What is the diagnosis and management for an 87-year-old male with a history of unwitnessed fall, good baseline functional capacity, and no known comorbidities, presenting with periorbital edema, soft nontender abdomen, and abnormal cranial CT scan findings?

Diagnosis: Severe Traumatic Brain Injury with Multiple Intracranial Hemorrhages

This 87-year-old male has sustained severe traumatic brain injury (TBI) with multiple hemorrhagic lesions requiring immediate neurosurgical consultation, close neurological monitoring, and aggressive management to prevent secondary brain injury and death. 1

Primary Diagnosis

The cranial CT scan reveals a constellation of life-threatening injuries:

• Hemorrhagic contusions in bilateral frontal and temporal lobes 1
• Acute interhemispheric subdural hemorrhage 2
• Minimal subacute subdural hemorrhage in right frontoparietal and left temporoparietal regions 1
• Linear frontal bone fracture extending to vertex with subgaleal hematoma 1
• Chronic right superior parietal lobe infarct with periventricular white matter disease 3
• Atherosclerotic disease of vertebrobasilar and bilateral internal carotid arteries 1

Critical Management Priorities

Immediate Hemodynamic Management

Maintain systolic blood pressure >110 mmHg at all times to prevent secondary brain injury and reduce mortality. 1 The current BP of 130/80 is acceptable, but any episode of hypotension (SBP <90 mmHg) will worsen neurological outcome and markedly increase mortality, particularly with SBP <110 mmHg. 1 Use vasopressors (phenylephrine or norepinephrine) immediately if hypotension develops rather than waiting for fluid resuscitation effects. 1

Neurosurgical Consultation

Immediate neurosurgical evaluation is mandatory given the presence of:

• Acute subdural hemorrhage (interhemispheric location) 1
• Multiple hemorrhagic contusions with mass effect potential 1
• Skull fracture (linear frontal bone fracture) 1

Neurosurgical intervention may be required if subdural thickness exceeds 5 mm with midline shift >5 mm, or if there is clinical deterioration. 1

Risk of Progressive Hemorrhage

This patient is at extremely high risk (approximately 50%) for progressive hemorrhagic injury (PHI) within the first 24 hours. 4 Key risk factors present include:

• Male sex 4
• Advanced age (87 years) 4
• Multiple hemorrhagic lesions, particularly cerebral contusions (51% progression rate) 4
• Slightly prolonged PTT (42.6 vs 34.9) 4

Repeat CT scan should be performed within 6-12 hours or immediately if any neurological deterioration occurs. 4 Progressive hemorrhage occurs in 48.6% of patients scanned within 2 hours of injury and is associated with elevated intracranial pressure. 4

CT Angiography Indication

CT angiography of supra-aortic and intracranial vessels should be performed urgently given multiple risk factors: 1

• Basal skull fracture (frontal bone fracture extending to vertex) 1
• Advanced atherosclerotic disease already noted on initial CT 1
• Focal neurological findings (right retro-orbital ecchymosis, altered mental status) 1

Even without classic risk factors, CT angiography is indicated in severe TBI where neurological examination may be limited. 1

Secondary Diagnoses Requiring Attention

Respiratory Compromise

The patient presents with:

• Bibasal crackles and wheezes 1
• Productive cough with difficulty expectorating 1
• Tachypnea (RR 22) 1
• Recent dry cough and poor appetite 1

Airway control and ventilation monitoring are critical priorities. 1 While not currently requiring intubation (SpO2 98% on room air), close monitoring of respiratory status is essential as hypoxia will worsen brain injury. 1

Cardiac Concerns

• Tachycardia (HR 117) with regular rhythm 1
• Periorbital edema (bilateral) 1
• 60 pack-year smoking history 1

The periorbital edema in this acute setting is likely related to facial trauma and retro-orbital ecchymosis rather than cardiac or endocrine causes. 5

Critical Information That Must Be Elicited

Anticoagulation/Antiplatelet Status

Absolutely critical to determine immediately:

• Any anticoagulant use (warfarin, NOACs, heparin) 1
• Any antiplatelet agents (aspirin, clopidogrel) 1
• Over-the-counter NSAIDs or supplements 1

This information is vital because anticoagulated patients with TBI have significantly higher risk of delayed intracranial hemorrhage and may require reversal agents. 1

Detailed Fall Mechanism

• Exact height of fall 1
• Surface landed on 1
• Any witnessed loss of consciousness (family reports <1 minute unresponsiveness) 1
• Any seizure activity (reportedly none, but witness account critical) 1
• Any alcohol intoxication at time of fall 1

Neurological Baseline Assessment

Document precisely:

• Exact GCS components (currently E4V4M6 = GCS 14) 1
• Pupillary size and reactivity 1
• Motor strength in all extremities 1
• Cranial nerve examination 1
• Any focal deficits 1

The patient is oriented only to name (not place or time), indicating significant cognitive impairment requiring close monitoring. 1

Comorbidity Verification

The history states "no known comorbidities," but this requires verification given:

• Chronic infarct on CT suggests prior cerebrovascular disease 3
• Extensive atherosclerotic disease 1
• Periventricular white matter changes suggesting chronic microvascular disease 1
• Age 87 with 60 pack-year smoking history 1

Specifically inquire about:

• Hypertension (common with microvascular disease) 1
• Diabetes 1
• Prior stroke or TIA 1
• Atrial fibrillation 1
• Chronic kidney disease (Cr 0.9 is relatively low for age) 1

Functional Status Details

• Baseline ambulation (uses assistive device?) 1
• Baseline cognitive function (lives independently? manages medications?) 1
• History of prior falls 1
• Vision or hearing impairment 1

Medication Reconciliation

Despite "no maintenance medications" reported, verify:

• Any recent medication changes 1
• Compliance with prescribed NAC, vitamin C/zinc, Appebon 1
• Any borrowed medications from family 1

Monitoring Requirements

This patient requires:

• Neurosurgical intensive care unit admission 1
• Continuous neurological assessment (hourly GCS minimum) 1
• Repeat CT head within 6-12 hours 4
• Continuous cardiac monitoring (given tachycardia) 1
• Strict blood pressure management (maintain SBP >110 mmHg) 1
• Intracranial pressure monitoring consideration if neurological deterioration occurs 1

The combination of advanced age, multiple hemorrhagic lesions, skull fracture, and pre-existing cerebrovascular disease places this patient at extremely high risk for clinical deterioration and death without aggressive monitoring and intervention. 1, 4