Teaching Case

Struck in the head by lightning. Cardiopulmonary resuscitation was started immediately by witnesses to the accident. The victim resumed spontaneous breathing. Upon arrival in the hospital, he was comatose. Neurologic examination revealed repetitive convulsions, with eye deviation to the left, and myoclonias in the right side of the body (status epilepticus).

An 18-year-old man was struck in the head by lightning. Cardiopulmonary resuscitation was started immediately by witnesses to the accident. The victim resumed spontaneous breathing. Upon arrival in the hospital, he was comatose. Neurologic examination revealed repetitive convulsions, with eye deviation to the left, and myoclonias in the right side of the body (status epilepticus). A non-contrast CT scan of the head was performed. A few days later, the patient was transferred to another hospital for further evaluation. The patient was conscious. Physical examination upon admission demonstrated systemic hypertension: blood pressure was 190/100 mm Hg. Neurologic examination revealed quadriplegia, with deep pareses predominantly of the left hand and leg, as well as paralysis of upper body musculature. Six weeks after the incident, an MRI examination of the brain was performed.

It is estimated that 2 out of 3 people survive a lightning stroke. In most reported cases, the victim suffers a cardiorespiratory arrest and neurologic symptoms. Neurologic effects range from transient deficits (e.g. loss of consciousness, weakness, amnesia and paresthesia) to devastating long-term or permanent sequelae. In our case, the lightning bolt struck the victim on the left side of the head. The electrical current was conducted through the left side of his body and through his left leg to the earth. In such cases, it is reported that a basal ganglia hemorrhage on the affected side can occur. Several hypotheses have been proposed to explain this phenomenon: direct electrolytic effect of the electrical charge passing through the brain; heating effect of the electrical current; mechanical trauma of the lightning stroke (less likely); intense peripheral vasoconstriction leading to acute hypertension (less likely). The left basal ganglia hemorrhage in our patient, documented by CT and MRI, was concordant with the neurologic finding of a right-sided hemiplegia. The left-sided hemiplegia was most probably caused by axonal polyneuropathy as a result of the electrical current passing through the left side of his body and left leg into the ground. After one year of intense physical therapy, the clinical condition and neurologic status of the patient improved significantly.