Which sign is most indicative of an expanding subdural hematoma with brain shift?

Which sign is most indicative of an expanding subdural hematoma with brain shift?

• A. Decreased LOC, ipsilateral pupil dilation, contralateral motor deficit
• B. Seizures, bilaterally pinpoint pupils, slow, irregular respirations
• C. Agitation, scleral hemorrhages, midpoint, nonreactive pupils
• D. Stiff neck, severe headache, projectile vomiting

Answer: (A)

Expanding subdural hematoma creates mass effect that pushes brain tissue across rigid compartments, leading to herniation. When the temporal lobe herniates (uncal herniation), the oculomotor nerve on the same side is compressed, producing ipsilateral pupil dilation that may be sluggish or nondilated if severe. As the herniation progresses, the corticospinal tract nearby can be compressed, causing weakness on the opposite side of the body. The overall level of consciousness drops because of rising intracranial pressure and brainstem involvement. This combination—decreased LOC, ipsilateral dilated pupil, and contralateral motor deficit—best fits the pattern of expanding mass with brain shift. Other patterns described in the distractors align more with different conditions (such as brainstem or metabolic issues, meningitis, or non-specific intracranial pressure signs) and don’t reflect the classic uncal herniation signs seen with a unilateral expanding subdural hematoma.

Expanding subdural hematoma creates mass effect that pushes brain tissue across rigid compartments, leading to herniation. When the temporal lobe herniates (uncal herniation), the oculomotor nerve on the same side is compressed, producing ipsilateral pupil dilation that may be sluggish or nondilated if severe. As the herniation progresses, the corticospinal tract nearby can be compressed, causing weakness on the opposite side of the body. The overall level of consciousness drops because of rising intracranial pressure and brainstem involvement. This combination—decreased LOC, ipsilateral dilated pupil, and contralateral motor deficit—best fits the pattern of expanding mass with brain shift.

Other patterns described in the distractors align more with different conditions (such as brainstem or metabolic issues, meningitis, or non-specific intracranial pressure signs) and don’t reflect the classic uncal herniation signs seen with a unilateral expanding subdural hematoma.