Case Report

Vertebrobasilar Territory Ischemic Stroke After Electrical Injury:
Delayed Sequelae
Rajendra S. Jain, DM, Pankaj K. Gupta, MD, Rahul Handa, MD, Kadam Nagpal, MD,
Swayam Prakash, MD, and Rakesh Agrawal, MD

Electrical injuries are of very common occurrence in India and can be rarely fatal.
Usually most of the patients recover without any serious complications. Rarely,
neurologic aftereffects have been observed in some survivors. These neurologic insults can occur as immediate or delayed manifestations and can affect the nervous
system at various levels resulting in hemiplegia, aphasia, parkinsonism, choreoathetosis, and can also involve brainstem, spinal cord, peripheral nerves, and autonomic
nervous system. The involvement of vertebrobasilar territory is a rare complication
of electrical injury. We herein report a case of 55-year-old male laborer who presented with vertebrobasilar territory ischemic stroke, which occurred 2 weeks after
an electrical injury. To the best of our knowledge, this is the first ante mortem case
report of a posterior circulation ischemic stroke occurring as a delayed complication
of electrical injury. Key Words: Vertebrobasilar territory—electrical injury—delayed
sequelae—posterior circulation.
Ó 2014 by National Stroke Association

Introduction
Electrical injuries are of very common occurrence in India and can be rarely fatal. There are few factors governing the severity of the impact of the electrical injury that
are voltage, pathway, type of current, duration of contact,
and resistance of the skin.1 Alternating current at 220240 V can have fatal outcome; however, fatalities have
been seen at lower voltages also.2 Most commonly
affected organs are heart, muscles, skin, blood vessels,
nervous system, and kidneys; however, it can affect
various other organs or tissues as well.3 Usually most of
From the Department of Neurology, SMS Medical College, Jaipur,
Rajasthan, India.
Received November 19, 2013; revision received December 12, 2013;
accepted December 16, 2013.
Address correspondence to Rahul Handa, MD, Department of
Neurology, SMS Medical College, Jaipur, Rajasthan, India. E-mail:
rahulhanda0411@gmail.com.
1052-3057/$ - see front matter
Ó 2014 by National Stroke Association
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.12.023

the patients recover without any serious effect.4 Rarely,
neurologic aftereffects have been observed in some survivors.4 These neurologic insults can occur as immediate or
delayed manifestations and can affect the nervous system
at various levels resulting in hemiplegia, aphasia, parkinsonism, choreoathetosis, and can also involve brainstem,
spinal cord, peripheral nerves, and autonomic nervous
system.4
The involvement of vertebrobasilar territory is a rare
complication of electrical injury. We herein report a case
of vertebrobasilar territory ischemic stroke, which
occurred 2 weeks after an electrical injury.

Case Report
A 55-year-old male laborer sustained an indirect electrical injury when trying to save his coworker who came in
contact with high tension line (66,000 V). The other
laborer died on the spot, whereas our patient suffered
injury in the right hand resulting in tingling sensation
and severe pain in the right upper limb and neck followed

Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2014: pp 1-3

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by loss of consciousness lasting for 30 minutes. He was
managed conservatively in emergency department and
discharged. He remained asymptomatic for 2 weeks. Subsequently, in a family function after taking lunch, he suddenly experienced 2 episodes of vomiting, followed by
dysarthria, dysphagia, instability of gait with swaying toward left side, and numbness of left half of upper face.
There was no history of diabetes mellitus, hypertension,
cardiac disease, transient ischemic attack (TIA) or cerebrovascular accident in the past, or any other antecedent
medical illness, abuse/addiction. Examination revealed
pulse rate of 84 beats/minute regular in rate and
rhythm and blood pressure of 130/80 mm Hg. General
examination showed a scar mark of electrical injury
over dorsum of the right hand. Systemic examination
was unremarkable.
Neurologic examination revealed normal higher
mental functions, extraocular movements, and fundus.
There was Horner’s syndrome on left side, left fifth, ninth,

R.S. JAIN ET AL.

and 10th cranial nerve palsies, loss of pain and temperature sensation over right half of body, and bilateral asymmetric (left more than right) cerebellar signs.
On investigations, routine hemogram, biochemistry
including renal and liver function test, electrocardiogram,
and chest x-ray were found to be normal.
Diffusion-weighted magnetic resonance imaging of
brain showed acute infarct in left cerebellar hemisphere
including vermis and lateral part of medulla with mass
effect on the opposite side (Fig 1, A,B). Computed tomography (CT) angiography showed diffuse narrowing of left
vertebral artery (Fig 1, C).
The patient was managed conservatively with antiplatelet drugs and rehabilitation program including
speech therapy. Patient on follow-up after 6 months had
no neurologic deficit, and his repeat CT angiography
showed a significant spontaneous improvement in the
left vertebral artery narrowing suggestive of vasospasm
(Fig 1, D).

Figure 1. (A) T2-weighted axial image showing
hyperintensity in left cerebellar hemisphere and
left half of medulla. (B) Diffusion-weighted image
showing diffusion restriction in left cerebellar
hemisphere and left half of medulla. (C) CT angiogram of brain at the time of stroke showing diffuse
left vertebral artery narrowing. (D) CT angiogram of brain 6 months after the stroke showing
a significant spontaneous improvement in left
vertebral artery narrowing. Abbreviation: CT,
computed tomography.

VERTEBROBASILAR STROKE AFTER ELECTRIC INJURY

Discussion
After an electrical injury, certain focal and nonfocal deficits can appear after days to months, comprising the delayed effects of an electrical injury. The focal deficits can
affect brain, spinal cord, or peripheral nerves manifesting
as hemiplegia, aphasia, transverse myelitis, progressive
muscular atrophy, amyotrophic lateral sclerosis, neuropathy, and radiculopathy.1,4,5
There are various proposed pathophysiological mechanisms of neurologic impact of the electric injury, which
include thermal injury, electroporation, and vascular damage through a direct or indirect mechanism.6 The nervous
system provides a low resistance area, and neurons with
larger surface area are at a higher risk of damage by electroporation, which is a process by which permanent conformational changes occur in the membrane protein causing
increase in the cell permeability and conductivity ultimately leading to cell death. There occurs a loss of heat
with the flow of current from low to high resistance areas
damaging the intima and adventitia of the blood vessels resulting in thrombosis and vasospasm.6,7 Thus, the possible
mechanisms of stroke after an electrical injury include
coagulation necrosis of the blood vessel walls with
aneurysmal dilatation, rupture of intramural thrombus,
intense vasospasm, increase in blood pressure, intramural
dissection, and/or transient circulatory arrest.8
In our patient, the pathway of an electric current was
from right hand to neck resulting in right upper limb
and neck pain and loss of consciousness followed by vertebrobasilar ischemic stroke 2 weeks later. Our patient
experienced stroke, even when the brain was outside
the shortest current pathway. Vascular damage through
an indirect injury could be the possible mechanism that
is supported by the evidence of left vertebral artery vasospasm in CT angiography in our case, which is supported
by a significant spontaneous improvement in the left
vertebral artery narrowing over a period of 6 months.

3

Conclusions
Anterior circulation ischemic stroke as a delayed
complication of nonfatal electrical injury is well known;
however, the involvement of posterior circulation has
not been reported so far. Thus, to the best of our knowledge, this is the first ante mortem case report of a posterior
circulation ischemic stroke occurring as a delayed complication of electrical injury. Infarct on the side opposite to
the site of contact is an unusual finding, which has not
been reported earlier in the literature and can be explained possibly by vascular damage leading to intense
vasospasm because of the indirect injury.
Clinicians should be aware of this rare complication resulting from distant vasospasm and should keep the patient of an electrical injury under close follow-up.

References
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