A 21-year-old man* was ejected from a speeding motor vehicle after it slammed into a tree. Emergency medical services personnel found him unconscious with stable vital signs. On examination in the emergency department, he became agitated and required intubation, sedation, and transfer to the intensive care unit. His girlfriend, who was not in the car, arrived later and provided his history.
Past medical and psychiatric history is negative; family history is unremarkable. The patient takes no medications and has no allergies. He does not smoke or abuse alcohol; however, he uses marijuana regularly. He is single and works as a chef at a local restaurant. When the accident occurred, he had been on his way to celebrate his birthday.
The next day, the patient wakes up and is extubated. He complains of pain in his right arm and left leg, a severe headache, and blurry vision.
Physical and neurological examination
He has a large scalp hematoma and swelling of the right arm and left leg. He can state his name and knows he is in the hospital. He does not know the day of the week or the date. He recalls getting into his car the previous afternoon but has no memory of the accident or transport to the hospital. His speech is so rapid that his words are nearly incomprehensible. He sits up impulsively and almost falls out of bed. The rest of his neurological examination, including cranial nerves, motor, reflexes, sensory, and coordination, is intact.
Laboratory and imaging studies
Results of a routine chemistry panel, complete blood cell count, and coagulation studies are unremarkable. Imaging reveals right arm, left femur, and pelvic fractures. A head CT scan is normal. CT angiography of the neck does not show carotid or vertebral arterial injury. Brain MRI T2 images are normal, but T2 gradient echo (GRE) sequences reveal hypodense lesions in both frontal lobes, the left temporal lobe, and cerebellum (Figure 1 and Figure 2).
The following day, the patient undergoes surgical fixation of his limb fractures. By the fifth hospital day, he is fully oriented. His speech has more normal pacing. He still has no recollection of the accident. His girlfriend reports that his behavior is almost normal. The patient is discharged to home to follow up in orthopedic and neurology clinics.
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