Bilateral Lower Cranial Nerve Palsy after Closed Head Injury: A Case Report and Review of Literature

Case Series and Systematic Review of Electronic Scooter Crashes and Severe Traumatic Brain Injury

OBJECTIVE

Electric scooters (e-scooters) are an increasingly popular form of transportation, but their use has also resulted in increased incidence of traumatic brain injury (TBI). Previous reports have predominantly described mild TBI with limited attention to other injury patterns. Our objective was to evaluate the impact of e-scooter use on rates of severe TBI.

METHODS

We performed a multicenter retrospective case review of patients who presented with severe TBI (Glasgow Coma Scale score 3-8) related to e-scooter use and undertook a systematic literature review to identify other reports of severe TBI related to e-scooter use.

RESULTS

Of the 19 patients (mean age, 38 ± 16 years; 73.7% male) included in the case series, 13 (68.4%) experienced a fall and 6 (31.6%) were involved in a collision. Various cerebral injury patterns, associated craniofacial fractures, and cervical spine injuries were also seen. Twelve patients (63.2%) underwent intracranial pressure monitor placement and 6 (31.6%) underwent a decompressive hemicraniectomy. Most patients (n = 12; 63.2%) were discharged to acute rehabilitation, with a median modified Rankin Scale score of 2 at 4.9 ± 7.7 months follow-up (52.6% had a good outcome of modified Rankin Scale score ≤2), but 4 patients died of primary injuries. The systematic review identified 18 studies with 77,069 patients between 2019 and 2021, with 37 patients who required intensive care and 6 patients who had neurosurgical intervention.

CONCLUSIONS

Severe TBI after e-scooter use is associated with high morbidity and is likely underdiagnosed in the literature. Awareness and public policies may be helpful to reduce the impact of injury.

A Case of Post-trauma Dysphagia: Peculiar Swallowing Dynamics Due to Associated Laryngeal Paralysis

Background:

Associated laryngeal paralysis (ALP) is defined as vagus nerve impairment combined with other lower cranial nerve paralysis. Traumatic ALP is reported infrequently.

Case:

A 72-year-old man was injured on the back of the head when a large tree fell on him; he was admitted to a general hospital, where he was diagnosed with brain concussion and Guillain-Barre syndrome (GBS). The patient developed aspiration pneumonia due to severe dysphagia. Although he underwent treatment and rehabilitation for 6 months, some disabilities persisted, and a percutaneous endoscopic gastrostomy tube was placed. Six months after the accident, the patient was transferred to our rehabilitation hospital. Videoendoscopic examination and videofluoroscopy revealed persistent upper esophageal sphincter (UES) opening, left dominant bilateral IX and X nerve paralysis, and left XII nerve paralysis; moreover, these examinations showed that the swallowing reflex was absent, although a bolus could pass through the UES. We suspected that the patient’s condition was not GBS and performed head computed tomography and magnetic resonance imaging; these revealed a bone fracture at the skull base. Consequently, the patient’s diagnosis was changed to bilateral ALP. He received swallowing rehabilitation for 2 months and could orally consume alternative nutrition. Finally, the patient was able to eat orally texture-modified foods (Food Intake LEVEL Scale level 8).

Discussion:

While post-trauma dysphagia due to bilateral ALP might be severe, patients can regain the ability to eat orally if clinicians understand the etiology of dysphagia and provide appropriate swallowing rehabilitation techniques, including patient position adjustment while eating and selection of food textures.