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ZyraDoc #60 - September 30, 2026

#59

What's the Best Next Step?

#61

A 24-year-old male is brought to the emergency department following a high-impact motor vehicle collision with a brief initial loss of consciousness, followed by a 'lucid interval' of normal mental status, and a subsequent rapid neurological decline with severe headache, confusion, and vomiting.

On physical examination, his Glasgow Coma Scale (GCS) score is 9/15, with an ipsilateral dilated and sluggishly reactive pupil on the right, contralateral left-sided hemiparesis, and Cushing's triad (hypertension, bradycardia, and irregular respirations).

An emergency non-contrast head CT demonstrates a hyperdense, biconvex (lens-shaped) extra-axial fluid collection in the right temporoparietal region that does not cross cranial suture lines, accompanied by an underlying linear temporal bone fracture and significant midline shift, confirming an Acute Epidural Hematoma.

Case Summary

Clinical Focus:

  • The diagnosis is Acute Epidural Hematoma (EDH), a neurosurgical emergency.

Aetiology/Cause:

  • Traumatic head injury causing a skull fracture (most commonly of the temporal bone at the pterion).
  • Laceration of the middle meningeal artery or its branches running in the epidural space between the inner table of the skull and the dura mater.
  • Rapid arterial bleeding under high pressure strips the dura from the cranium, restricted by cranial sutures where the dura is tightly adherent.

Clinical Features:

  • Classic presentation: blunt head trauma with transient loss of consciousness, followed by a temporary 'lucid interval' before rapid neurological deterioration.
  • Signs of uncal herniation: ipsilateral dilated non-reactive pupil ('blown pupil') due to oculomotor nerve (CN III) compression and contralateral hemiparesis.
  • Cushing's triad of severe intracranial hypertension: systemic hypertension, bradycardia, and respiratory irregularity.

Diagnosis and Investigations:

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