In the context of a motor vehicle collision, what should be primarily suspected if a patient presents with unequal pupils and a contusion above the eye?

In the scenario described, the primary suspicion should be cerebral herniation. This condition is a serious consequence of increased intracranial pressure, which can occur following a traumatic brain injury such as those sustained in a motor vehicle collision.

Unequal pupils, or anisocoria, often indicate a neurological issue, particularly when associated with a contusion above the eye. This could indicate swelling or bleeding in the brain that is leading to increased pressure, which in turn can cause parts of the brain to shift, or herniate, through openings in the skull. The presence of a contusion suggests there may be impact-related damage that could further exacerbate intracranial pressure.

Therefore, while ocular trauma might be present, the combination of unequal pupils and a contusion is much more indicative of a central nervous system problem such as cerebral herniation, necessitating immediate medical evaluation and intervention.