressure (ICP) further damaging the brain. The ICP increase leads to
subfacial or transtentorial herniation. Transtentorial herniation can cause ipsilateral pupillary
dilation and eventually death. Since time since incident aids in identification of the type of SH,
this patient probably is suffering from a subacute SH due to her fall happening over 48 hours
prior but less than two weeks. Her increasing confusion is due to the delayed fashion in whichher SH is expanding. As it expands, it creates more ICP and reduces her cerebral blood flow.
She could develop more symptoms as her ICP increases and her hematoma progresses such as
nausea, vomiting, headache, increased confusion and decreased level of consciousness,
eventually leading to comatose state or death[Mea16].
Patient Requiring Emergent Surgery and Rationale
The 25 year old patient with the EH would most likely need emergent surgery to evacuate
his bleed. His bleed is most likely arterial in nature and therefore will “fill up” his skull faster
than a venous bleed. Upon entering the ER, he would be CT scanned due to the temporal injury
and most likely be intubated after EH was confirmed. If the EH is not evacuated, the bleed will
continue to grow and lead to further midline shift and herniation which will then kill the patient.
With quick treatment, his prognosis is good[Mea16]. The 65 year old female may need surgical
intervention, however, it is not emergent due to her having the bleed for several days. Her bleed
may be accumulating, but she is conscious and the bleed should be either clotted or in the
process of doing so. Her bleed is also venous in nature and therefore does not bleed as fast as an
arterial bleed (Price, et al., 2016).
Case Study 2
A 38 year old was driving his 1970 Chevy Corvette to a Milwaukee Brewers baseball game
when a deer jumped out in front of him on the highway. He swerved his car and hit a telephone
pole instead. His head hit the windshield and he suffered severe head trauma.
Type of Head Injury Sustained
This patient most likely has a coup-contracoup leading to a brain contusion. When the
patient’s head hit the windshield at high speed, his skull was stopped by the windshield, but his
brain was stopped by the frontal aspect within his skull injuring the frontal lobe of his brain
(coup) and shearing his subdural veins, and then the head rebounded in the contracoup motion
causing his brain to “bounce” off the posterior portion of the inside of his skull injuring the
posterior brain and causing a shearing injury as well. This leads to a cerebral contusion, or
bruising of the brain. Given his age, he could also have a subdural hematoma or an epidural
hematoma. Due to the likelihood of the coup-contracoup injury, subdural hematoma would be
the most likely if he has a brain hemorrhage in addition to his contusion[McC13].
Treatment Plan
Treatment of a cerebral contusion revolves around control of ICP and managing symptoms.
However, if the patient has a large contusion, brain laceration, and/or bleed, it may need to be
excised surgically. Upon entering the emergency room, he would first be stabilized
physiologically. He would then be transferred to a neurological unit for further treatment where
they would decide on surgery or ICP monitoring and control. As recommended by the National
Guideline Clearinghouse (NGC), ICP monitoring should take place if his Glasgow Coma Scale
score is <9 or when the patient cannot receive repeated neurological evaluation due to pain
medication or anesthesia. It may also be considered if this patient’s systolic blood pressure drops
below 90mmHg or over 40 years old (which this patient is not)[Nat12]. Hyperosmolar agents,
such as hypertonic saline or mannitol, may be used to reduce ICP prior to monitoring if there are
signs of neurological decline not due to physical reasons (hypotension) and/or signs of
herniation. The patient may be sedated to reduce anxiety as it increases ICP. The head of his bedwould be placed at 30° to encourage adequate blood return. He would have all vitals monitored
as hypertension and respiratory decline is common in brain injuries and increases ICP. His
environment would also be quiet, dark and be void of stimulation as much as possible to allow
the brain to heal and keep ICP low. If these measures do not keep the ICP in normal limits, then
a craniotomy may be required to give the brain room to swell and prevent further damage.
Hypothermia may also be considered[Ran08].
Conclusion
Epidural hematomas, subdural hematomas, and cerebral contusions all can be life threatening.
The key to the best possible prognosis is early diagnosis and treatment. If caught early enough
and treated quickly, each of these brain injuries has a fighting chance to heal.