Which is the most likely injury in the following patient of the patient’s presentation? A 27-year-old woman is brought to the emergency department with an intense headache, left-sided weakness, and blurred vision that began after she was ejected from her vehicle in a motor vehicle accident. Paramedics report that she was ambulatory and cooperative at the scene of the crash but was unable to tell them what had happened. The patient had an episode of projectile vomiting while in the ambulance, and her mental status has deteriorated since then. A CT scan of the head shows extra-axial fluid collection on the right side and a temporal bone fracture on the same side.

Middle meningeal artery

The correct answer is B. Such a presentation is consistent with a significant mechanism of injury such as ejection from a vehicle at a high rate of speed. The patient was able to talk with the police at the scene of the accident but was unable to recall how the accident occurred, which likely demonstrates an initial loss of consciousness followed by normal mentation and subsequent deterioration of consciousness. This lucid interval is classically seen with an epidural hematoma. An urgent neurosurgical consult is indicated for immediate evacuation of the clot to prevent herniation Answer A is incorrect. Injury to the inferior cerebral veins would result in subarachnoid bleeding. Bleeding from the inferior cerebral veins does not result from a fracture of the temporal bone and is unlikely to cause the rapid deterioration evident in this case because it has a slower rate of bleeding. However, subarachnoid bleeding is frequently seen in the setting of trauma and could be an associated finding with the epidural hematoma Answer C is incorrect. The posterior ethmoidal artery supplies the anterior superior nose and nasal septum with blood; its tearing would not result in an epidural hematoma secondary to a temporal bone fracture Answer D is incorrect. Injury to the sigmoid sinus would result in a subarachnoid hemorrhage. Thus such a finding is inconsistent with an injury to the temporal bone, the lucid interval in this patients history, and the CT findings Answer E is incorrect. Injury to the superior sagittal sinus would also result in a subarachnoid hemorrhage, but this is a far less likely cause of this patients deterioration than an epidural hematoma.