By Tedler D. Depaynos, MD
The 24 year old patient was brought to a government hospital near their place when he suddenly slipped while walking down the steps in their yard and hit his head on a stone. He “lost consciousness” according to his friends who brought him there only to recover when they reached the ER. Although he was a little tipsy since they have been drinking with his close friends to enjoy the holidays, he could exactly recall what happened to him. He was going down to pee, when he stepped on a loose stone which made him slip and fell landing on his head. Apparently he was more than tipsy despite his denial which is expected of somebody who had too much alcohol according to his attending surgeon.
His head wound was easily sutured with minimal local anesthesia and when the surgeon requested that x-rays of his head should be done because he seemed to feel a “depressed fracture”, the patient refused because he felt alright and insisted on signing a waiver. The surgeon warned his companions of his findings and advised them to bring back the patient for work-up. Although smelling of alcohol too, they agreed.
Two days later, the patient started to be ”very irritable and seems not to know what he was doing”. He was “forgetting things” and he seemed to be having “mild seizures” from time to time. He was then brought back to the hospital.
An emergency head CT scan confirmed the impression of the surgeon who sutured the wound that there was a skull fracture. It further showed bleeding in the brain tissues or “interparenchymal” bleeding with hematoma formation. The fracture was on the left side of the skull so that bleeding was expected on the left side of the brain. To the surprise of the attending MDs at the ER, there was also bleeding on the right side of the brain so the trauma must have been severe. The right brain was pushed severely on the right skull when his head hit the stone so that it was likewise traumatized and bleeding ensued. This is what they call “contrecoup bleeding”.
Initially the patient manifested no brain damage except headaches which was relieved by analgesics. When edema worsened together with the bleeding, the brain enlarged. Because the skull is a closed space, it cannot accommodate the enlarging brain so that eventually it would be compressed. With more swelling the manifestations of the patient occurred. With more brain enlargement, necrosis of the brain may have occurred followed by paralysis and probably permanent good bye.
The patient was then immediately referred to a neuro-surgeon, who wasted no time doing the surgery even at the wee hours of the morning.
He removed a section of the traumatized skull to relieve the closed space and give space to the expanding swelling brain and drained the “hematomas”. The bleeding was controlled and a suction drain was placed routinely. The segment of the skull removed was buried in the abdominal subcutaneous tissue of the patient which would be replaced once the patient recovers. Of course massive antibiotics and medicines to control the swelling and pain were also given.
It took time for the patient to recover and happily he was able to regain consciousness and was able to recognize his visitors. He underwent rehabilitation sessions and eventually he could move all his extremities without difficulty.
The young attending neurosurgeon gave this as an example of uncontrolled alcoholic habit and gave a lengthy lecture on alcoholic intake and its metabolism. The patient’s relatives especially the father who sometimes was with alcoholic breath watching the patient were amazed with the expertness of the young surgeon. Although the patient recovered well, the happiness of the Christmas and New Year holidays were lessened because of the unfortunate incident due to alcohol.**
