A Head-Scratching Head-to-Head Case

Abstract

HISTORY: A 16-year-old high school defensive linebacker with a history of two prior concussions sustained a head injury with impact on the left side of his head. He immediately fell to the ground and with loss of consciousness for 1-2 seconds. Once he awoke, he was able to stand and be assisted off the field. He noted bilateral upper extremity numbness and weakness along with right-sided facial “heaviness.” He was assessed on the sideline and did not show signs of focal deficits but was symptomatic after vestibular testing and was held from playing the rest of the game. Approximately one hour after the injury, he became increasingly fatigued with return of his bilateral upper extremity numbness and right facial heaviness. He was transported to the emergency department at this point. PHYSICAL EXAMINATION: Sideline exam at time of injury revealed symmetric and normal cranial nerve exam, no C-spine tenderness, and symmetric upper and lower extremity strength and sensation. He exhibited dizziness with VOMS testing but no irregular eye movements. In the ED, he had right-sided facial droop, decreased sensation in the right cheek and jaw, and an otherwise normal exam. DIFFERENTIAL DIAGNOSIS: 1. Intracranial hemorrhage 2. Cranial nerve palsy 3. Cervical neuropraxia 4. Concussion TEST AND RESULTS: CBC, CMP, and coagulation tests all normal. CT head and neck: normal MRI brain and neck: normal. MRA brain and neck: irregular petrous segment of right internal carotid artery lumen with concern for stenosis, possibly due to artifact versus nonocclusive arterial dissection, CTA recommended. CTA head and neck: normal. FINAL WORKING DIAGNOSIS: 1. Concussion 2. Neuropraxia of cervical spine 3. Neuropraxia of right marginal mandibular nerve (CN V) and zygomatic and buccal branches of right facial nerve (CN VII) versus entrapment of CN VII TREATMENT AND OUTCOMES: 1. Hospitalized for two days with evaluation by neurosurgery, trauma surgery, plastic surgery, and neurology 2. 5-day course of oral steroids 3. School accommodations given related to concussion symptoms 4. Right-sided facial droop fluctuated and persisted for 2 weeks with subsequent resolution 5. Cleared to start return to play protocol by neurosurgery at 3 weeks once exam returned to baseline 6.Finished seasons with no additional issues related to injury