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Case 173

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Male patient, 25 years of age, brought by the SAMU (Mobile Emergency Service) to the emergency room of the João XXIII Hospital, after falling off a motorcycle. On physical examination, the patient was intubated and hemodynamically stable. He received three points in the Glasgow coma scale, pupils of equal size, measuring 2mm each, both reactive to light. A computed tomography (CT) was requested.

Based on the clinical picture and the images, what is the most likely diagnosis and the most probable origin of the bleeding?

a) Acute subdural hematoma originated from fronto-temporal lesions on the veins between the dura mater and the skull.

25%

b) Epidural hematoma on the vertex originated from a superior sagittal sinus injury.

25%

c) Traumatic subarachnoid hemorrhage affecting the central lobe due to a lesion originated in the anterior cerebral artery.

25%

d) Bifrontal intraparenchymal contusion originated from cortical lesions in the arteries associated with cerebral laceration.

25%
   

Image analysis

Image 1: Head CT without contrast, axial view, shows hyperdense areas (in red) in the convexity of the skull.

 

Image 2: Head CT without contrast, sagittal view, shows a hyperdense area (in red) with the format of a "bi-convex lens" on the convexity of the skull.

Highlights

- The epidural hematoma is the most commonly seen injury in young adult trauma;

- Generally, the Epidural hematoma is associated with a fractured skull;

- In the CT, the characteristic morphology of a bi-convex lens is very suggestive of anepidural hematoma;

- Despite being a serious head injury, some patients have a favorable resolution with an expectant management.

References

- Araujo JLV, Aguiar UP, Todeschini AB, Saade N, Veiga JCE. Análise epidemiológica de 210 casos de hematoma extradural traumático tratados cirurgicamente. Rev Col Bras Cir. 2012; 39(4). Available at: http://www.scielo.br/rcbc;

- William McBride. Intracranial epidural hematoma in adults. UpToDate, 2014. [access in October, 2014]. Available at: http://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults.

- American College of Surgeons. Advanced Trauma Life Support - ATLS. 9 ed. Chicago, IL.2012. p. 421.

- Miller DJ, Steinmetz M, McCutcheon I. Vertex Epidural Hematoma: Surgical versus Conservative Management: Two Case Reports and Review of the Literature. Neurosurgery. 1999;45(3). 

Author

Hercules Hermes Riani Martins silva, 5th year medical student at UFMG. Email: herculesriani[at]gmail.com

Supervisors

Alexandre Varella Giannetti, neurosurgeon and professor at UFMG’s School of Medicine. Email: agjg[at]terra.com.br

José Nelson Mendes Vieira, Professor of the Department of Anatomy and Image at UFMG's School of Medicine. Email: zenelson.vieira[at]gmail.com

Reviewers

Lucas V Rodrigues, Letícia Horta, Fábio M. Satake, Amanda Oliveira, Júlio Guerra Domingues

Translated by

Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG. Email: barbara.bragaglia[at]ufmg.br

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