Transient Paraplegia in a Patient with Bilateral Posterior Frontal Contusions and Traumatic Thoracic Aortic Dissection

Abstract

Background: In the setting of multi-system traumas, the etiology and pathophysiology of neurologic injuries can be difficult to identify. Methods: A unique case of a pedestrian struck by a motor vehicle that presented with acute paraplegia after an endovascular stent placement for a traumatic thoracic aorta dissection. The patient had no significant motor function in the lower extremities, but full preservation of all sensory modalities. Initial admission computed tomography (CT) imaging was negative for intracranial trauma, but noted an acute cranial fracture; no spinal trauma was identified. Results: The patient had a lumbar drain placed to maximize spinal perfusion pressures and was immediately evaluated with magnetic resonance imaging (MRI) of the neural axis. Acute bilateral posterior frontal contusions were identified on brain imaging, which were not present on preprocedural CT head. No spinal cord injury or ischemia was seen on spinal imaging. The patient recovered and regained use of his lower extremities following a short rehab stay. Conclusion: In the setting of multi-system trauma, a high level of suspicion should exist for alternative etiologies of neurologic injuries. Thorough neurologic examinations and imaging assessments of the nervous system should be conducted to avoid misdiagnosis and improper management of occult injuries. This is the first reported case of acute paraplegia due to vertex trauma which may be a rare mechanism of injury and/or under-recognized. INTRODUCTION Trauma is the leading cause of mortality for patients less than forty years of agecheck. Further multi-system trauma has been associated with increased mortality, especially when it involves vascular injuries.4 Therefore, prompt diagnosis and management is crucial and increases the probability of survival and a favorable outcome. Acute paraplegia is an associated complication of traumatic thoracic spinal cord and aortic injuries. Further, it can also result from open and endovascular repair of this injury due to decreased perfusion to the cord and ensuing ischemia and infarction.4,5,14 Few cases of acute lower extremity monoparesis have been reported from traumatic injury to the frontal lobe.2,10 We present the first case of acute paraplegia resulting from bilateral para-sagittal frontal contusions in a patient with concomitant thoracic aorta injury. CASE REPORT A 31 year-old male pedestrian was struck by a high velocity vehicle and thrown approximately seventy feet from the initial site of impact. The patient was intubated at the scene and transported to an outside hospital. At the time he was following commands and moving all extremities. CT of the brain revealed a bicoronal scalp laceration and underlying skull fracture with no intracranial hemorrhage or contusion; CT of the chest, abdomen and pelvis revealed an aortic isthmus tear, bilateral pneumo-hemothoraxes and pulmonary contusions, multiple ribs and right clavicle fractures, liver laceration with intraperitoneal hemorrhage. Upon transfer to our facility, the patient remained stable. He would open his eyes to voice, pupils were equal round and reactive, he would follow simple commands in all four extremities with some efforts against gravity. The patient was urgently taken to the operating room for endoscopic repair of the thoracic aortic tear. The procedure was completed without complication, with placement of a Gore TAG 26mm x 10cm endoprosthesis. The patient remained intubated and neurologic Figure 1 Magnetic resonance imaging of the brain demonstrating bilateral parasagittal contusions. (A) T2-weighted sequence, axial cut; (B) T2-weighted sequence, coronal cut. A B