Trauma related or coincidental neurological symptoms?

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17 year old male, no significant medical history, sustained a kick to the
right side of the head/neck 2 months ago (rugby injury). He had a brief loss
of consciousness and transient (3-4hrs) tingling over his right shoulder
with associated severe neck pain and headache. He attended another facility,
where CT neck (non-con) was normal, the paraesthesia resolved and he was
discharged home.

 

2 months later he collapses at school with a brief grand mal seizure, and
has a second on the way to the ED. On arrival he is GCS 15 and examination
is unremarkable. He states he has had diplopia since getting up that
morning, but no other symptoms.

 

CT brain is normal.

 

About thirty minutes after CT he complains of left sided paraesthesiae and
is found to have developed a 4/5 weakness of the left arm and 4/5 weakness
of the left leg. Reflexes are intact. He begins to have predominantly left
sided myoclonic jerking and brief (5-10 second) ?absences, between which he
is vague and post-ictal.

 

CT angio head and neck does not show any abnormality.

 

He is loaded with phenytoin 18mg/kg with no improvement. Clonazepam 1mg IV
terminates the absence episodes and partially abates the myoclonic jerks,
and restores him to GCS 15.

 

The hemiplegia is very slowly progressive.

 

We do not have MRI or interventional angio at our facility (small rural ED)
and he was transferred out after 3 hours of phone wrangling with various
referral centres. Clearly he needs MRI, but I am at a loss as to what the
underlying pathology is.

 

Questions:

 

Is 2 months too long a lag for this to be related to the trauma? I was
suspicious because of the right-left trauma/symptom pattern, and was
initially told that the trauma had been two weeks prior to today's events,
which precipitated the CT angio. I might have hesitated had I known the true
length of time.

 

Neurosurgeons maintained that CT angio is as good a predictor for intimal
tears as formal angio. I have been trained to believe otherwise. What is the
right answer?

 

 

 

 

I get twitched by these cases - I have seen 3 intimal tears resulting in
stroke. 2 patients died. Every time I have had extreme difficulty persuading
anyone to take the presentation seriously until it is too late.

 

 

Fiona Wallace

Director ED

Tasmania

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