Famous Patients, Famous Operations, 2003 - Part 5: Case of the Man With a Hole in His Head

Albert B. Lowenfels, MD

Disclosures

October 13, 2003

Introduction

A 40-year-old male sustained a fall while climbing a flight of stairs. He fell backwards, striking his head against the floor. After the injury, he arose, rubbed his head, and did not seem incapacitated. Prior to the fall he had complained of periodic headaches, but had no other recognized neurologic symptoms. Otherwise he was considered to be in good health. About 20 minutes later he vomited. Half an hour after the fall he began to feel drowsy, followed by gradually increasing stupor, eventually leading to coma.

Several hours after the injury, the patient was seen by a surgeon, who noted that the patient could not be aroused. His breathing was labored and his pulse was only 40 bpm, regular, and bounding. Blood pressure was not obtained. There was no evidence of external injury to the scalp. No other information about the physical examination or the history is available. The surgeon performed an operation soon after completing his initial examination.

What is the most likely diagnosis?

  1. Epidural hematoma

  2. Brain tumor

  3. Cerebral abscess

  4. Subdural hematoma

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Which operation was performed?

  1. Excision of a brain tumor

  2. Insertion of a catheter to measure intracranial pressure

  3. Trepanation

  4. Hemicraniectomy

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Who was the patient?

  1. Benjamin Franklin

  2. Leon Trotsky

  3. Michael Schoch

  4. King George II

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Who was the surgeon?

  1. Harvey Cushing

  2. Benjamin Carson

  3. Walter Dandy

  4. John Syng Dorsey

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Which instruments were used?

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Was the operation successful?

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How would a similar patient be managed today?

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Is epidural hematoma usually associated with a skull fracture?

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Do epidural hematomas occur outside of the cranial cavity?

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Is there a role for hypothermia in the management of acute brain injuries?

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Was trepanation performed during the prehistoric period?

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What were the reasons for early trepanation?

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Did any of the patients who underwent trepanation in its early days survive?

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Are there new indications for trepanation?

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