Journal of Neuro-Ophthalmology, June 2003, Volume 23, Issue 2

Self-inflicted Blindness and Brown-Sequard Syndrome

A 30-year-old paranoid schizophrenic man suffered a psychotic episode while flying on an airplane, locked himself in the bathroom, detached the temples of his sunglasses, and stabbed them deeply into both medial orbits. He then secured one temple into the door hinge and rammed the back of his neck repeatedly against it. The injuries caused no light perception from optic nerve trauma and a Brown-Séquard hemitransection of the spinal cord.

PHOTO ESSAY Self- inflicted Blindness and Brown- Sequard Syndrome Tim L. Gray, MBBS, Arthur Karagiannis, FRACO, John L. Crompton, FRACO, and Dinesh Selva, FRACO FIG. 1. Plain cervical spine x- ray shows C4 level penetra­tion of the temple of the patient's glasses. Abstract: A 30- year- old paranoid schizophrenic man suf­fered a psychotic episode while flying on an airplane, locked himself in the bathroom, detached the temples of his sunglasses, and stabbed them deeply into both medial orbits. He then secured one temple into the door hinge and rammed the back of his neck repeatedly against it. The injuries caused no light perception from optic nerve trauma and a Brown- Sequard hemitransection of the spinal cord. ( JNeuro- Ophthalmol 2003; 23: 154- 156) A3 0- year- old Canadian man had a paranoid psychotic episode while flying from Canada to Melbourne, Aus­tralia. He became convinced that the cabin staff was plot­ting to kill him and decided to commit suicide. While Department of Ophthalmology ( TLG, AK), Head of Neuro- Ophthalmology Service ( JLC), and Oculoplastic & Orbital Unit ( DS), Royal Adelaide Hospital, Adelaide, South Australia. Address correspondence to John L. Crompton, FRACO, Department of Ophthalmology, Royal Adelaide Hospital, North Terrace, Adelaide 5000, Australia; E- mail: raheyes@ mail. rah. sa. gov. au FIG. 2. Axial T2 orbital MRI shows orbital fat herniated through medial canthal puncture wounds ( arrows) and mixed signal and contour deformity at the orbital apices consistent with contusion of the optic nerves and surround­ing soft tissues. locked in the airplane's bathroom, he removed the temples of his sunglasses, stabbed them deeply into both medial or­bits and then jammed one of the temples into the hinge of the restroom door. He proceeded to hit the back of his neck against the temple, piercing his spine, and fell to the ground, partially paralyzed. On presentation to our medical facility, he com­plained of blindness and left- sided weakness. Examination revealed no light perception in both eyes with dilated, non-reactive pupils. There were bilateral periocular hematomas, puncture wounds at both caruncles and a small right medial conjunctival laceration. Extraocular movements were intact on the left but a complete ophthalmoplegia was present on the right. Examination of the fundi was unremarkable. Neu­rological testing revealed a left hemiparesis and ipsilateral loss of vibration and position sense. On the right side of his body, caudal to the fourth cervical spinal segment ( C- 4), he had reduced temperature and pain sensation [ spinothalamic Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 154 J Neuro- Ophthalmol, Vol. 23, No. 2, 2003 Blindness and Brown- Sequard Syndrome JNeuro- Ophthalmol, Vol. 23, No. 2, 2003 fibers cross the spinal cord approximately two spinal levels above their point of entry ( 1)]. These findings were consis­tent with a Brown- Sequard ( spinal cord hemitransection) syndrome at C- 2. A cervical x- ray demonstrated the arm of the sun­glasses extending into his spinal canal between the first and second cervical spinous processes ( Fig. 1). The patient was taken to the operating room for exploration of the wounds. The temple was removed and intravenous methyl-prednisolone was administered for 48 hours. Magnetic resonance imaging ( MRI) confirmed direct injury to both optic nerves at the orbital apices ( Fig. 2) and to the cervical spinal cord ( Figs. 3,4). Visually evoked potentials ( VEPs) were absent for the OD and poorly developed for the left. Three months later, his vision had improved to hand movements on the left but he remained at hand movements on the right. He now had a full range of extraocular move­ments bilaterally. His right pupil was nonreactive to light and the left showed a sluggish response. Funduscopic ex­amination demonstrated bilateral optic disc pallor. VEPs confirmed some minor improvement in responses for the OS but responses from the right were still very depressed. There was moderate neurologic recovery from his spinal cord injury so that he was able to walk with a walking frame. Six months after returning to Canada, during a pe­riod of noncompliance with antipsychotic medication, he committed suicide by hanging himself. This case is extraordinary for the devastating injuries inflicted with what would normally be considered an innocuous instrument- a pair of sunglasses. It is, we be­lieve, the first documented case of a combination of self-inflicted bilateral optic nerve damage and Brown- Sequard syndrome. Brown- Sequard syndrome is named after Charles- Edouard Brown- Sequard ( 1817- 1894), a French physician who worked on both sides of the Atlantic- in New York, Richmond, Boston, and Geneva. He contributed to many fields of medicine, most notably to our understanding of spinal pathway anatomy and physiology. A founding phy­sician at the National Hospital for Nervous Diseases, Queen's Square, London ( 2), he later succeeded Claude Bernard in the chair of experimental medicine at the Col­lege de France in Paris. The features of Brown- Sequard syndrome, or hemitransection of the spinal cord, are most often caused by trauma or neoplasm ( 3). In most cases, the hemi­transection is partial and not all the signs are found. Additional signs not seen in our case include an ipsilateral lower motor neuron paralysis resulting from destruc­tion of the anterior gray column or nerve root, and a band of cutaneous anesthesia resulting from destruction of FIG. 3. Sagittal T2 MRI shows high signal of reactive edema around the penetrating injury in the spinal cord ( arrow). There is soft tissue edema in the suboccipital path of the wound. FIG. 4. Axial T2 MRI at the CI- 2 level shows a band of low signal extending through the spinal cord ( arrow) consistent with the fresh hemorrhage of a penetrating injury. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 155 JNeuro- Ophthalmol, Vol. 23, No. 2, 2003 Gray et al. the posterior root of the spinal nerve at the level of the lesion. Injury to the optic nerves may have occurred by sev­eral mechanisms. Direct trauma to both optic nerves result­ing in ischemic neuropathy from disruption of the pial ves­sels supplying them is the most likely. A subperiosteal hematoma can compress the optic nerve at the canal but was not seen in the MRI ( 4). An intraconal hematoma or edema could have directly compressed the optic nerve, third, fourth, and sixth cranial nerves and would be the likely cause of the neurapraxia leading to the temporary complete right ophthalmoplegia. REFERENCES 1. Tattersall R, Turner B. Brown- Sequard and his syndrome. Lancet 2000; 356: 61- 3. 2. Haas LF. Charles Edouard Brown- Sequard. J Neurol Neurosurg Psychiatry 1998; 64: 89. 3. Koehler PJ, Endtz LJ. The Brown- Sequard syndrome: true or false? ArchNeuro 1986; 43: 921- 4. 4. Stannard K, Leonard T, Holder G, et al. Oedipism reviewed: a case of bilateral ocular self- mutilation. Br J Ophthalmol 1984; 68: 276- 80. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 156 © 2003 Lippincott Williams & Wilkins