One thursday afternoon when every one started to relax in prepration for the coming week end , actually i was feeling tired after a busy week ,when my mobile phone rang , he was one of my colleagues in one of our hospital wards , He said ,sorry for calling you at the end of your duty but i have a critical patient for your consultation suspected CNS infection ,He was admitted yesterday evening with mild fever and severe headache associated with nuchal rigidity now the patient is confused .I think the patient needs ICU admission for fear of more deterioration , he said . The patient was 21 years old ,driver , not known to be diabetic or hypertensive , no history of drug abuse or addiction , no history of seizure attacks but there is a history of head trauma three months earlier no history suggestive of CSF rhinorrhea .. Family history was not contributory .
The condition started five days before admission by severe headache not releived by anagesics , the pain was frequent with increasing intensity , there was repeated vomiting and the relatives reported that he suffered from memory deterioration during the preceding two months . On examination the patient was confused , GCS : mild 14/15 E4V4M6 ., Neck : rigid . Pupils : RRR, no signs of external trauma was notable Vital signs : temperature : 37.8 C Pulse: 88/m B.P .130/70 mm hg , RR : 20/m Chest : clear Heart : Normal S1 ,S2 Abdomen : soft Joint and lymph node examination was normal . Neurological examination revealed : hyperreflexia on the right side with decreased motor and sensory power , No signs of cranial nerve affection Investigations : CBC, chemistry electrolytes ,liver , renal and coagulation profile was normal . CSF examination revealed : cells : 20 all lymphocytes , sugar: 80 mg/dl proten : 16 mg/dl
(Q) was this patient indicated for lumbar puncture ?
I asked the relatives about the brain CT Scan and after seeing it . I immediately prepared for transfering the patient for neurosurgical interference . (Q) What are the findings in the CT scan ? What's your diagnosis ? Discussion :The clinical course of the disease started with symptoms suggestive of increased intracranial pressure ( headache and vomiting ) , the neck stiffness ,fever and altered sensorium make the CNS infection is a likely diagnosis , but the history of head trauma should not be neglected , also the focal neurological signs in the form of asymmetrical reflexes , and right sided hemiparesis raise the possiblity of intracranial mass effect , so lumbar puncture is a contraindication as brain stem herniation can be expected with sudden respiratory arrest and brain CT scan has a priority
CT scan of the brain in this patient revealed an isodense crescentic subdural mass lesion extending from the left frontal and parietal lobes with mass effect ( effacement of the left cortical sulci, compression of the left lateral ventricle and shifting of the midline to the right side .
Diagnosis left subacute subdural hematoma . for neurosurgical evacuation.
Take home message : any patient with focal signs e.g. monoplegia ,hemiplegia,hemiparesis ,asymetrical reflexes ,aphasia ,focal fits ,papilledema ,lumbar puncture should be delayed until brain CT brain examination is done to exclude mass effect otherwise brain herniation with sudden respiratory arrest can occur
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