YAJEM-57773; No of Pages 3 American Journal of Emergency Medicine xxx (xxxx) xxx–xxx Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Delayed cerebellar infarction after a slight electric injury Lei Yang a, Chenmin Cui b, Huijie Ding c, Jianjiang Fan'g c, Zhouzhou Dong a,⁎ a ICU, Ningbo Medical Center Lihuili Eastern Hospital, No 1111, Jiangnan Rd, Ningbo 315100, China Nephrology Department, Guangxing Hospital of Zhejiang Chinese Medical University, No 453, Tiyuchang Rd, Hangzhou 310007, China c Emergency Department, Ningbo Medical Center Lihuili Eastern Hospital, No 1111, Jiangnan Rd, Ningbo 315100, China b a r t i c l e i n f o Article history: Received 25 July 2018 Received in revised form 23 August 2018 Accepted 25 August 2018 Available online xxxx Keywords: Cerebellar infarction Electric injury Case report a b s t r a c t Electrical injury causes direct damage to nerves. It may manifest as peripheral nerve injury, spinal cord damage, cerebellar ataxia, hypoxic encephalopathy, or intracerebral hemorrhage. Various factors determine the severity of electric injury, including type of current, amperage, voltage, tissue resistance, pathway of the current, and duration of contact with the body. However, the severity of the electrical injury is not proportional to the source voltage, visible burns, loss of consciousness, or neuroimaging findings. While most neurologic aftereffects due to electric injuries are immediate and transient, delayed and permanent manifestations are also known. We report a case of a middle-aged man who accidentally sustained cerebellar infarction without burns, which occurred 4 days after a slight electrical injury. Magnetic resonance imaging of the brain showed an acute infarct in the bilateral cerebellar and left occipital regions. The exact mechanism of the delayed cerebellar infarction after a slight electric injury still remains unknown. The initial electrical injury might result in a transient neurapraxia-like situation, but progressive cellular damage and death accounts for the evolution of delayed-onset symptoms. We learned from this case that we should not underestimate any potential risk of electrical injury; continuous observation should be made in case of subsequent neurologic dysfunction. © 2018 Elsevier Inc. All rights reserved. A 47-year-old man while working accidentally touched a wire carrying 330 V with his left hand. He dropped the wire several seconds later, did not lose consciousness and showed no obvious burns at the point of electrical contact or anywhere else. Approximately 10 min later, however, the patient began to experience nausea and vomiting and was soon afterwards taken to our hospital emergency room (ER). Vital signs were normal at first evaluation upon ER admission. The patient was conscious, articulate, and oriented to place, but he continued to feel nausea and kept vomiting. There were no obvious burns or wounds throughout his body and no signs of cardiovascular, respiratory, abdominal, or neurological involvement. There was no history of transient ischemic attack, stroke, hypertension, or any other diseases. Laboratory values on admission showed a white blood cell count of 9.9 × 109/L and a serum potassium level of 2.42 mmol/L. Coagulation profile, myocardial enzyme spectrum level, and renal function tests were found to be normal. An electrocardiogram showed a sinus rhythm and slight changes in the T wave of the front wall and the anterolateral wall of the heart. Computed tomographic scans of the brain and chest were normal. Treatments consisted of the administration of normal saline and potassium and symptomatic treatment with lansoprazole and naloxone IV. ⁎ Corresponding author. E-mail address: NBICUDONG@163.com (Z. Dong). The patient presented to our emergency observation wards for further treatment 18 h after initial hospitalization. Upon admission, the patient remained nauseated and lay in bed listlessly. No obvious sensory or motor deficits were found through physical examination. The patient gradually recovered from nausea and weakness. On the fourth day of admission, however, he became unable to walk steadily without help and developed cerebellar signs including finger-nose incoordination, gait ataxia, and dysdiadochokinesia on his right side. Subsequent diffusion weighted magnetic resonance imaging of the brain showed an acute infarct in the bilateral cerebellar hemisphere (right more than left), vermis, and left occipital areas (Figs. 1 and 2). However, computed tomographic angiography of the neck and brain vessels was normal. The patient was managed conservatively with antiplatelet therapy and other supportive treatment along with rehabilitation services. He gradually improved and was able to walk slowly without support within a week. The patient was discharged after fourteen days. The patient on follow-up after two months was ambulatory without support. Neurologic examination, however, still showed evidence of cerebellar signs including right-handed finger-nose in-coordination and gait ataxia. Electrical injury causes direct damage to nerves [1]. Neurologic sequelae of electrical injury are uncommon and include peripheral nerve injury, spinal cord damage, movement disorders, neuropsychological symptoms, cerebellar ataxia, seizures, hypoxic encephalopathy, and intracerebral hemorrhage [3-5]. There are few factors governing the severity of electric injury including voltage, pathway, type of current, https://doi.org/10.1016/j.ajem.2018.08.064 0735-6757/© 2018 Elsevier Inc. All rights reserved. Please cite this article as: Yang L, et al, Delayed cerebellar infarction after a slight electric injury, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.064 2 L. Yang et al. / American Journal of Emergency Medicine xxx (xxxx) xxx–xxx Fig. 1. Magnetic resonance imaging brain showing hypointensity in the bilateral cerebellar and left occipital area on diffusion-weighted imaging (DWI). Fig. 2. Hyperintensity seen in the bilateral cerebellum (right more than left), vermis, and left occipital areas on the T2-weighted image. Please cite this article as: Yang L, et al, Delayed cerebellar infarction after a slight electric injury, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.064 L. Yang et al. / American Journal of Emergency Medicine xxx (xxxx) xxx–xxx duration of contact, and tissue resistance [2,4]. The severity of the electrical injury is, however, not proportional to the source voltage, visible burns, loss of consciousness, cardiac arrest, or neuroimaging findings [1]. In our patient, the electrical injury was minimal in view of its low voltage, absent burns, no loss of consciousness, and short duration of contact, but the injury resulted in serious effects of cerebellar infarction. Most neurologic aftereffects due to electric injuries are immediate and transient; however, delayed and permanent manifestations are also known [2,4]. Delayed-onset neurologic symptoms after electrical injury have a poorer prognosis for recovery than acute neurologic symptoms do [1]. The involvement of delayed cerebellar infarction due to slightly electric injury is a rare complication of electrical injury. In addition, the cause of delay in onset of ischemic stroke and the mechanisms of recovery are currently unknown. One hypothesis has been offered, stating that the initial electrical injury might result in a transient neurapraxialike situation but that progressive cellular damage and death account for the evolution of delayed-onset symptoms [1]. We have learned from this case that we should not underestimate any potential risk of electrical injury; continuous observation should be made in case of delayed neurologic dysfunction. Comprehensive evaluation and timely treatment for patients with ischemic stroke due to electrical injury could prevent further deterioration and relieve suffering. Competing interests 3 Source(s) of support Nil. Presentation at meetings None. Conflicts of interest and source of funding None. Acknowledgment We thank Dr. Yixia Zhou and Dr. Yinv Chen for the medical history presentation and discussion. References [1] Wesner ML, Hickie J. Long-term sequelae of electrical injury. Can Fam Physician 2013; 59(9):935–9. [2] Singh JR, Kumar S, Suresh DT, Agarwal R. Acute vertebrobasilar ischemic stroke due to electric injury. Am J Emerg Med 2015;33(7):992.e3–6. [3] Blee RC. Injury by electrical forces: pathophysiology, manifestation and therapy. Curr Probl Surg 1997;34(9):667–765. [4] Jain RS, Gupta PK, Handa R, Nagpal K, Prakash S, Agrawal R. Vertebrobasilar territory ischemic stroke after electrical injury: delayed sequelae. J Stroke Cerebrovasc Dis 2014;23(6):1721–3. [5] Christensen JA, Herman RT, Balis GA, Wuamett JD. Delayed neurological injury secondary to high-voltage current, with recovery. J Trauma 1980;20:166–8. Nil. Please cite this article as: Yang L, et al, Delayed cerebellar infarction after a slight electric injury, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.064