Traumatic Cerebral Infarction - Basketball

Abstract

HISTORY: A 19 year old white male was struck by an elbow in his left neck during a basketball game. He was knocked to the ground but did not lose consciousness or sustain head trauma. He did, however, immediately develop right-sided hemiparesis and dysarthria. His symptoms improved after a short period of time and he went home. The next day the patient still had difficulty speaking and noticed right-sided visual loss. He was taken to the hospital where MRI/MRA of his brain was negative for carotid dissection but did show a left occipital lobe infarct. Subsequent CT angiogram revealed a sub-acute occlusive thrombus in the left posterior communicating artery. The patient was started on intravenous heparin and transferred to a tertiary care center where he was medically stabilized and underwent additional diagnostic testing that confirmed the thrombus and cerebral infarction. PHYSICAL EXAMINATION: His PHYSICAL EXAMINATION was significant for left hemiparesis and ataxia and right homonymous hemianopsia with moderate expressive aphasia, dysarthria and parasphasic errors. He also displayed significant cognitive deficits. DIFFERENTIAL DIAGNOSIS: 1. Vertebral Artery Dissection 2. Cerebral Vascular Accident 3. Epidural Hematoma 4. Traumatic Brain Injury TEST AND RESULTS: VIR arteriography: Slight dilation of the left internal carotid artery without clearly demonstrated dissection. Complete occlusion of the left posterior cerebral artery without partial filling around a clot. Occlusion is complete and posterior cerebral artery was likely fetal, filling from the internal carotid artery. MR angiography neck: Subtle contour abnormality of the left internal carotid artery but no findings to suggest acute dissection. CT head/brain without contrast: Small infarction in the left occipital lobe. FINAL WORKING DIAGNOSIS: Traumatic left posterior cerebral artery thrombosis with occipital lobe infarction. TREATMENT AND OUTCOMES: The patient was treated with intravenous heparin therapy and gradually showed improvement with functional restoration measures including multi-disciplinary therapy and rehabilitation. More rapid recognition of the possibility of this condition in the field of play could lead to potentially improved neurologic outcomes with thrombolytic therapy.