A 72-year-old male patient suffered a severe traumatic brain injury due to a traffic accident, presenting on admission with a score of 8 on the Glasgow Coma Scale. Clinically, he was associated with severe thoracic and pelvic trauma requiring orotracheal intubation and thoracic drainage. Cranial CT showed intraventricular bleeding and a slight right frontoparietal frontoparietal subarachnoid haemorrhage, which evolved as subdural hygromas. There were no lesions in the posterior fossa. The facial CT scan showed a multiple fracture of the facial mass including the roof and medial wall of the left orbit.
When the patient left the ICU and was clinically stable, the ophthalmological study revealed a VA of 0.7 in both eyes. Biomicroscopy showed moderate phacosclerosis with no other abnormalities. Funduscopy revealed myelinated nerve fibres in both eyes, normal papillae and no posterior pole abnormalities or peripheral lesions. The study of intrinsic ocular motility revealed anisocoria with mydriasis in the left eye. Extrinsic motility showed complete paralysis of both abducens nerves and the left common ocular motor (including ptosis). Clinically it manifested with torticollis as well as diplopia in all positions, which was disabling.
Since none of the lesions described radiologically justified the clinical findings, nor were they amenable to surgical treatment, it was decided to complete the study by means of a cranial MRI in order 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 presented a combined paralysis that had not improved clinically. As a therapeutic procedure, botulinum toxin (5 IU Botox) was injected into both medial rectus. The clinical improvement was maintained for three months, after which the symptoms reappeared.