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... However, paraplegia is rarely caused by cerebral contusions. [4] We experienced a case of acute pure motor paralysis of both legs caused by cerebral contusions in the bilateral precentral gyri. ...
... We know of only one previous case report describing paraplegia [4] and six cases of monoplegia [1] caused by cerebral contusion. The former case also exhibited severe paraplegia; however, the patient fully recovered after 2 weeks possibly because the FLAIR MRI lesion was smaller than the lesion in our patient. ...
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Background Paraplegia is mainly caused by spinal cord disease and rarely occurs due to head trauma. In this report, we describe a case of paraplegia caused by cerebral contusions in the bilateral precentral gyri. Case Description A 72-year-old man was admitted to our hospital with mildly impaired consciousness and severe pure motor paralysis in both legs. He was healthy until the morning of the day, but his wife found him injured in front of his house upon returning home. He had a subcutaneous hematoma in his occipital region, and seemed to have slipped by accident. Computed tomography of the brain and magnetic resonance imaging (MRI) of his spinal cord revealed no apparent cause of the paraplegia, although an MRI of his brain clearly revealed cerebral contusions in the bilateral precentral gyri. The cerebral contusion was diagnosed as the cause of pure motor paralysis of lower extremities. He received rehabilitation, and manual muscle testing of his legs revealed improvements. In the subacute phase, the precentral gyrus lesion disappeared on MRI. Conclusion We must emphasize that cerebral contusion can be a differential diagnosis for paraplegia. In the acute phase, fluid-attenuated inversion recovery (FLAIR) MRI coronal and sagittal images are useful for identifying precentral gyri contusions. Paraplegia caused by a cerebral contusion may be misdiagnosed as a spinal concussion due to the disappearance of the precentral gyrus lesion on FLAIR MRI in the subacute phase.
... Lower limb weakness as one of many clinical features of VEDH can be explained by direct pressure of hematoma on the motor cortex representing the leg area. Gauge [7] Matsumura [8] and Zeller [9] articles are the only three that describe paraplegia revealing cerebral contusions found on MRI as in our case. The literature offers only a limited number of studies devoted to studying motor recovery trends [10], [11]. ...
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Paraplegia is rarely reported as a consequence of isolated blunt head trauma. We report a case of a 28-years old patient admitted to our department after a traumatic brain injury. On admission he presented a paraparesis without sensory disturbance in both legs. Spine CT (Computed Tomography) scan and MRI (Magnetic Resonance Imaging) scan of the spine were both normal. Brain CT scan and MRI showed bilateral precentral gyri contusion. Early rehabilitation was key to quick motor recovery. Our case highlights traumatic brain injury as a differential diagnosis of paraplegia.
... The most common etiologies reported are bilateral frontal lobe infarctions secondary to ACA stroke 1-3 or traumatic brain injuries. 4,5 Other causes like multiple sclerosis 6 and aneurysmal subarachnoid hemorrhage with hydrocephalus 7 are extremely rare, but have been reported in the literature. ...
Article
Objective: To report an atypical case of acute onset sensorimotor paraparesis secondary to bilateral cerebral stroke. Background: Acute onset paraparesis or paraplegia is usually secondary to a spinal cord disease. Central or cerebral causes of paraparesis are rare and include parasagittal and bilateral precentral lesions. Design/Methods: Case report and literature review. Results: A 65-year-old man presented with acute onset weakness of both lower limbs, associated with pins and needle sensation. On examination, he was found to have paraparesis (grade 2/5, both legs) and an asymmetric sensory loss in both legs and thighs. Spinal magnetic resonance imaging ruled out any compressive or noncompressive etiology. Magnetic resonance imaging of the brain showed an acute infarction in the bilateral cerebral hemisphere in both the pre- and postcentral gyrus. An angiogram of the brain revealed an aplastic right ACA-A1 with left ACA-A1 feeding bilateral A2. There was distal left ACA-A1 stenosis seen, the probable cause of bilateral stroke in this patient. The patient was treated conservatively and showed symptomatic improvement during the course of stay at the hospital. Conclusion: This case of acute paraparesis secondary to bilateral cerebral infarction demonstrates the need to always look for a cerebral cause. In patients with cerebral infarction, who present early to a hospital, it may provide a window for thrombolytic or endovascular therapy.
... With a diagnosis of installed acute paraplegia, whatever the underlying cause, the prognosis will be reserved, if not infaust. The neurosurgical and orthopedic consultancies are among the first steps to be undertaken, even when trauma is not present in the history, since it might have been minor, trivial, neglected, or not involving directly the vertebral column and its structures, thus leaving little space to suspicion [10,11] . Once a traumatic event is completely ruled out, and appropriate imaging studies have documented its absence; the role of the neurologist and eventually of the infectious disease specialist will be of primary importance [12,13] . ...
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Acute flaccid paraplegia is a clinical occurrence with extreme importance, due to the dramatic presentation, the severity of the underlying disorder, and the generally poor prognosis that follows such a condition. Among etiological factors, the traumatic events are of particular interest, with the clinical treating dealing with a severely ill patient, following fall from height, motor vehicle collisions, and direct shocks applied over the vertebral column. The non-traumatic list is more numerous; however the severity of the acute paraplegia is not necessarily of a lesser degree. Viral infections, autoimmune disorders, and ischemic events involving feeding spinal arteries have been imputed. However, chemical and medications injected during procedures or accidentally intrathecal administration can produce acute flaccid paraplegia. A careful neurological assessment and complete electrophysiological and imaging studies must follow. In spite of the poor prognosis, different therapeutic options have been proposed and applied. Neurosurgical and orthopedic interventions are often necessary when trauma is present, with high dose glucocorticoids treatment preceding the intervention, in a hope to decrease edema-related compression over the spinal cord. Immunoglobulins and plasmapheresis are logical and helpful options when a polyradiculoneuritis produces such a clinical picture. The role of decompression, as neurosurgical exclusivity, has been considered as well.
Article
A 57-year-old male sustained a blunt head injury after discharging a mortar firework off the vertex of his head. Physical examination revealed a stellate scalp lesion and pure bilateral leg paraplegia. Initial spinal computed tomography and magnetic resonance imaging were negative for pathology. Initial head computed tomography revealed open, nondisplaced, frontal, and parietal skull fractures with underlying subdural and subarachnoid hemorrhage. Follow-up magnetic resonance imaging one week later showed bilateral precentral gyri frontal lobe contusions involving the lower extremity motor cortices and subcortical white matter extending anteriorly into the region of the supplementary motor areas. The patient's complete paraplegia informed the subsequent hospital rehabilitation. However, motor recovery was more rapid than anticipated, with the patient regaining ambulatory function before inpatient rehabilitation discharge after 27 days of hospitalization. He continued to have issues with spasticity after discharge. We discuss the current literature surrounding paraplegia secondary to head trauma and the recovery that follows. Firework misuse is a known cause of head injury but has not been recorded as a cause of isolated bilateral paraplegia. Isolated precentral gyri contusion must be considered in patients presenting with paraplegia following trauma to the vertex of the head and normal spinal imaging. We show the importance of repeat imaging to follow the evolving nature of traumatic head injuries presenting with paraplegia. We also illustrate the variability in rehabilitation planning and the need for adjustment in rehabilitation planning for paraplegic patients following head trauma.
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Cranial CT has been the most extended evaluation means for patients suffering head trauma. However, it has low sensitivity in the identification of diffuse axonal injury and posterior fossa lesions. Cranial MR is a potentially more sensitive test but difficult to perform in these patients, a fact that has hampered its generalised use. To compare the identification capability of traumatic intracranial lesions by both diagnostic tests in patients with moderate and severe head injury and to determine which radiological characteristics are associated with the presence of diffuse injury in MR and their clinical severity. 100 patients suffering moderate or severe head injury to whom a MR had been performed in the first 30 days after trauma were included. All clinical variables related to prognosis were registered, as well as the data from the initial CT following Marshall et al., classification. The MR was blindly evaluated by two neuroradiologists that were not aware of the initial CT results or the clinical situation of the patient. All lesions were registered as well as the classification following the classification of lesions related to DAI described by Adams et al. CT and MR findings were compared evaluating the sensitivities of each test. Factors related to the presence of diffuse injury in MR were studied by univariate analysis using chi2 test and simple correlations. MR is more sensitive than CT for lesions in cerebral white matter, corpus callosum and brainstem. It also detects a greater number of cerebral contussions. The presence of diffuse axonal injury depends on the mechanism of the trauma, being more frequent in higher energy trauma, specially in traffic accidents. Among the radiological characteristics associated to DAI the most clearly related is intraventricular haemorrhage. The presence of a deeper injury and a higher score in the scales of Adams is associated with a lower score in the GCS and motor GCS, and so with a worse level of consciousness and bigger severity of injury, confirming Ommaya's model.
Article
THE INTERHEMISPHERIC SUBDURAL hematoma is a relatively uncommon type of subdural hematoma, especially seen in patients with blood clotting disturbances. When its mass becomes sufficiently large, specific neurological abnormalities such as hemiparesis and signs of the falx syndrome are seen. Treatment can consist of conservative observation or craniotomy and is dictated by the clinical course. Conservative management is the treatment of choice for patients without disturbances of consciousness and for patients with stable clinical conditions. Surgical treatment is necessary in patients with progressive deterioration. Three case reports are presented, as well as a review of 64 cases described in the literature. The salient aspects of this clinical entity are discussed.
Article
Interhemispheric subdural hematoma (ISDH), although not infrequent in children, has been rarely encountered in adults. Spread of CT, ISDH has been reported sporadically, and so far more than 40 cases have been reported. But bilateral ISDH is an extremely rare lesion, with only 5 cases reported in the literature. We report a sixth case of bilateral ISDH in adults. A 68-year-old woman was admitted because of headache and vomiting. Two days before admission she had fallen, striking her occiput, and had lost consciousness for a few minutes. Neurological examination on admission revealed hyperreflexia of her extremities, especially in her left leg. However, motor weakness was not recognized. There was no fracture visible on the plain X ray films of the skull. Axial CT scan demonstrated a high density lesion along the falx and its extension down over the tentorium. Coronal CT scan also demonstrated a convexo-convex high density lesion beside the falx, and its extension onto the tentorium. Cerebral angiogram showed lateral displacement of the callosomarginal artery, and an avascular area beside the falx and onto the tentorium. After admission she was managed conservatively, but on the 14th day after head trauma, paraparesis and left arm paresis were recognized. This condition deteriorated and she developed an inability to stand. On the 19th day parasagittal craniotomy and evacuation of the hematoma were performed. Her postoperative course was uneventful and she was discharged with no neurological deficits.
Article
"Gliding" contusions, ie, hemorrhagic lesions in the parasagittal white matter, were analyzed in 434 fatal nonmissile head injuries in humans. It is concluded that gliding contusions are a type of diffuse brain damage occurring at the moment of injury. Gliding contusions are significantly associated with road-traffic accidents, with the absence of a skull fracture or a "lucid interval," and with the presence of diffuse axonal injury and deep hemispheric traumatic hematomas.
Article
Severe head injury or diffuse axonal injury is frequently associated with spastic hemiplegia/paraplegia. However, the causative lesion has not been well elucidated. Especially, the relationship between the gliding contusion and spastic hemiplegia has not been inferred yet. We have analyzed 6 brain concussion cases and 19 cases of diffuse axonal injury. None of the concussion cases experienced hemiplegia in their courses. Among the 19 cases, 10 were left with persistent and disabling hemiplegia/quadriplegia, whereas 5 showed persistent but mild hemiplegia. Among the 10 cases, one was incapacitated by a brainstem hemorrhage. The remaining 9 cases exhibited, in the parasagittal white matter, small hemorrhagic spots in the acute phase CT, low-density areas in the chronic phase CT, and/or T2 high and T1 low signal lesions in the MRI. In 8 cases, the lesion was in accord with the hemiplegic side, but in one case the low density area was on the ipsilateral side. Two of the 3 cases showing quadriplegia exhibited bilateral parasagittal lesions. None of the 5 mild hemiplegia cases and 10 nonhemiplegia cases showed such abnormality. Superficial brain contusions were found in 17 cases altogether, but they were not at all correlated with the occurrence of hemiplegia. Thus, it was concluded that parasagittal white matter shearing injury or so called gliding contusion could be the manifestation of injury to the corticospinal tract in the corona radiata.
Article
Neuromotor impairment is a common sequela of severe traumatic brain injury (TBI) but has been understudied relative to neurocognitive outcomes. This multicenter cohort study describes the longitudinal course of neurological examination-based motor abnormalities after severe TBI. Subjects were enrolled from the four lead Department of Veterans Affairs and Defense and Veterans Brain Injury Center sites. The study cohort consisted of 102 consecutive patients (active duty, veteran, or military dependent) with severe TBI who consented during acute rehabilitation for data collection and completed all follow-up evaluations. Paresis, ataxia, and postural instability measures showed a pattern of improvement over time, with the greatest improvement occurring between the inpatient (baseline) and 6-month follow-up assessments. Involuntary movement disorders were rare at all time points. Two years following acute rehabilitation, more than one-third of subjects continued to display a neuromotor abnormality on basic neurological examination. Persistence of tandem gait abnormality was particularly common.
There are bilateral parasagittal contusions (white arrows) and a right frontal lobe contusion (black arrow)
  • Axial
Axial T2 weighted MRI. There are bilateral parasagittal contusions (white arrows) and a right frontal lobe contusion (black arrow).
There are bilateral parasagittal contusions (black arrows)
  • Coronal
  • Mri
Coronal FLAIR MRI. There are bilateral parasagittal contusions (black arrows).
Interhemispheric subdural hematoma in adults: case reports and a review of the literature
  • Bartels