A 47-year-old woman was admitted to the emergency service because of a motor vehicle crash in which she experienced head trauma. She was sitting in the front seat of the car and was not using a seatbelt. At the time of the accident, she lost consciousness for about 5 minutes. Her first neurological examination revealed non-specific findings. No gaze palsy was noted on initial assessment and diplopia was not present. She had a GCS of 15 points and showed several abrasions with scratches over the right forehead and tongue. Other systemic examinations were normal. Computerized tomography (CT) images of the skull and parenchyma were normal (Figure 1).
Approximately 3 hours after the concussion, she had headache and diplopia. Neurologic examination revealed lateral gaze palsy of both eyes (Figures 2 and 3). The hypoglossal nerve was not initially evaluated because of stitches in her tongue.A follow-up neurologic examination revealed tongue deviation to the left side and CT imaging showed no newly developed abnormal lesions (Figure 4). In her cranial magnetic resonance imaging (MRI) she had contusion areas in the parietal and occipital lobes (Figure 5).The MRI angiography result was normal (Figure 6). Digital substraction angiography was performed after 1 month to exclude fistula formation and the result showed no abnormality. She was treated with methylprednisolone and was discharged with antibiotics and oral steroids prescribed for a period of 3 weeks. At 1-year follow-up, her sixth nerve palsy and hypoglossal nerve palsy was fully recovered (Figures 7 and 8).