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Chapter 20. Neurosurgical Emergencies

A 50-year-old man is brought into the emergency department (ED) after being stuck by a car moving at high speed. Upon arrival to the hospital, the patient is found to have no eye opening, verbal sounds, or motor movement to stimulation. Following intubation, resuscitation, and placement of an intracranial pressure monitor, the patient is admitted to the intensive care unit. His computed tomography (CT) and follow-up magnetic resonance imaging (MRI) scans are shown below. What is the source of the diffusion restriction seen in the corpus callosum and white matter on MRI?


Axial head computed tomography at the level of the superior thalami.


Axial magnetic resonance imaging of the brain diffusion weighted image (DWI) sequence at the level of the thalami and splenium of the corpus callosum.

A. Embolic infarctions from carotid dissection

B. Diffuse axonal injury

C. Hypoxic ischemic injury from the lack of timely intubation

D. Subclinical seizures

E. Intracranial hemorrhage from his trauma

B. In patients with high-energy injuries, diffuse axonal injury is a common source of poor neurologic exam. These lesions may be present in multiple locations and are best visualized on MRI. The diffusion-weighted sequence will classically show restricted diffusion lesions in the gray-white junction, corpus callosum, and brainstem. These classic locations make embolic infarcts, seizures, and hemorrhage less likely.

A 50-year-old man suffered a traumatic brain injury with subsequent hemicraniectomy 3 months prior. He was transferred to an acute rehabilitation facility. On arrival, he was initially awake and able to participate in therapy, but the patient became progressively more somnolent. He was also noted to have intermittent tachycardia without fevers. A CT scan was obtained and is shown below. What is the source of the patient’s altered mental status, and what is the appropriate treatment?


Axial head computed tomography at the level of the bilateral lateral ventricle atria.

A. Urinary tract infection; antibiotics

B. Hydrocephalus; ventriculoperitoneal shunt

C. Seizures; antiepileptic medications

D. Sympathetic storming; β-blocker medication

E. Syndrome of the trephined; cranioplasty

E. Delayed neurologic deterioration in a patient with traumatic brain injury has a challenging differential diagnosis, and any of the listed choices is possible. Loss of cerebral volume combined with the weight of the skin against the brain can frequently cause “sinking skull flap syndrome” or “syndrome of the trephined.” The signs ...

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