Long term follow up after transorbital penetrating injury: A case report

PURPOSE: Traumatic brain injury is the leading cause of mortality and disability among young individuals. Unfortunately, there are few publications concerning long term follow up of patients with these types of injuries. We present a case of trans-orbital penetrating brain injury with an 18 year follow up. OBSERVATIONS: A 43-year-old, previously healthy, male was accidently impaled on a fencing foil resulting in a penetrating brain injury. Initial symptoms included diplopia, ophthalmoparesis, a non-reactive pupil, decreased visual acuity, decreased sensation across the cheek, dysphagia and dysarthria. CT scan taken on presentation showed a clear tract of the foil traversing the various structures of the brain. One week after the trauma, the patient developed a unique constellation of paroxysmal attacks of autonomic dysfunction consisting of profuse diaphoresis and decreased skin temperature on the left side of the body, as well as dilation of the left pupil. Three months after the accident, the patient suddenly experienced severe constant pain affecting the left side of his body associated with thermal and tactile allodynia. On latest follow up, 18 years after the accident, the patient continues to have chronic pain, allodynia, and lack of temperature sensation throughout the left face, arm, and leg. He has a wide based, hemi-ataxic gait, with the left leg swinging out and around. EMG and nerve conduction studies have found no voluntary activity in the temporalis and masseter muscles resulting in atrophy and fibrosis. An MRI shows linear encephalomalacia along the path of the foil extending to the pons, involving the right spinothalamic tract, and cerebellum. CONCLUSIONS AND IMPORTANCE: Our case illustrates the importance of such a longitudinal follow up. It demonstrates the possible severity of the sequelae from these types of injuries including chronic pain and gait ataxia, as well as EOM and autonomic dysfunction. Due to the potential ongoing needs of such patients, it is important to plan a long-term, team-based approach that centers around physical therapy and improving long term quality of life.