Traumatic Brain Injury and Intracranial Hemorrhage Induced Cerebral Vasospasm and Delayed Cerebral Ischemia in a Patient with a Fall - Significance of the High-Cost Tertiary Investigations in Medico-Legal Practice; a Case Report

Abstract

Delayed morbidity and mortality following traumatic and spontaneous intracranial haemorrhages (ICH) are common in both neurosurgical units and autopsy rooms. However, the causes of the delayed morbidity and mortality are complications of prolonged bed care such as aspiration or hypostatic pneumonia, urinary tract infection, dehydration, electrolyte imbalance, malnutrition and sepsis following bed sores. It can also be caused during the conservative management up to 14-21 days by delayed vasospasm and cerebral ischemia. A 67-year-old man with a history of hypertension was admitted to an ETU following a fall backwards. He lost his consciousness immediately after the fall for less than five minutes with retrograde amnesia, right sided paralysis and vomiting. On admission, blood pressure was 200/100mmHg and random blood sugar was 117mg/dl. Initial CT-brain revealed bilateral frontal lobe contusions with subarachnoid haemorrhages. In the second CT, an isolated left sided ICH that was not continuous with the brain surface was detected and the right sided hemiplegia was improved following evacuation. However, after 48 hours, he developed left sided hemiplegia. Repeat CT-brain, CT-angiogram and DSA-scan revealed no new hemorrhages, infarction, necrosis etc. There were no external injuries on the body. However, the MRI brain, showed a localized oedema of right supra-callosal area. Contre-coup contusions identified by CT-scan were compatible with the given history of fall backwards. Isolated left ICH identified in the second CT was compatible with a spontaneous ICH resulting right sided hemiplegia and could have precipitated the fall backwards. This ICH may be due to rupture of vessels due to long standing hypertension. The delayed left sided hemiplegia could have been due to the oedema of right supra-callosal area probably initiated by delayed cerebral ischemia fallowing vasospasm. This case also highlights the importance of radiological investigations in clinical forensic medicine for reconstruction of the events.