Acute onset progressive hemiparesis in a case of head and neck injury
A 22-year-old male patient presented two hours after a high-velocity road traffic accident (the vehicle collided with a lorry while he was driving the vehicle). There was history of transient loss of consciousness, oral and nasal bleed with multiple episodes of vomiting. There was no history of seizures. His general and systemic examination was unremarkable. Neurologically Glasgow coma scale was 14/15 (E3, V5, M6-eye opening to call, obeying command and oriented). He was moving all four limbs equally; pupils were bilaterally equal and reacting to light. Local examination revealed multiple lacerations over right side of the neck, massive bruising and swelling over right side of the neck, fracture mandible and massive swelling involving right upper limb []. His blood investigations were normal. X-ray chest was normal, x-ray right shoulder showed comminuted fracture of upper end of right humerus []. Initial computerized tomography scan (CT scan) of the brain showed anterior cranial fossa fractures and pneumocephalus []. CT scan of neck showed massive swelling involving right side of the neck and mandible fracture with normal vertebral column []. The patient was planned to be managed conservatively. Neck wounds were thoroughly cleaned and sutured. About six hours after the injury the patient developed progressively increasing weakness of left upper and lower limbs and became drowsier (GCS-E3, V4, M5). In view of new onset of neurological deficits and initial early normal CT scan a possibility of expanding intracranial hematoma was suspected. As the patient also had significant neck injury a differential diagnosis of blunt carotid injury with thrombo-embolic event was also suspected. Urgent repeat magnetic resonance imaging (MRI) showed evidence of the infarct in the right middle cerebral artery territory []. However, while the patient was recovering he suddenly developed hypotension and tachypnea and features suggestive of pulmonary embolism. In spite of aggressive management he did not recover and succumbed to it.