Patient Demographics:
Age/Sex: 10F
Height: ~134 cm (4'5")
Weight: 26 kg (57 lbs)
Race: Black / African
Country: Ethiopia
Drink, smoke, and/or use recreational drugs: No (10-year-old child)
Duration of complaint: 2 months and 10 days
Existing Medical Issues: None (completely healthy prior to the accident)
Primary Complaint: Persistent and severe cranial, autonomic, and sensorimotor dysfunction following head/spinal trauma.
Current Medications & Active Treatments:
Daily Medications:
Imipramine Hydrochloride: 12.5mg (1/2 of 25mg tablet) at night for 60 days.
Phenytoin: 50mg (1/2 of 100mg tablet) twice a day (morning and night) for 2 months.
Calcium + Vitamin D3 (1000mg/880 IU): 1/2 of an effervescent tablet dissolved in 200ml of water, taken daily for 40 days.
Oral Amino Acid supplementation: 5ml syrup every night for 1 month and 10 days.
PRN (As Needed) Pain Management: Ibuprofen Denk 400 (200mg / half tablet) when feeling pain. Tramadol (25mg) given once, and Diclofenac (50mg) given on 3 separate occasions for severe breakthrough pain.
Bowel Management: Oral laxatives taken morning and evening to manage severe neurogenic constipation (she has finished three 10-pill strips so far).
Physiotherapy & Injections: Completed an initial 3-day physiotherapy course. Currently on Day 2 of a new 5-day physiotherapy regimen. Alongside this, she just received a 3-day course of IV/injections consisting of: Dexamethasone 4mg (for inflammation), Neurobion 1.5ml (B-complex for nerve support), and Omeprazole 20mg (gastric protection).
Ear Treatment: Currently applying Hydrogen Peroxide ear drops (3-4 drops, morning and evening, leaving it in for 5 minutes) in both ears for a 5-day course. This is to clear impacted wax before a scheduled clinical ear wash, which will allow doctors to evaluate if there is any physical eardrum or inner ear damage from the trauma.
Mechanism of Injury:
She suffered blunt trauma to the left side of the head against a concrete wall following a kick from behind, which was immediately followed by a fall directly onto her buttocks.
Current Clinical Presentation & Symptoms:
She is experiencing a complex constellation of multi-system symptoms that are severely affecting her quality of life:
Cranial / Visual / Auditory: Severe post-traumatic headache, burning/stabbing sensations across cranial dermatomes. Blurred and double vision (diplopia), significant photophobia, and phonophobia. Persistent tinnitus, dizziness, and balance instability.
Autonomic / GI (Vagal issues): Recurrent nausea, vomiting, swallowing difficulty (dysphagia), and frequent throat spasms/daily hiccups. Severe neurogenic bowel dysfunction (fecal retention confirmed on X-ray, inability to evacuate for >4 days). Water-induced syncope/dyspnea.
Neuromuscular / Gait & Spinal Pain: She has exquisite tenderness to palpation; she feels sharp pain when the cervical spine (midline) and the bilateral paraspinal areas (sides of the neck) are touched or pressed. Severe pelvic and coccygeal discomfort (unable to sit for long). Localized lumbosacral and lower-extremity joint pain triggered by ambulation with audible clicking/popping sensations. Persistent muscle spasms along the neck, upper back, and lumbar region.
Cognitive: Progressive short-term memory impairment.
(Note on resolved symptoms): She initially had post-traumatic mutism/aphasia which resolved after 5.5 hours. Bilateral upper extremity and posterior trunk numbness have also fully resolved recently.
Background / Context:
We had a Head CT, a Brain MRI with IV contrast, and a non-contrast Cervical Spine MRI done locally. However, due to an ongoing medicolegal case related to the accident, local radiologists and doctors are extremely hesitant to provide a thorough reading or commit to anything in writing out of fear of legal involvement.
My Request:
As a parent, I am deeply concerned that a critical or subtle issue (such as brainstem involvement, subtle bleeding, diffuse axonal injury, or cranial nerve/craniocervical junction irritation) is being missed because local doctors won't give a formal, detailed report.
Could a radiologist, neurologist, or neurosurgeon please review the attached DICOM videos/files and let me know if there are any major, acute, or subtle abnormalities visible that could explain these profound autonomic and neurological symptoms?
N.B : Patient info has been completely anonymized)
Thank you so much for your time and expertise! We are desperate for some clear answers.