1. A CT scan of the head without contrast is performed, which shows an extra‐axial, isodense 17‐mm crescent‐shaped collection across the right hemisphere which crosses suture lines. No midline shift is noted. What is the most likely diagnosis?
   
   
   
   1. Subarachnoid hemorrhage
      
   2. Epidural hematoma
      
   3. Intraventricular hemorrhage
      
   4. Subacute subdural hematoma
      
   5. Intracerebral hemorrhage

Question 2:

2. Which of the following is the most appropriate next step in the management of this patient?
   
   
   
   1. Perform a lumbar puncture
      
   2. Administer recombinant tissue plasminogen activator
      
   3. Observe the patient for 24 hours
      
   4. Administer low‐molecular‐weight heparin (LMWH)
      
   5. Perform craniotomy and clot evacuation
   
   

   This patient has a history of recent blunt head injury and progressive neurological deterioration. He has sustained a subacute subdural hematoma (SDH) from a traumatic brain injury. Rapid acceleration and deceleration can lead to shearing of bridging veins of the cranium. These bridging veins are the connections between the intraparenchymal veins of the brain and the dural venous sinuses. This patient’s advanced age and long‐term alcohol consumption have likely contributed to brain parenchymal atrophy, leading to increased stretch on these bridging veins, placing him at high risk for subdural hematoma formation even with minimal trauma. First‐line imaging indicated for the diagnosis of SDH is computed tomography (CT) of the head without IV contrast. Classic findings include a crescent‐shaped, biconcave lesion that crosses suture lines but not the midline. There may or may not be a midline shift. The density of lesions depends on the timeframe of SDH. Acute SDH (symptom onset within 3 days of injury) will be hyperdense, subacute SDH (symptom onset within 4–20 days of injury) will be isodense to hyperdense, and chronic SDH (symptom onset beyond 21 days of injury) will be hypodense on imaging. An epidural hematoma would have a biconvex lens‐shaped hyperdense lesion on head CT, that does not cross suture lines. A subarachnoid hemorrhage would reveal hyperdensities in the subarachnoid space, usually having a star‐shaped appearance, on head CT. An intracerebral hemorrhage would reveal a hyperdensity within a lobe of the brain. An intraventricular hemorrhage would reveal hyperdensities within the third, fourth, or lateral ventricles on head CT.

   
   

   All patients should receive supportive care, monitoring, and frequent neurological examinations, along with prevention of secondary bleeding or progression of existing bleed (immediate discontinuation or reversal of anticoagulant or antiplatelet medications), neuroprotective measures, and ICP management. Indications for neurosurgical intervention include hematoma size> 10 mm, midline shift > 5 mm, ICP > 20 mm Hg, signs of cerebral herniation, rapid neurological deterioration, and failure of conservative management. Options for neurosurgical intervention include decompressive craniectomy, craniotomy and clot evacuation, or emergency temporizing burr hole craniotomy.

   

   
   

   Left: Acute subdural hematoma. Right: Post‐craniectomy

   
   

   Fomchenko EI, Gilmore EJ, Matouk CC, Gerrard JL, Sheth KN . Management of subdural hematomas: part II. Surgical management of subdural hematomas. Current Treatment Options in Neurology 2018; 20(8):34.

   
   

   Mutch CA, Talbott JF, Gean A . Imaging evaluation of acute traumatic brain injury. Neurosurgery Clinics. 2016; 27(4):409–439.

   
   

   Wind JJ, Leiphart JW . Bilateral subacute subdural hematomas. New England Journal of Medicine 2009; 360(17):e23.

   
   

   Q1 Answer: D

   
   

   Q2 Answer: E

   
   

   The following vignette applies to questions 3 and 4:

   
   

   A 40‐year‐old man is brought to the emergency department 30 minutes after crashing his car into a telephone pole. He has a history of alcohol abuse. On arrival his pulse is 63 beats/min, respiratory rate is 10 breaths/min, and blood pressure is 100/70 mm Hg. His pupils are sluggish. There are multiple bruises over the face, chest, abdomen, and upper extremities, a 5‐cm laceration across his left cheek, and tactile crepitus over the left face. There are decreased breath sounds over the right lower lung field. His abdomen is soft but diffusely tender to palpation in all quadrants without guarding or rebound. Both wrists and elbows are swollen.

   
   
3. He does not respond to commands but makes groaning sounds. Pinching his sternum tightly causes him to open his eyes and withdraw all his extremities. What is this patient’s Glasgow Coma Scale (GCS)?
   
   
   
   1. 3
      
   2. 5
      
   3. 8
      
   4. 10
      
   5. 15
   
   
4. What is the next best step in the management of this patient?
   
   
   
   1. CT scan of the head and neck
      
   2. Insertion of an intercostal chest tube
      
   3. Focused assessment sonography for trauma (FAST)
      
   4. Intubation and mechanical ventilation
      
   5. Bilateral x‐rays of upper extremities
   
   

   The Glasgow Coma Scale (GCS) should be determined for all injured patients. It is calculated by adding the scores of the best motor response (1–6), best verbal response (1–5), and eye‐opening (1–4). Scores range from 3 (the lowest) to 15 (normal). Scores of 13–15 indicate mild head injury, 9–12 moderate injury, and 8 or below severe injury. The GCS is useful for both triage and prognosis. The GCS score has been shown to have a significant correlation with outcome following severe TBI, both as the sum score or as just the motor component. A recent study has shown that pupil reactivity together with the GCS motor component correlates best with mortality. In patients with a different motor response between the left and right side, the best movement is used. This patient’s GCS score is calculated as follows: groans = 2 (best verbal response); opens eyes to pain = 2 (best eye response); withdraws extremities to painful stimuli = 4 (best motor response); GCS score = 8.

   
   

   Patients with a GCS score of 8 or below as a result of traumatic brain injury must be intubated and mechanically ventilated to protect their airway and ensure adequate respiratory function. These patients are most at risk of aspiration and hypoxia from the lack of gag reflex and decreased brainstem respiratory drive. Although the patient may eventually require all the other option choices listed (chest tube placement for possible hemothorax, head and neck CT to evaluate injuries, FAST to rule out abdominal or pericardial hemorrhage, x‐rays to evaluate for extremity fractures), intubation and mechanical ventilation should be the next immediate step.

   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

   Score	Eyes	Verbal	Motor
   1	Does not open eyes	Makes no sounds	Makes no movements
   2	Opens eyes to painful stimuli only	Incomprehensible sounds	Extension response to pain (decerebrate posturing)
   3	Opens eyes in response to voice command	Inappropriate words	Abnormal flexion response to pain (decorticate posturing)
   4	Eyes are open spontaneously	Confused, disoriented	Flexion/withdrawal from painful stimuli
   5	N/A	Oriented, converses normally	Localizes painful stimuli
   6	N/A	N/A	Obeys commands

   
   

   Q3 Answer: C

   
   

   Q4 Answer: D

   
   

   Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury. Neurosurgery 2017; 80(1):6–15.

   
   

   Hoffmann M, Lefering R, Rueger J, Kolb J, Izbicki J, Ruecker A, et al. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. British Journal of Surgery 2012; 99(S1):122–130.

   
   

   Mayglothling J, Duane TM, Gibbs M, McCunn M, Legome E, Eastman AL, et al. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery 2012; 73(5):S333–S340.

   
   

   Teasdale G, Jennett B . Assessment of coma and impaired consciousness: a practical scale. The Lancet. 1974; 304(7872):81–84.

   
   

   The following vignette applies to questions 5 and 6:

   
   

   A 40‐year‐old man presents after being thrown off his motorcycle and striking his head on the pavement. His breath smells of alcohol. He is unconscious. He has a 6 cm laceration across the right side of his head. Deep tendon reflexes are absent on the right side. His pupils are sluggish. His vitals are normal except for a respiratory rate of 8 breaths/min. He is immediately intubated and mechanically ventilated. Head CT is ordered, which reveals a depressed skull fracture, a 9 mm epidural hematoma and multiple 8 mm intraparenchymal hemorrhages of the right parietal and temporal lobes.

   
   
5. The attending trauma surgeon declares the patient to be Brain Injury Guidelines (BIG) category 3. Which of the following additional findings would be most consistent with a BIG 3 categorization?
   
   
   
   1. Trace subarachnoid hemorrhage found on head CT.
      
   2. A 2 mm subdural hematoma on the right side found on head CT.
      
   3. A normal neurological examination.
      
   4. A 5 year history of taking aspirin for coronary artery disease.
      
   5. No intraventricular hemorrhage found on head CT.
   
   
6. According to BIG, what should the management plan for this patient include?
   
   
   
   1. Only observe the patient for 6 hours.
      
   2. Admit the patient, but do not order a repeat head CT.
      
   3. Admit the patient and order a repeat head CT, but do not consult neurosurgery.
      
   4. Let the patient go home and return for follow‐up the next day.
      
   5. Admit the patient, request a neurosurgical consult, and order repeat head CT.
   
   

   Modern computed tomography (CT) technology has advanced to the point that even minor intracranial injuries are identified, often prompting reflex escalation of care. This has led to the over‐utilization of valuable healthcare resources. The Brain Injury Guidelines (BIG) were developed and subsequently validated as a triage tool for acute care surgeons in the setting of traumatic brain injury (see figure below). Based on the patient’s history, neurologic examination (an abnormal neurologic examination is defined as the presence of altered mental status, focal neurological deficits, or abnormal pupillary response), and initial head CT findings, BIG can help guide decisions on admission, repeat imaging, and neurosurgical consultation. Patients presenting with blunt TBI and positive initial head CT findings are stratified into one of three BIG categories. Failure to meet even one criterion of BIG category 1 or 2 (e.g., history of antiplatelet or anticoagulant use, displaced skull fracture, large or scattered intracranial hemorrhages, or abnormal neurologic examination) will immediately upgrade the patient to BIG category 3. Each BIG category then has a recommended therapeutic plan which will help decrease over‐ and under‐triage of patients.

   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

   Brain Injury Guidelines
   Variables	BIG 1	BIG 2	BIG 3
   LOC	Yes/No	Yes/No	Yes/No
   Neurologic examination	Normal	Normal	Abnormal
   Intoxication	No	No/Yes	No/Yes
   CAMP	No	No	Yes
   Skull Fracture	No	Non‐displaced	Displaced
   SDH	≤4mm	5 –7 mm	≥8 mm
   EDH	≤4mm	5 –7 mm	≥8 mm
   IPH	≤4mm, 1 location	3 –7 mm, 2 Locations	≥8 mm, multiple locations
   SAH	Trace	Localized	Scattered
   IVH	No	No	Yes
   THERAPEUTIC PLAN
   Hospitalization	No Observation (6hrs)	Yes	Yes
   RHCT	No	No	Yes
   NSC	No	No	Yes

   
   

   BIG, brain injury guidelines; CAMP, Coumadin, Aspirin, Plavix; EDH, epidural hemorrhage; IVH, intraventricular hemorrhage; IPH, intraparenchymal hemorrhage; LOC, loss of consciousness; NSC, neurosurgical consultation; RHCT, repeat head computed tomography; SAH, subarachnoid hemorrhage; SDH, subdural hemorrhage

   
   

   Q5 Answer: D

   
   

   Q6 Answer: E

   
   

   Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, et al. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. Journal of Trauma and Acute Care Surgery 2014; 76(4):965–969.

   
   

   Joseph B, Aziz H, Pandit V, Kulvatunyou N, Sadoun M, Tang A, et al. Prospective validation of the brain injury guidelines: managing traumatic brain injury without neurosurgical consultation. Journal of Trauma and Acute Care Surgery 2014; 77(6):984–988.

   
   

   Martin GE, Carroll CP, Plummer ZJ, Millar DA, Pritts TA, Makley AT, et al. Safety and efficacy of brain injury guidelines at a Level III trauma center. Journal of Trauma and Acute Care Surgery 2018; 84(3):483–489.

   
   

   The following vignette applies to questions 7–10:

   
   

   A 45‐year‐old man is brought to the trauma bay after being an unrestrained passenger in a high‐speed motor vehicle collision. He has a 7 cm laceration on the left side of his head, and multiple lacerations on his right upper and lower extremities. He is unresponsive, and is intubated and mechanically ventilated. His blood pressure is 140/90 mm Hg. Head CT reveals a depressed parietal bone fracture, multiple punctate hemorrhages at the gray‐white junction, an 8 mm epidural hematoma, and 4 mm midline shift.

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