Case: 68-year-old Man with Progressive Altered Mental Status

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.