Endgames Picture Quiz

Focal neurological deficits after trauma

BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g4520 (Published 14 July 2014) Cite this as: BMJ 2014;349:g4520
  1. R Nandhagopal, senior consultant neurologist
  1. 1Department of Neurology, College of Medicine and Health Sciences, PO Box 35, SQU, Al-Khod, Zip 123, Muscat, Oman
  1. Correspondence to: R Nandhagopal rnandagopal{at}yahoo.com

A 38 year old woman developed headache (without neck pain) and weakness of her left upper and lower limbs after a concussive head trauma with scalp lacerations in a motor vehicle crash. On examination (more than 4.5 hours after the trauma), she was conscious, alert, and in cardiac sinus rhythm. There was no carotid bruit. She scored 7 points on the National Institute of Health stroke scale (maximum possible score 42). Positive neurological findings included mild blunting of the left nasolabial fold; left hemiparesis, with extensor muscles being weaker (3/5) than flexors in the left upper limb (4+/5), flexors being weaker (4 to 4+/5) than extensors in the left lower limb (4+ to 5/5), and distal more than proximal weakness in the left arm and leg. She also had brisk deep tendon reflexes in the limbs on the left side; a left extensor plantar response; left hemianopia; and left hemisensory (including the face) hypoaesthesia for pain, cold, and touch. Eyelid ptosis or paresis of extraocular movements were not present, and pupillary size and light reaction were normal.

She had no history of hypertension, diabetes, cigarette smoking, polyarthritis, stroke, or cardiac disease. Plain computed tomography of the brain did not detect acute parenchymal or extraparenchymal injury. In view of her persistent left hemiparesis, she underwent cranial magnetic resonance imaging (fig 1A-E) and computed tomographic cerebral angiography (fig 1F) two days after the trauma.

Fig 1 (A-E) Cranial magnetic resonance imaging. (A) Diffusion weighted image. (B) Corresponding apparent diffusion coefficient map. (C) Axial fluid attenuated inversion recovery sequence. (D) Susceptibility weighted image. (E) Fluid attenuated inversion recovery image of the skull base with fat suppression. (F) Computed tomographic angiogram of the cervical portion of the carotid and vertebral arteries

Questions

  • 1. What abnormalities are shown in the figure?

  • 2. What was the …

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