Clinical Challenge: Blunt Trauma to Head and Neck

History and Present Illness

A man in his mid-20s comes to the emergency department (ED) with a 2-week history of right frontal headache. The patient reports crashing into someone at a skate park. He fell and hit his head on the ground (he was not wearing a helmet) and then the other person landed on top of him “nailing him in the neck” with an elbow. He has an ongoing right frontal headache that he reports is getting worse and no real improvement in his neck pain. He denies any weakness, numbness, fever, vomiting, change in vision, or other complaints.

Vital Signs and Physical Examination

The patient’s vital signs are normal. Physical examination is otherwise normal except for tenderness to the right head and neck. The patient’s pupils appear slightly asymmetric: the right pupil looks normal and the left looks larger. Initial diagnostic testing, including computed tomography (CT) of the head is normal. Imaging of the patient’s neck is shown in the Figure.