Question
During a boxing match, a contestant is “knocked out” by a blow to the lateral skull. He recovers after a few minutes, and is asymptomatic for the next 12 hours. He then develops a severe headache, changes in mental status, nausea, and vomiting. Which of the following is the most likely diagnosis?
| A. |
Basilar skull fracture
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| B. |
Epidural hemorrhage
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| C. |
Intracerebral hemorrhage
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| D. |
Subarachnoid hemorrhage
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Show Answer
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Correct Answer � B
Explanation
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All of the lesions listed in the answers can occur in brain trauma. However, the scenario described is classic for epidural hemorrhage.
In this scenario, a severe blow to the lateral skull causes both skull fracture and laceration of the middle meningeal artery (know the name of this artery, as it is frequently tested), leading to a momentary loss of consciousness, which is followed by a lucid (asymptomatic) period of 1-48 hours before the patient’s neurologic condition deteriorates.
This scenario is frequently tested in examinations, but you should be aware that in real clinical life, there may be no initial loss of consciousness and the patient may not have sought medical help for skull trauma.
Basilar skull fractures are usually located in the vicinity of the petrous bone or along the sphenoid bone.
Clinical signs of basilar skull fracture include hemotympanum (blood visible behind the tympanic membrane), delayed ecchymosis over the mastoid process (Battle’s sign), or periorbital ecchymosis (“raccoon sign”). CSF leakage (sometimes from the nose), or pneumocephalus may also occur.
Intracerebral hemorrhage is most often due to hypertension, anticoagulant use, cerebral amyloid angiopathy, or cocaine and/or methamphetamine abuse.
Subarachnoid hemorrhage is most commonly caused by rupture of a cerebral berry aneurysm, but may also be associated with arteriovenous malformations or intraparenchymal hemorrhage.
