A 28-year-old male is ejected from a vehicle during a high-speed collision. He is unconscious, GCS 6, with unequal pupils (left pupil dilated and sluggishly reactive, right pupil normal). He has a laceration to his left temple. His blood pressure is 160/90 mmHg, heart rate 60 bpm, and respirations 8 with irregular pattern. These findings are most indicative of which type of intracranial hemorrhage?
- AIntracerebral hemorrhage
- BEpidural hematoma
- CSubarachnoid hemorrhage
- DSubdural hematoma
Show answer & explanationAnswer & explanation
Correct answer: B. Epidural hematoma
The classic presentation of an epidural hematoma includes a lucid interval (though not always present, especially with severe impact), followed by rapid deterioration in consciousness, a fixed and dilated pupil on the side of the injury (due to uncal herniation compressing CN III), and Cushing's triad (hypertension, bradycardia, irregular respirations). The laceration to the left temple suggests impact to the temporal bone, which can tear the middle meningeal artery, the typical source of an epidural hematoma.
Why the other options are wrong
- A. Intracerebral hemorrhage can cause similar signs, but without specific focal neurological deficits or a clear mechanism for a deep bleed, EDH is more likely with the temporal impact and rapid onset of uncal herniation signs.
- C. Subarachnoid hemorrhage is often characterized by a 'thunderclap' headache and nuchal rigidity, and while it can cause altered mental status and Cushing's triad, the specific pupil finding and rapid deterioration after blunt trauma point more to EDH.
- D. Subdural hematomas typically present with a slower onset of symptoms and are more common in elderly patients or those with brain atrophy, though acute SDH can be rapid. Pupils and Cushing's triad are less specific to SDH than EDH in this acute presentation.
Epidural Hematoma
A collection of blood between the dura mater and the skull, typically caused by arterial bleeding (e.g., middle meningeal artery) after head trauma.
- Often associated with temporal bone fracture.
- Classic presentation: 'lucid interval' followed by rapid deterioration.
- Key signs: Ipsilateral fixed and dilated pupil, Cushing's triad.
Memory trick: Epidural's Evil: Pupil's Peril, Pressure's Peak.