A 72-year-old male patient who suffered a severe traumatic brain injury due to a traffic accident presented at the time of admission an 8-point Glasgow coma scale.
Clinically, it was associated with severe thoracic and pelvic trauma requiring orotracheal intubation and chest drainage.
Cranial CT showed intraventricular bleeding and mild right frontoparietal subarachnoid hemorrhage, which evolved as subdural hygromas.
There were no lesions in the posterior fossa.
The facial CT showed a multiple fracture of the facial mass including the roof and the medial wall of the left orbit.
When the patient leaves the ICU and is clinically stable, the pathological study showed a VA of 0.7 in both eyes.
A moderate phacoemulsification was observed without the presence of other alterations.
Funduscopy found incidental honeyinized nerve fibers in both eyes. The papillae were normal and there were no posterior pole alterations or peripheral lesions.
Anisocoria with mydriasis of the left eye was found in the intrinsic ocular motility study.
A complete paralysis of the left common ocular motor (including ptosis) and both irritants was observed.
Clinically, it manifested with torticollis, as well as diplopia in all positions, resulting disabling.
Since none of the lesions described radiologically justified the clinical findings or were susceptible to surgical treatment, it was decided to complete the study by means of a cranial MRI to find a pathophysiological explanation for the clinical findings.
This examination revealed the existence of subcortical petechiae and focal lesions of the corpus callosum, all compatible with the diagnosis of diffuse axonal damage.
No structural lesions were found in the brainstem.
After four months of evolution the patient had a combined paralysis that had not improved clinically.
Botulinum toxin injection (5 IU Botox) was performed in both middle rectums as a therapeutic procedure.
Clinical improvement was maintained for three months, after which symptoms returned.
