Pressing Emergency At The Concussion Center

HISTORY: 24 year-old male without significant medical or prior TBI history referred to concussion center for head injury, balance, and visual problems. 15 days prior, he slipped and hit the back of his head on a car door frame. He denied LOC, but did have emesis x1. Over next 2 weeks, patient had 3 ED visits for headaches and visual changes. During each visit, he was treated with dexamethasone and sumatriptan with temporary benefit. Labs were significant for ESR of 34. CT and CTA of head and neck were normal. In the 24 hours prior to presenting at the concussion center, he experienced severe worsening balance, headache, and new kaleidoscope vision which left him functionally blind. PHYSICAL EXAM: SCAT score: 89/132CN: EOMI, but cannot see to track a finger, hand. Otherwise CNI. Cerebellar: ++Romberg, unsafe to stand w/o support. Provocative: Severe photophobia. Oculomotor exam precluded by inability to see. Remainder of a complete neuro exam was unremarkable. MENTAL STATUS: Concussion MS exam not performed d/t extreme headache. Patient lucid in thought, speech. Had good vocabulary and expressed himself accurately. Neck: FROM. Visual acuity:20/100 OU. Functionally blind DIFFERENTIAL DIAGNOSIS: 1.Concussion, complicated2.Partial seizure3.Migraine with aura4.Cerebral vasculitis5.Posterior reversible encephalopathy syndrome 6.Infectious etiology RESULTS: MRI BRAIN w/ & w/o Contrast: Symmetric diffusion abnormalities within the posterior parietal and occipital lobes. CSF studies including viral panel, bacterial panel, immunoglobulins, glucose are negative with the exception of increased WBCs. WORKING DIAGNOSIS: Posterior Reversible Encephalopathy Syndrome (PRES) with Balint’s triad (optic ataxia, oculomotor apraxia, simultagnosia) and migraine with aura. We believe this is the first report of PRES associated with concussion. TREATMENT AND OUTCOME: 1.PRES is usually self-limited. With supportive treatment, patient’s vision improved during 4 day hospitalization and he felt 85% better by neurology follow 3 weeks post discharge. Patient now treated with lamotrigine, amitriptyline, and PRN triptans.2.Follow-up MRIs show continued resolution of diffusion abnormalities. Repeat LP was normal. At 5 month follow up, patient is nearly back to baseline with only mild visual graininess and floaters.