False-positive presentation of Battle's sign during hepatic encephalopathy

Battle's sign is a classical clinical sign that has long been held to be synonymous with fracture of the basal skull. As such the presence of Battle's sign is a strong indicator that a basal skull fracture could be present in the head injured patient, as exemplified by its inclusion as a major risk factor in scoring systems designed to assess the likelihood of basal skull fracture.

We present a case that describes the occurrence of this classic clinical sign in an unlikely setting and, for the first time since it was described more than 120 years ago, re-examine the pathologic basis for its appearance.