Virginia Research Day 2021

A Case of Intracranial Hematoma in a 57 year old Male

Christopher Jeu, D.O., Candace Wise, D.O., Dirk Danielson, M.D.

Background

Imaging

Discussion

• The patient symptoms of expressive aphasia were significant because they suggested that at least one area of the brain affected involved the area of the dominant hemisphere (the left hemisphere in 98% of R handed individuals) involved in speech (Broca’s area). This correlated well with the region of injury seen on CT Head imaging of the temporal lobe as well as the physical exam findings of ecchymosis and swelling on the L side of the head. • Aphasia is a recognized but under-reported sequela of closed head injury. Severity can range from minor flaws in word selection to a total loss of communication ability. Patients who have persistent deficits of this type benefit from early recognition and prolonged

• Intracranial hemorrhage is a potentially devastating condition which should be promptly diagnosed and treated. • It can be classified by location:

• Etiologies: include AVM, Aneurysm, Cerebral venous sinus thrombosis, HTN, Cerebral amyloid, Tumor, Trauma • Clinical Manifestations: may include: Decreased level of consciousness, Nausea and Vomiting, Headache, Focal neurological deficits • General Workup: CT brain, Angiography, LP, Coagulation studies Case A previously healthy 57-year old male presented to the emergency department after experiencing an abrupt onset of difficulty speaking and uncontrollable shaking of arms and legs after sustaining a head injury. By patient’s account, he was outside trimming a tree when he was brushed on the left side of his head by some branches. His wife stated that he went back inside his house shortly afterward and began to have difficulty with speech and attempted to write a message to his wife but was unable to write coherently. Patient then had two 1-2 minute long episodes of uncontrollable shaking in upper and lower extremities. This was followed by a prolonged period of confusion and disorientation. PMH None, no hx of seizures PSH None FH M: T2DM, HTN / F: CAD, HTN MEDS None ALL NKDA Occupation Chemistry Professor SH Never smoker, no EtOH use. Physical exam: T: 98.1 °F HR: 96 RR: 16 BP: 145/76 General: middle-aged male lying supine in bed in no acute distress. A&Ox4 Neck: Trachea midline, no masses, no nuchal rigidity Cardiovascular: RRR, no m/r/g, Normal S1 and S2 Neurological: Cranial Nerves II-XII grossly intact, +2 DTRs, 5/5 strength in BL UE/LE, GCS 15; GCS 13 by EMS (E3 V4 M6) Psychiatric: cooperative with normal mood, affect, and cognition

speech and language rehabilitation therapy.

Findings and Intervention

• CT FINDINGS: There is a scalp swelling over the left temporal region. There is widening of the left temporozygomatic duct suture, and sphenoid squamous suture, which may reflect injury/fracture. There is associated extra-axial fluid collection in the left temporal pole, measuring 8 mm in thickness . There is a pocket of gas reflecting pneumocephalus as well. There is no significant mass effect, midline shift, or other parenchymal injury to the brain. The ventricles are normal in size and configuration. • IMPRESSION: Skull fractures involving the left zygomatic bone and left sphenoid squamous suture with an associated extra-axial hematoma in the left temporal pole , containing a pocket of gas compatible with pneumocephalus . • Findings were diagnostic of a subdural hematoma. Patient was emergently transported to tertiary care center for neurosurgical evaluation and possible intervention.

References • Liebeskind , David. “Intracranial Hemorrhage.” Intracranial Hemorrhage , 7 Dec. 2018, emedicine.medscape.com/article/1163977-overview. • McBride , William. “Intracranial Epidural Hematoma.” UpToDate , 2019, www.uptodate.com/contents/intracranial-epidural-hematoma-in- adults?search=intracranial%2Bhematoma&source=search_result&sele ctedTitle=1~150&usage_type=default&display_rank=1. • Sabatine, Marc. Pocket Medicine . Aspen Publishers, Inc, 2014. • Tintinalli, Judith. Tintinalli’s Emergency Medicine . Mcgraw-Hill Education, 2015.

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

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