00:01
In this talk,
we're going to review head trauma
and begin with an orientation for what is
head trauma and how do we think about it.
00:11
Let's start with a case.
00:13
This is a 68 year-old man with no
significant past medical history
who presents to the
emergency department
with progressive
altered mental status.
00:22
The patient initially fell from a
small ladder in his home 4 days ago.
00:27
His family says that he appeared
normal immediately after the fall.
00:30
And over the past few days,
he has become progressively weaker,
began to trip with his right
leg and uses his right arm less.
00:38
Today, the patient became
progressively more confused
and has not been speaking.
00:44
On examination, he is awake and
his eyes are open spontaneously.
00:48
He has a left gaze preference,
he prefers to look left.
00:51
But is able to look past
the midline to the right.
00:55
He moves his left hemibody
with full strength
but has significant or
severe right hemiparesis.
01:00
He's weak on the right
side of the body,
and is only able to
withdraw to pain.
01:06
So how do we think
about this case?
And let's talk about
some of the key features.
01:10
First,
there was an initial trauma.
01:11
He fell and could a sustained
some type of head injury.
01:15
Second, the course has
been progressive over time.
01:19
It began with this injury and it's
progressively become more confused,
develop this right hemiparesis
and now with significant worsening
prior to his presentation.
01:29
And then the last is this,
the patient has a right hemiparesis
and the localization of this problem
is to the left side of the brain.
01:38
So what's the most
likely diagnosis?
Has this patient suffered
an epidural hematoma,
subdural hematoma,
a subarachnoid hemorrhage,
or is this the presentation
of glioblastoma?
Well, this doesn't
sound like glioblastoma.
01:54
The patient has a subacute
course after a fall.
01:58
Patients with malignant brain tumors can
present over the course of several weeks.
02:02
But this presentation is much more
suggestive of a traumatic brain injury
than a neoplasm.
02:11
This is not the typical presentation
of an epidural hematoma.
02:15
With epidural hematomas,
we often hear of a lucid interval,
an initial trauma where the patient has
slightly altered immediately afterwards,
followed by a period
of normalization.
02:26
And then typically within
hours or less than a day,
the patient presents with
progressive neurologic decline.
02:31
And this has been a more gradually
progressive course over several days,
which is not typical for what we
hear with an epidural hematoma.
02:40
This also is not the typical
presentation of subarachnoid hemorrhage.
02:44
The patient has a subacute
progressive course.
02:48
And with subarachnoid
we often worry about
or hear about a thunderclap headache
or a severe rapid onset headache
with evidence of meningeal
irritation, nausea, vomiting
and increased intracranial pressure
which we don't have in this case.
03:03
And so this is really the
typical presentation of a patient
who has a subdural hemorrhage.
03:08
An initial traumatic event, followed by
gradual progression of neurologic symptoms
and focal neurologic
deficits on exam
that result from the area where the
hemorrhage has irritated the cortex.