Case Study 1: Unresponsive at a Bus Stop

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Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Case study 1: Mitch—Unresponsive at a bus stop

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A 63 y/o male is brought into the ED after being found unresponsive at a bus stop. His pupils are slightly unequal in size, and he only responds to painful stimuli. He is identified presumptively by the wallet in his jacket pocket, and has previously been seen in the ED for acute ETOH intoxication. His current blood alcohol level is 0.15. There is a scrape on his forehead. The ED physician orders a non-contrast head CT, which is shown here.

Question

Which of the following is the most likely diagnosis?

The patient’s history, clinical presentation, and imaging findings are consistent with the diagnosis of a subdural hematoma. His CT demonstrates a crescent-shaped hyperintensity along the left frontal lobe and 2 mm midline shift. He could have hypothetically experienced any type of brain injury, especially in the setting of suspected trauma (scrape on forehead). However, the imaging findings (crescent-shaped hyperintensity with midline shift) are virtually pathognomonic for a subdural hematoma. 

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