Close Your Eyes and See: Stroke Sequelae versus Functional Neurological Disorder in a Physician

The first author is a left-handed, 51-year-old nephrologist who experienced a neurologic event. She underwent neurosurgery complicated by hemorrhage. Postoperatively, she developed persistent vertigo and unilateral tongue pain which persisted for over 5 years. Early neuroimaging revealed expected encephalomalacia but no neuroanatomical basis for her symptoms. A functional neurological disorder was suspected, and she was seen by several psychiatrists and psychotherapists. However, she suspected a neuroanatomical lesion would better explain her unrelenting symptoms. After seeing many neurologists, a neuroanatomical diagnosis was finally made. The theory and practice of medicine mandate that subjective complaint guides the modality and interpretation of objective evidence. The final neurologist knew where on neuroimaging to look because she was guided by the patient's complaints - vertigo and unilateral tongue pain. In this case, detailed scrutiny of neuroimaging by a neurologist, after encephalomalacia and gliosis were fully completed, gave a more accurate neuroanatomical diagnosis and a more realistic prognosis.

Traumatic acute epidural hematoma caused by injury of the diploic channels

Background

Traumatic acute epidural hematomas (EDHs) commonly develop by rupture of the meningeal arteries. EDH caused by an injury of the diploic channel (DC) has not been reported.

Case Description

A 21-year-old man suffered a head injury while falling off the skateboard. At presentation, the patient was drowsy but did not exhibit any focal neurological deficits. Cranial computed tomography (CT) revealed a biconvex intracranial hematoma with 18-mm thickness in the high parietal region and a linear fracture that involved both the outer and inner tables and passed above the hematoma. A well-developed and large DC was observed near the hematoma. Patient's consciousness level decreased at 12 h after admission with considerable growth of the hematoma. A frontoparietal craniotomy revealed an EDH. The dura mater and the meningeal arteries underneath the hematoma were intact. The medial bone cut caused brisk bleeds from the large DC. Postoperative CT revealed the cut of the DC and other finer DCs exhibiting air density and lying near the fracture. Based on these findings, we assumed that the EDH was developed by an injury of the DCs.

Conclusion

Traumatic EDH can develop by an injury of the DCs. Careful observation of patient's neurological status and precise interpretation of neuroimages is important to identify venous EDHs.

A case of renal vein branch injury identified by multidetector computed tomography

A 39-year-old male fell from a forklift and was urgently transported to our hospital. His vital signs were stable at the initial visit. Contrast imaging computed tomography (CT) showed extravasation (Ev) of contrast medium emigrating outside of the renal capsule and hematoma around the right kidney, and he was diagnosed with traumatic right renal injury, Grade IV laceration [American Association for the Surgery of Trauma classification]. When imaging the inferior renal artery branch extremity perfusing the area where Ev was found in the following blood vessel contrast imaging, obvious Ev was not found in the arterial phase; however, massively spreading Ev was found in the area adjacent to the renal laceration in the venous phase after taking a contrast image of the renal parenchyma. Thus, he was diagnosed with a renal vein branch injury. The transcatheter arterial embolization (TAE) was performed to the area, resulting in the disappearance of Ev. The effectiveness of TAE for renal injury has been established; however, it is only performed for arterial hemorrhage. TAE for venous injury has not previously been considered because a tamponade is supposedly effective for hemostasis of venous hemorrhage due to the anatomy surrounding Gerota's fasciae. This is an extremely rare case in which only venous injury was identified, without obvious arterial hemorrhage. Gerota's fasciae were broken and hemostasis treatment was required. Because the renal artery is the end artery, the venous hemorrhage was controlled with arterial embolization. In our case, renal vein branch injury was identified on CT and hemorrhage was terminated using TAE for the renal artery branch. TAE can be used as a non-operative management for the successful treatment of renal vein branch injury.