LETTER TO EDITOR Year : 2023  |  Volume : 71  |  Issue : 5  |  Page : 1048-1049

Quadriplegia following Isolated Traumatic Brain Injury: A Rare Presentation of a Common Event

Kent K Reji, Ananth P Abraham, Mathew Joseph, Pavithra Mannam, Ranjith K Moorthy
Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India

Date of Submission10-May-2023Date of Decision02-Aug-2023Date of Acceptance28-Aug-2023Date of Web Publication18-Oct-2023

Correspondence Address:
Ranjith K Moorthy
Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0028-3886.388048

How to cite this article:
Reji KK, Abraham AP, Joseph M, Mannam P, Moorthy RK. Quadriplegia following Isolated Traumatic Brain Injury: A Rare Presentation of a Common Event. Neurol India 2023;71:1048-9
How to cite this URL:
Reji KK, Abraham AP, Joseph M, Mannam P, Moorthy RK. Quadriplegia following Isolated Traumatic Brain Injury: A Rare Presentation of a Common Event. Neurol India [serial online] 2023 [cited 2023 Oct 19];71:1048-9. Available from: https://www.neurologyindia.com/text.asp?2023/71/5/1048/388048

Sir,

Quadriplegia is an uncommon presentation following traumatic brain injury (TBI) without cervical cord or brainstem injury. We report the case of a 30-year-old male who was admitted at another center with a Glasgow Coma Scale (GCS) score of 10/15 and quadriplegia following a motor vehicle accident. Computed tomography (CT) brain done immediately post trauma revealed bilateral posterior and left inferior contusions and intraventricular hemorrhage, without brainstem involvement [Figure 1]a and [Figure 1]b. Magnetic resonance imaging (MRI) of the cervical spine with T2-weighted screening of the whole spine ruled out any cord injury [Figure 1]b. His GCS score gradually improved to 15/15 over the next 2 weeks. CT scan done 3 weeks post trauma to monitor the status of contusions as he had persistent quadriplegia showed resolution of the frontal contusions [Figure 1]c. Over the next 6 months, he had gradual improvement of power in all four limbs. He presented to our hospital 15 months following trauma with persistent quadriparesis, requiring support to walk. On examination, both his lower limbs were spastic, left more than right. He had residual left hand grip weakness and grade 4/5 power in the left lower limb, except for ankle dorsiflexion, which had grade 2/5 power. Sensory examination was normal. Deep tendon reflexes were exaggerated bilaterally with spontaneous patellar and ankle clonus on the left. MRI brain done at the time of presentation to our hospital showed gliosis with volume loss in bilateral precentral gyri. Diffusion tensor imaging (DTI) showed interruption of the corticospinal fibers in the region of the contusions [Figure 2]a, [Figure 2]b, [Figure 2]c.

Figure 1: (a) Axial CT brain done following trauma showing bilateral posterior frontal hemorrhagic contusions; (b) sagittal T2W MRI of cervical spine showing no cervical cord or brainstem injury and no extrinsic spinal cord compression; (c) axial CT brain done 3 weeks post trauma showing resolving contusions in bilateral posterior frontal regions

Click here to view

Figure 2: (a) Axial MRI brain done 15 months post trauma showing gliosis with volume loss in both the precentral gyri, indicated by the arrows; (b and c) DTI showing interruption of the corticospinal tract fibers in the region of the contusions, indicated by the arrows

Click here to view

A review of the literature identified three other cases of supratentorial TBI causing quadriplegia/quadriparesis without cervical cord or brainstem injury. The causes for quadriparesis in these patients were mild hemorrhage in both the frontal lobes anteriorly with DTI-demonstrated injured corticofugal tracts from the supplementary motor area,[1] midline depressed skull fracture compressing the superior sagittal sinus causing bilateral frontoparietal venous infarction,[2] and supratentorial gunshot injury with the bullet tract passing through left cerebellar, temporal, and posterior frontal regions into the right posterior frontal region.[3] In our patient, although there was resolution of the contusions, interruption of the corticospinal tracts in this region resulted in persistent quadriparesis.

In conclusion, traumatic bilateral posterior frontal contusions and disruption of the corticospinal tracts can lead to quadriplegia as an uncommon consequence of TBI without synchronous brainstem or spinal cord involvement. When evaluating patients presenting with quadriparesis following trauma, neurosurgeons and emergency room physicians should consider this possibility.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Jang SH, Kim SH, Seo JP. Recovery of an injured corticofugal tract from the supplementary motor area in a patient with traumatic brain injury. Medicine (Baltimore) 2018;97:e9063.  
    2.Mathew MJ, Pruthi N, Savardekar AR, Tiwari S, Rao MB. Midline depressed skull fracture presenting with quadriplegia: A rare phenomenon. Surg Neurol Int 2017;8:39.  
  [Full text]  3.Horan J, Tromp S, Mankahla N. Transient incomplete locked-in syndrome secondary to supratentorial gunshot wound. World Neurosurg 2019;126:560-3.  
    
  [Figure 1], [Figure 2]