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Abstract: After being drunk, the patient fell down with sudden vertigo while walking, landed on the occiput, and had headache, dizziness, nausea and vomiting after standing up. He came to our hospital for CT examination and was found to have cerebral contusion and subdural hematoma with brain herniation, which was an intracranial injury. The patient was admitted to the hospital and treated with right-sided craniotomy and subdural hematoma removal in an emergency.
Basic information】Male, 59 years old
Disease Type】Intracranial injury (bilateral cerebral contusion, right subdural hematoma, subarachnoid hemorrhage, brain hernia)
Hospital】Liaoning Provincial People’s Hospital
Date of Consultation】April 2022
Treatment plan】Surgical treatment (right craniotomy with decompression + subdural hematoma removal) + drug treatment (Olanzapine injection)
Treatment period】21 days of inpatient treatment, 1 month of outpatient follow-up
Treatment effect】The patient was discharged with a clear hematoma, brain herniation, and consciousness.
I. Initial consultation
The patient returned home after being drunk, fell down in the bathroom after being dizzy at home, and was sent to our hospital immediately after his family found that he was confused. Head CT examination revealed bilateral temporal lobe and left frontoparietal brain contusions, small hemorrhage foci in the right parietal lobe, right frontoparietal temporo-occipital subdural hematoma, right intracerebroventricular blood accumulation, subarachnoid hemorrhage, and midline structural deviation. The patient was comatose on admission, with a right pupil diameter of 4 mm and no photoresponse, and a left pupil diameter of 2 mm, with photoresponse present and no movement of the extremities. The initial diagnosis was bilateral cerebral contusions, right subdural hematoma, subarachnoid hemorrhage, and brain herniation.
II. Treatment history
After the patient was admitted to the hospital, because the patient had brain herniation and was at risk of death with further progression, the family actively requested treatment after explaining the patient’s condition to them. After completing the relevant preoperative examination, a right-sided craniotomy with decompression and subdural hematoma removal was performed in an emergency. The size of the open bone window was about 12×10 cm, and the dural tension was high. Postoperatively, the dilated pupil on one side of the patient was reduced, and a repeat head CT showed that the subdural hematoma was cleared, the midline was centered, and the brain herniation was relieved. Postoperatively, olanzapine injection was given to nerve nutrition, and at the same time, care was strengthened for sputum removal. The patient was awake after one week, with reasonable questions and answers and fair movement of the limbs. He was hospitalized for 21 days and discharged after observation of normal indicators.
III. Treatment effect
After systematic treatment, the patient’s consciousness gradually improved and he could open his eyes on his own. After the operation, the patient’s lumbar puncture was performed every day to drain the blood in the brain, and the family was instructed to call the patient’s name diligently, and the patient had to be turned and buckled and aspirated every day. After 2 weeks, the patient was able to stand on the side of the bed, and after 3 weeks, he could walk without assistance, and the hematoma on the head CT was completely absorbed, so the patient was discharged from the hospital, and was asked to come back for review in 1 month.
IV. Notes
I was very relieved to see that the patient was discharged conscious. However, since part of the skull of the patient’s head was removed, the brain tissue at the surgical site was only blocked by a layer of scalp with the outside world, and because the external atmospheric pressure was higher than the intracranial pressure, it would lead to the depression of the skull defect site, so after discharge, we should avoid trauma to this site, especially the injury of sharp objects, which may directly cause brain tissue damage, and try to protect it well, and skull repair surgery can be done after 3 months.
Since the patient has the presence of cerebral contusions, hematoma absorption is still a risk of epilepsy, so be careful not to engage in dangerous activities in the near future to avoid unnecessary injury from delirium during seizures, and family members should also observe the patient’s condition at all times after discharge and supervise the patient to avoid alcohol abuse.
V. Personal insight
“Time is life” is perfectly reflected in this case. The subdural hematoma and cerebral contusion caused rapid increase of cranial pressure on one side and rapid progress of brain herniation. The patient’s condition was significantly controlled after active treatment. Therefore, if you encounter sudden symptoms, you must seek medical attention in a timely manner to gain time for treatment and avoid irreversible consequences of delaying the condition.