Hx: A prisoner in his mid 20’s presents with a facial injury. History from EMS is that the patient had a syncopal episode and hit his face on the edge of a sink sustaining a lip laceration and facial contusion. The patient states he got out of bed, passed out, and hit his face on the way down. He cannot recall anything about the syncope but does recall awakening on the ground with others around him. He denies any medical problems. When asked about why he passed out, he states it is because he took an excedrin tablet for a headache early in the morning. Though he notes he has taken it multiple times in the past few weeks for migraines without any adverse reaction. He still has the global headache which he rates as 7/10, dull throbbing and constant. He arrives by EMS with a cervical collar in place and on a backboard.
PMHx: migraines
SocHx: frequent tobacco use, no alcohol or drugs.
Exam:
- Vital signs: pulse 65, BP 110/80, RR 16, O2sat 100% room air, temp normal
- General: moderate distress due to facial injury
- HEENT: large lower lip laceration through vermillion border and into the orbicularis oris muscle, no loose teeth, no mid face bony instability. Edema of soft tissue around the nose without bony deformity. TM’s normal. Pharynx clear.
- Neck: normal, non-tender cervical spine
- Res: clear bilaterally.
- Cardiovascular: regular, normal pulses
- Chest: normal
- Abdomen: non-tender, no bruising
- Back: non-tender, normal
- Extremities: no deformities
- Neuro: awake, oriented, follows commands, GCS 15
Differential: (Head Injury, Syncope, Headache)
- Head injury
- Migraine
- Seizure
- Intra-cranial mass
- Intra-cranial hemorrhage
- Facial fracture
- Mandible fracture
- Arrhythmia
- Drug use
- Electrolyte Abnormality
ED Course:
- Laboratory testing is normal
- ECG shows sinus rhythm without abnormality (no pre-excitation)
- CT facial bones is normal
- CT cervical spine is normal
- CT head demonstrates the following images: a mixed density right frontal sub-dural hematoma is seen. Red mark the older, darker blood while the yellow arrows show the more acute, newer, brighter blood. There is significant right to left shift due to mass effect from the hematoma. Blue line represents the midline and orange line represents how far the structures have shifted.
- Further discussion with the patient regarding the CT findings reveals that he has never been diagnosed with migraines. He labeled them as migraines when he began having the headaches 3 weeks prior. He notes the headaches have been present daily for 3 weeks but adamantly denies any assault or injury 3 weeks ago.
- The patient’s lip laceration is repaired and he is subsequently taken to the operating room for decompression of his sub-dural hematoma.
Discussion:
This case demonstrates several interesting findings. The patient’s neurological examination was normal. Given the remarkable right to left shift and mass effect from the mixed density hematoma, we can conclude that the original hematoma was slow forming allowing for compensation. This also explains the relative hypodense (dark) blood composing most of the hematoma. The fresh blood can be attributed to one of two mechanisms. Since the patient is amnestic to the events immediately surrounding his injury the day of presentation, an exact cause cannot be determined.
It is possible that he had fresh bleeding into a chronic sub-dural hematoma resulting in a brief loss of consciousness, and his fall with facial injury. In this scenario it would be expected that he present with some residual deficits, but there were none on arrival. It is also possible that he began to experience problems with strength and coordination due to the chronic hematoma which resulted in him falling, striking his head, losing consciousness, and developing fresh blood within the hematoma. In this scenario as well, it would be expected that he present with some neurological defects. Lastly, it is possible that the patient had an unrelated syncopal event, or no syncopal event but instead an assault that he is hesitant to report, and the injury sustained to his head caused acute bleeding within a chronic subdural. In this scenario, it would be possible for him to be neurologically intact on arrival. Regardless of the underlying etiology, evacuation of the hematoma is required and his lack of neurological findings can be attributed to the slow, chronic, development of the initial sub-dural hematoma.