Fatal Brain Bleed Goes Undiagnosed

This case involves a fifty-year-old male who was involved in a motor vehicle accident and sustained severe whiplash associated with a lucid interval of consciousness. Three days after the accident, the patient presented to the ER complaining of headaches and mild nausea. The ER physician’s initial impression was a concussion and mild neck strain, and the plan was to have the patient take Tylenol and return to his PCP in three weeks if no improvement was seen. Approximately two weeks later, the patient began to display signs and symptoms consistent with a subdural hematoma. A CT scan showed a severe midline shift and mass effect in the cerebral ventricles. The patient underwent an immediate craniotomy for decompression but continues to have residual motor and sensory deficits.

Question(s) For Expert Witness

1. What is the means for making a prompt diagnosis and when should a craniotomy be considered?

Expert Witness Response

In a patient who suffers a motor vehicle accident and complains of a headache, should have an emergent heat computed tomography (CT) to rule out hemorrhage. Many ER physicians are trained in the standard Advanced Trauma Life Support guidelines and thus performing a head CT is one of the first procedures done in a MVA. At times, the first head CT may be normal, which can be deceiving as subdural hematomas may not be visible on the first head scan. In fact, the patient should be observed for another 24 hours and obtain another head CT to see any evolving hemorrhage. Subdural hemorrhages take longer to evolve and the symptoms may not be so evident. Thus, once the head CT shows a subdural hematoma, the trauma team and neurosurgeon must determine quickly which lesions warrant immediate evacuation. Craniotomy should be considered if the patient is developing worsening neurological deficits, and if subsequent head CT’s are showing a significant midline shift with an evolving mass. Usually, the neurosurgeon will give intravenous corticosteroids to control the edema and inflammation, and then will decompress the mass surgically.