RD7.4 | Imaging in Surgery — Assignment

CLINICAL SCENARIO

A 19-year-old male is brought to the surgical casualty after a high-speed motorcycle collision. He was wearing a helmet but had a brief loss of consciousness at the scene. On arrival his airway is patent, he is haemodynamically stable, GCS is 13 (E3 V4 M6), and he has vomited twice. There is boggy swelling and bruising over the left temporal region and clear fluid is noted from the left ear. Over the next 30 minutes his GCS drops to 9 and his right pupil becomes sluggish. A non-contrast CT head is requested, which shows a hyperdense biconvex extra-axial collection over the left temporoparietal region that does not cross the suture lines, with effacement of the adjacent sulci and 6 mm of midline shift. This case requires you to integrate the imaging findings into a structured surgical management plan for a head-injured patient, the integrate (KH) core of competency RD7.4.

Using a validated decision rule (Canadian CT Head Rule / NICE), identify which features in this patient justified urgent imaging. Explain why non-contrast CT (NCCT) head is the modality of choice in acute head injury rather than contrast CT, MRI or skull radiography, referring to the physical basis of why acute blood is hyperdense on unenhanced CT.

Interpret the described appearances. Name the lesion and justify your diagnosis from its shape and relationship to the sutures. Contrast extradural with subdural haematoma (shape, suture/midline behaviour, vascular source — middle meningeal artery vs bridging veins). Comment on the significance of midline shift and sulcal effacement as signs of mass effect, and on the clinical relevance of the clear ear discharge.

Construct a time-sensitive management plan that integrates the imaging with the deteriorating GCS and pupillary change. Address resuscitation and neuroprotection priorities, the urgency and nature of neurosurgical intervention indicated by an expanding extradural haematoma with mass effect, and the role of repeat imaging. State explicitly how the imaging report changes the surgical decision.

Discuss the common errors in head-injury imaging decisions (over-scanning low-risk patients; observing a high-risk patient who should be scanned; the talk-and-deteriorate lucid interval of extradural haematoma). Explain when MRI adds value (e.g. suspected diffuse axonal injury when clinical state is worse than CT appearances) and why it is not the acute first-line investigation.