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Something doesn’t add up… March 26, 2012

Posted by Andy Jagoda, MD in : Cardiovascular, Neurologic, Trauma , trackback

A 29-year-old woman is brought in by EMS after a motor vehicle accident in which she was an unrestrained driver. She was found by the medics lying across the steering wheel with a large gash on her forehead. At the scene, she was awake, but disoriented, and there was a strong odor of alcohol on her breath. Her ED assessment revealed a small right-sided subdural hematoma and a zygoma fracture. Her serum ETOH level was 260 dL/mL, and she was placed under observation status on the trauma service. Six hours later, she becomes agitated and then rapidly develops left-sided weakness and neglect. Your first thought is that she must have had a seizure and is left with a Todd paralysis . . . but it doesn’t quite add up, and you wonder what else might have happened.

Is there anything you should be doing?

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Comments»

1. dr suresh naidu - March 31, 2012

1- progression of intracranial bleed, either the one already happen or another new bleed- to repeat ct brain maybe ct angio..to rule out dissecting aneurysm of cranial vessels
2- central cord syndrome? need mri
3- carotid artery dissection,cervical artery dissection, vertebral artery dissection- ct angio or mr angio

2. Peschanski - April 1, 2012

– Supra-aortic arterial dissection to consider.
Check with angio-CT of cervical region
– Cerebral edema due to intracranial bleeding.
Check with Cranial CT-scan

3. Peschanski - April 1, 2012

Should consider:
– Supra-aortic artery dissection: Angio-CT scan of the cervical region
– Sub-tentorial cerebral comitment: Cerebral CT-scan

4. Ramy Yakobi - April 1, 2012

I would assume Carotid Artery dissection.

5. Mary Ellen Barringer - April 1, 2012

Would order MRI/MRA head/neck to r/o progression of intracranial bleed and/or carotid artery dissection/cervical/vertebral artery dissections.

6. Rob Ferre - April 1, 2012

Epidural spinal hematoma.

7. K. Goodman - April 1, 2012

Carotid or vertebral artery dissection on right or possibly cerebral vasospasm d/t expanding hematoma or SAH. Repeat CT head with IV contrast with CTA of neck and/or US carotid vessels with Doppler.

8. dr. ashok mishra - April 1, 2012

increase in size of right side subdural

9. Thomas Gilbert - April 1, 2012

Carotid artery dissection.

10. Naga - April 1, 2012

A repaet CT may help to see the new bleed or extension with mass effect of the previous bleed, before that go for airway management and u can try esophageal echo to see aortic cause.

11. Annika Kramer - April 1, 2012

Repeat CT stat. Burr hole possibly needed?

12. fouzia ali - April 1, 2012

alcohol withdrwal;;

13. Jon Keary - April 1, 2012

Intubate/sedate. Maintain CTLS precautions.
Emergent neurosurgery consult.
Repeat Head CT w/o contrast.

Likely worsening of subdural or another new ICH.

14. zubaid rafique - April 1, 2012

aortic arch dissection occluding blood supply to the right carotid (right MCA territory) causing left sided neglect and weakness.

15. Douglas Hartman - April 1, 2012

Hypoglycemia? Check a fingerstick. If normal, either progression of SDH or a carotid dissection

16. Bob C - April 1, 2012

Blunt force trauma to the head causing venous bridging vessel damage and facial fractures may also cause arterial damage. My first thought would be to re-order a CT head non-contrast to re-evaluate size of subdural, immediately followed by a CT angio head and neck to evaluated for aortic/carotid dissection. As she was intoxicated at the time of presentation and now has metabolically sobered, a repeat blood pressure may help determine if need to treat hypertension, possibly from alcohol withdrawal.

17. D.Shiller - April 1, 2012

Likely small Sdh was epidural hematoma.

18. J Futtermenger - April 1, 2012

in tnis case where a young female is involved in a traumatic accident, my thought are, pregnacy, alcohol and other drugs.
dehydration is also an important consideration, therfore I would do a pregancy test which is importat in guiding me what drugs are safe to give, besides ETOH I would also consider other drug intake i.e. aphetamines, which can cause stroke like illnesses, thromboembolic as well as haemorrhagic and the other differential is a cerebral venous thrombosis in a young, dehydrated person, beyond that an extension of the bleed or a dissection has to be seriosly considered.

19. Ron Koury - April 1, 2012

Call the Neurosurgeon NOW, while you are intubating her (with lidocaine, fentanyl, propofol, and roc.). Raise HOB a little. Take to C.T. NOW for rescan to see how much shift,… is now there from the expanding SDH, while you’re letting house sup. know that pt will likely need emergent bolt/crani.,….

20. Jon Kerr - April 1, 2012

Though this process is likely a result of the already known pathology secondary to trauma – the SDH and zygomatic fx, you have to rule out other possibilities. First stabilize patient – ABCs, sedate, paralyze and intubate if necessary. Check blood sugar with a FS,ensure there is no SZ activity.
1. Consider worsening SDH with shift and edema affecting the putamen and thalamus,thus the contralateral hemiparesis and neglect – repeat head CT. Consider emergent craniotomy (burr hole) and phenytoin.
2. Zygoma fx and missed LeFort III with concomitant C spine injuries/carotid artery/vascular involvement – CT angio head and neck.
3. R/O ETOH W/D. Check vitals, give benzodiazepines PRN. EEG. Consider adding Dexmed gtt as needed.
4. Wernicke-Korsakoff syndrome. Perhaps less-likely in a young patient like this but not unheard of. Give thiamine, especially if patient was receiving any dextrose earlier.
5. The alcohol on her breath may have been just that – but consider ketones. Check FS, SMA-7, ketones – is there a gap? Eval and treat DKA if present.
6. Consider CXR and CTA of chest/aorta for De Bakey type I or II (Stanford A) Aortic dissection in this traumatic pt who was found lying across the steering wheel. This can lead to transient left hemiparesis–especially common in right carotid a. occlusion.

21. Roy C. Brown, MD - April 3, 2012

She should have secure IV lines in upon admission with trauma labs including type and cross and clotting studies. A sudden change in consciousness with neurological signs require a prompt CT scan with stat consultation to neurosurgery and neurology. Of course vital signs will be monitored an action taken accordingly. The OR will be on standby. I am thinking the patient’s small bleed has developed into a larger bleed that require urgent treatment. The zygoma fracture will be managed after she is stable. We will test any fluid for CSF.

22. Rauvan Averick - April 3, 2012

Check her blood sugar – may be daibetic on insulin/hypoglycemics. Low blood glucose can imitate stroke.

23. Dr. Shahbaz Ahmed - April 3, 2012

First thing to do is re-assess the ABC and GCS, intubate patient if necessary, stabilse if anything urgent, check pupils, give antiepileptic. Then shift to CT, to evaluate for expanding Rt. SDH with midline shift or a new EDH with midline shift, do a burr hole if necessary.
Before shifting to CT, do a repeat E-FAST, to check for intra-abdominal bleed, unrestrained driver can have a spleen laceration which has suddenly bled. The altered mental state could be due to a massive sudden loss of blood.
Do a CT C-Spine also to evaluate for any cord compressions or vertebral fractures.
Involve the Neurosugery Team, to take for decompression craniotomy if needed.

24. Wolfgang Orecchioni - April 5, 2012

Alcohol-related seizures occur 6 – 48 hrs after the last drink: a Todd paralysis is’nt completely wrong, but unlikely. 29 years seems too young for alcoohol-related cirrhosis and its coagulopathy, but a recent use of a NSAID for -may be- headache (or suicidal attempt)increases the bleeding. An expanding subdural haematoma with “focal” neurological signs only from the right hemisphere? May be, but unlikely. A significant Head + facial trauma = cervical trauma, in this case perhaps against the steering wheel (zygoma) and windshield (the gash) with at least some crushing neck hyperextension. Anisocoria, with miosis of the right eye? Something wrong palpable or visible exactly on the right side of her neck, does it hurt? A traumatic carotid artery dissection needs heparin and a NMR, not easy in a bleeding trauma patient. Second hypothesis: a cerebral hematoma in the right hemisphere not yet developed at the time of the first examination. I’m going to ask the radiologist if she/he is able to dissolve -rapidly- the doubt with another CT-scan, my hospital does not have a NMR. Hoping the girl is not pregnant, that’s not “simply” an embolism, that our guardian angel is not sleepin … greetings from Sardinia!

25. rita cohen - April 6, 2012

the patient m/p enlarged the right subdural hematoma , and now has intracranial pressure that evoked this left hemiparesis . it is an urgent medical situation , a CT of the head should be done immediately ( also to rule out epidural hematoma ) ,paralel to the CT , a neurosurgeon has to be informed immediately , in order to perform an urgent drainage of the hematoma,and reliefing the pressure in the brain.

26. darkblader akumajo - April 10, 2012

the patient had a stroke…. she may be drugged with anything else…. perform a toxic profile, and repeat the tomography searching for a complicatin (exacerbation ef the hemorragie, another hemorragie…. or a cord trauma)… thanks

27. KURDELL ESPINOSA - April 10, 2012

cerebral artery aneursym / carotid artery aneurysm.

MRI / MRA NEEDED.

28. Ajeet - April 11, 2012

First reexamine pt. additionally check pupils and for clonus.
Secure airway – intubate given rapid decline in mental status.
Reevaluate labs. Glucose, Coags, Platelets. cxr – ?widened mediastinum/aortic dissection

Given Left sided weakness and neglect most likely carotid artery dissection. Extended SDH or Epidural with herniation would give upper motor neuron signs such as posturing, clonus rather than weakess/neglect.

Call Neurosurg stat, order CT Angio Head and Neck (easier and more rapidly obtained than MRI)

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