Case History #56

Date of Admission: 10-16-1975

HISTORY OF PRESENT ILLNESS:

This 31-year-old right-handed white female bicycle racer was involved in a bicycle accident.  She was thrown off her bicycle, fractured her left forearm, and struck the right side of her head against the pavement.  She was not wearing a helmet.  She was dazed, but did not lose consciousness, and was brought to the emergency department (ED) for treatment of her left forearm fracture.  Initially, the patient was awake, alert, and oriented to person, place, and time.  Her neurological examination was normal, with intact cranial nerve, reflex, and motor examinations.
 
While having her left forearm fracture treated by an orthopedic surgeon in the ED, she became progressively less responsive, developed a dilated and fixed right pupil, and then developed right-sided weakness involving both the upper and lower limbs.  Neurological consultation was requested at this time.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  The patient was lethargic and opened her eyes only to pain.  Once she was aroused, she produced only incomprehensible moaning and was somewhat combative.  Her respiratory pattern was normal (eupneic).

Cranial Nerves:  There was ptosis of the right eyelid.  The right pupil was 8 mm in diameter and poorly reactive.  The left pupil was 4 mm in diameter and reacted to light normally.  External ocular movements were intact in the left eye.  Exotropia of the right eye was present on primary gaze, and there was absence of adduction, elevation, and depression of the right eye with oculocephalic reflex testing.  With supraorbital pressure, her grimace revealed weakness of the lower facial muscles on the right side, but eyelid closure was strong and symmetric bilaterally.  Other cranial nerve functions were intact (including corneal and gag reflexes).
 
Motor System:  There were no areas of focal muscular atrophy or fasciculations.  Muscle tone was normal in the left upper and lower limbs.  In the right upper and lower limbs, there was an increase in muscle tone.  Muscle power was normal on the left, with appropriate localization to painful stimuli with the left upper limb.  Marked weakness was present in the right upper and lower limbs, with only minimal movement (withdrawal) on that side to painful stimuli.
 
Reflexes:  Deep tendon reflexes were normal (2/4) on the left side and increased (4/4) on the right side.  Sustained ankle clonus was present on the right.  Plantar reflexes were flexor on the left and extensor on the right.

Sensory System:  The patient responded to painful stimuli in all 4 limbs, as mentioned above.  Other sensory testing could not be performed due to her diminished level of consciousness. 

Cerebellar Function:  Not tested.

Gait and Stance:  Not tested.

Questions

1.  What aspects of this patient’s head injury history are concerning?
 
2.  What was her Glasgow Coma Scale (GCS) upon arrival to the ED?

3.  What was her Glasgow Coma Scale (GCS) at the time of neurological evaluation?

4.  Is the weakness on the right side of the face of the upper motor neuron or lower motor neuron type? 

5.  Is the weakness on the right side of the body of the upper motor neuron or lower motor neuron type? 

6.  Indicate the specific structures involved by the pathologic process to produce each of the signs and symptoms experienced by this patient. 

7.  Indicate the level of the neurologic lesion in this case and the pathophysiological process producing the above signs and symptoms.

8.  What is the term describing the patient’s level of consciousness between the initial head injury and her subsequent deterioration in the ED?  What pathologic process is often associated with this phenomenon?  What is the vascular source for this lesion? 

9.  Explain why the eye findings and the weakness of the limbs are on the same side.  What is the term for this phenomenon? 
 
10.  What diagnostic procedure(s) would you undertake at this point?