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Help on this Question Please!!!

Discussion in 'Step I' started by bt9099, Jun 17, 2008.

  1. bt9099

    2+ Year Member

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    Can someone explain the answer and why?

    1. 75y/o woman brough to ER semicomatose 24 hours after hitting the back of her head in a fall. No symptoms present after fall, but she developed blurred vision and weakness of left extremities 18 hours after fall. Examinatino shows left hemiparesis; right pupil is dilated and unresponsive to light. CT scan w/o contrast shows diffuse extra-axial hemorrhage over the right cerebral hemisphere. WHich of the following is most likely mechanism of her injury?

    a. contusion of the brain
    b. laceration of a cerebral bridging vein
    c. laceration of small leptomeningeal blood vessel
    d. laceratino of middle meningeal artery
    e. shearing forces damaging white matter

    (by the way, what is "extra-axial hemorrhage over right cerebral hemishphere mean?)
     
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  3. BrisketAttack

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    answer is B. I don't worry about the crazy neuro lingo. very little of it makes sense to me. i just look for key terms and then answer. with this one, the bleed covers the hemisphere, which would not be seen with epidural hemmorhage (does not cross suture lines). therefore it's subdural and due to rupture of bridging veins. also, the fact that she hit her head on the back rather than the side makes me think less about epidural. one confounder is the rapid nature of the onset of her symptoms. my impression was that subdurals can take wks/months to present.
     
  4. tfom08

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    Yes B and the other hint would have been the length of time for onset of symptoms. Subdural is more likely to progress more slowly compared to epidural.
     
  5. bt9099

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    That's what I was thinking, but what about the "lucid interval" in epidural?

    And how can you tell that it does or doesn't cross the suture lines?
     
  6. butaloh666

    butaloh666 Junior Member
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    I would go with B as well. And as far as the relatively rapid onset, my impression is that the subdural bleeds which cause medical emergencies like this are usually re-bleeds. An injury occurs with a resulting subdural hematoma developing over a long period, which is then reabsorbed. But a subsequent trauma can cause bleeding in the same area that will be more acute and significant. The time frame for this re-bleed would be on the matter of days (as I understand it).
     
  7. butaloh666

    butaloh666 Junior Member
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    Lucid interval refers to a period without symptoms that follows an initial period of unconsciousness (or dizziness etc.). The vignette doesn't mention anything about an initial period of symptoms, so I would say that rules out a the presence of a lucid interval in her history.
     
  8. UCLAstudent

    UCLAstudent I'm a luck dragon!
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    The keys are the mechanism of injury (elderly woman falling and striking the back of her head) and the duration before symptoms. An epidural bleed would progress more rapidly (usually on the order of hours) and, classically, the patient would have had a blow to the side of her head. The CT description confirms it.
     
  9. bt9099

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    thanks a lot!!!1
     
  10. GynGuy1983

    GynGuy1983 C&A Psychiatry Fellow
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    +1

    The location of her injury, as well as her hemispherical bleed should rule out a epidural hematoma. The onset of symptoms is somewhat of a distractor, but if you continue reading, it's pretty straight forward.

    Now if she was hit in the side of the head with a baseball bat, came in lucid, and then within 24 hours, her symptoms started, it would be too obvious, thus not making it on the exam :p
     

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