Bilateral internuclear ophthalmoplegia following minor head trauma

Internuclear ophthalmoplegia (INO) is characterized by pathognomonic findings on neurological examination. It results from a lesion in the medial longitudinal fasciculus (MLF) and is rarely caused by head trauma. The neuroanatomy of INO is complex and the mechanism by which trauma causes this syndrome is controversial. In the context of trauma, INO occurs frequently in association with other neurological findings and should prompt a thorough investigation and ICU admission. A case of an individual with acute post-traumatic INO is reported and discussed.     

Isolated internuclear ophthalmoplegia from ischemic origin

A 67-year-old male with a medical history of hypertension, diabetes mellitus, and previous ischemic stroke applied to the neurology outpatient clinic due to acute onset double vision which had abruptly started 2 days ago. On neurological examination, the right eye could not adduct whereas nystagmus occurs on the left eye abduction (Figure 1). Upon history interrogation, it was learned that the patient had applied to the emergency department two days ago and cranial diffusion-weighted imaging (DWI) was performed which resulted in normal ranges (Figure 2).     

Left vertebral artery dissection causing bilateral internuclear ophthalmoplegia

A 21-year-old woman presented to the emergency department 1 day after a fall. On the day of presentation, she awoke with horizontal diplopia and posterior neck pain. Based on clinical findings, she was diagnosed with bilateral internuclear ophthalmoplegia. A conventional angiogram identified a left vertebral artery dissection. She was started on anticoagulant therapy, with gradual improvement of her diplopia over several months. Diplopia is frequently seen in the emergency department. Internuclear ophthalmoplegia is a cause of binocular diplopia and is important to recognize because it indicates a brainstem lesion requiring neurologic evaluation.     

Minor head injury

The evaluation and treatment of minor head injuries are reviewed, with particular emphasis on those problems of head injury commonly seen by family physicians. Clinical history, physical examination, and radiologic studies that are of value in diagnosing minor head injuries are highlighted.     

Ophthalmoplegic migraine with alternating unilateral and bilateral internal ophthalmoplegia

We describe a patient with ophthalmoplegic migraine and internal ophthalmoplegia with alternating unilateral involvement and bilateral involvement in whom brain MRI scan showed alternating gadolinium enhancement on the cisternal portion of the oculomotor nerve.     

Headache and head trauma

Headache is a common symptom following head trauma and not related to the degree of trauma. The term post-head-trauma syndrome is used to denote a group of symptoms following head trauma. Dizziness, vertigo, perceptual changes, memory loss, paresthesias, and tinnitus have been reported as well as psychological disturbances. Pathophysiology of headache and other symptoms in the syndrome are believed to relate to vascular and neuronal disturbances. Imaging techniques may provide objective evidence of changes in the brain. Often diagnostic studies do not reveal an abnormality. Treatment consists of diagnosing the type of headache and targeting appropriate therapy. Long-term prognosis is good, the majority of patients recovering after 1 year.     

Nutritional support and head trauma

Nutritional therapy in the head-injured patient is designed to prevent catabolism of lean body cell mass; minimize specific and potential complications; and assist the patient to return to normal nutritional status. Prompt nutritional support accompanied by physical therapy can enhance long term rehabilitation. The critical care nurse plays a major role in this process by providing nutrition along with hemodynamic and neurologic stabilization.     

Minor head injury may not be 'minor'

Trauma to the head and neck can cause minor head injury with a brief alteration in consciousness. Generally, neurologic examination yields normal findings. In some patients, however, postconcussion syndrome marked by headache, dizziness, and neuropsychological deficits (eg, fatigue, cognitive impairment, emotional symptoms) results. This acceleration-deceleration injury with cerebral axonal dysfunction is an organic disease having objective abnormalities that necessitate early neurologic testing and treatment to prevent serious complications.     

Pneumorrhachis following head trauma

Pneumorrhachis or air within the spinal canal is an extremely rare complication of skull fracture. We report a case of pneumorrhachis following head trauma, and review the other two documented cases. Although rare, the finding of air within the spinal cord on lateral cervical radiographs of a trauma patient is important. As these films are done early in the assessment of the trauma patient, this finding provides early indication of skull fracture and should direct the treating team to carefully evaluate for cerebral injury.     

Cervical injury in head trauma

Criteria for excluding cervical spine injury in patients who have sustained blunt head or neck trauma were prospectively studied at four hospitals in the Chicago area. The authors attempted to define a subset of these adult patients who, based on clinical criteria, could reliably be excluded from cervical spine radiography, thus avoiding unnecessary radiation and saving considerable time and money in their evaluation. Patients fell into four groups: (1) patients who were awake, alert, and had no complaint of neck pain or tenderness on physical examination; (2) patients who were awake, alert, but had complaint of neck pain or tenderness on physical examination laterally over the trapezius muscle only; (3) patients who were awake, alert, but had complaint of central neck pain or tenderness on physical examination over the cervical spine or center of the neck; and (4) patients who were not fully awake or alert, were clinically intoxicated, had other painful or distracting injuries, or had focal neurologic findings. Patients in group 4 had significantly more fractures (21/387) when compared with all other patients (7/478). Patients with central neck pain or tenderness (group 3) had significantly more fractures (7/237) than patients without pain or tenderness or with these findings limited to the trapezius area (0/236). It is clear that patients who have altered mental status, abnormal examination findings, distracting injury, or pain or tenderness over the cervical spine must have cervical spine radiographs.(ABSTRACT TRUNCATED AT 250 WORDS)     

Penetrating trauma to the head

Penetrating trauma to the brain is not as common as blunt trauma; however, the incidence is becoming a frequent occurrence in our society. Rapid transport to trauma centers where definitive care can be rendered is essential. Outcome depends on the site of the missile tract, the presenting neurologic status, and the extent of neurologic tissue destruction. Neurologic deterioration occurs rapidly, and outcome results seem to depend on the patient's neurologic status at the time of surgery. CT scanning is the diagnostic procedure of choice and should be performed if the patient's condition is stable (see Fig. 3). Aggressive removal of missile and bone fragments needs to be balanced by the knowledge that it is preferable to leave behind a few hard-to-reach fragments than to increase the patient's neurologic deficit. CT scanning in the postoperative period is very helpful in identifying abscess formation as well as new or recurrent hematomas, edema, and areas of tissue injury not evident at the time of initial scanning. Antibiotic therapy should be initiated preoperatively. Control of elevated ICP plays a significant role in decreasing mortality and morbidity. Judicious debridement of injured brain combined with medical management of increased ICP will maximize the quality of recovery and increase survivability. Although great strides have been made in reducing mortality and morbidity for trauma patients, the sad issue is that the majority of traumas are preventable. Until society is willing to understand that it needs to make firearm safety a priority, there will always be patients to care for who have sustained a penetrating injury.     

Radiologic assessment of head trauma

We have endeavored through the use of an actual clinical scenario to emphasize that reliance on skull radiographs for assessing the acutely traumatized patient is both unwarranted and unwise. Not only are these films fundamentally useless, but they have the potential to lull us into a false sense of security. A negative skull examination cannot and does not imply that the brain substance is normal. If there is a legitimate indication for any examination, that examination should be computed tomography. To reinforce this notion, we offer for your consideration the following algorithm for the management of head trauma (Table 1: see text).