Letters to the editor
Acute brachial plexus lesion
complicating a
stun-gun assault
A woman was assaulted with a stun gun (Security PlusTM
) and
received three brief, direct, high-voltage stun-gun shots to the
base of her neck behind the clavicle on the left side.
Immediately after receiving the electrical pulses, she was
completely paralyzed, while her left arm felt as if it were
anesthetized. Her initial examination on the following day
revealed two small burns situated precisely on Erb’s point on
the neck. Motor testing revealed complete palsy involving the
rotator cuff, deltoid and biceps muscles of the left arm,
although her intrinsic and extrinsic hand muscles were
spared. Multimodal sensory loss was also present along the
external left arm from the shoulder to the first three digits, and
was associated with severe neuropathic pain. Any reflexes in
her left arm were completely lost.
Magnetic resonance imaging (MRI) of the brachial plexus
failed to reveal any visible lesion. On day 10, electromyography
demonstrated abolition of sensory nerve potentials in the
lateral cutaneous nerve of the forearm as well as in the median
and radial nerves. Needle detection in the shoulder muscles at
rest revealed abundant denervation potentials in the infra-/
supraspinatus and deltoid muscles, and a moderate pattern in
the biceps muscle. No motor potentials were elicited during
voluntary contraction of these muscles. This pattern suggested
acute axonotmesis of the primary superior trunk of the
brachial plexus.
Follow-up at 2 years revealed the progressive resumption
of voluntary activity in all previously involved muscles. At the
time of the victim’s last visit, weakness was still present in the
deltoid muscle, as was also the painful sensory hypoesthesia
in the forearm, which has remained unchanged on both
clinical and electrical examinations. Any improvement was
compatible with ongoing axonal sprouting.
Electric stun guns aim to incapacitate subjects by administering
high-frequency pulses of high-voltage currents (up to
500 kV). The most popular brand is the TASER, a device that
shoots two metallic barbs attached to a cable a few meters long
to deliver an electrical shock at a distance, although many other
types of stun guns require direct application of the two probes at
the tip of the device, as was the case in our present patient.
Significant injuries are evidently seen in < 0.5% of subjects
in real-world use [1]. The side effects of these devices are
mostly superficial trauma resulting from penetration of the
barbs, but can also include ventricular fibrillation and sudden
death [2]. Isolated peripheral nervous system injuries have not
been described to date. In one brief report [3], severe burns and
long-term pain sequelae were claimed and described,
although no details were given regarding the neurological
injuries.
To our knowledge thus far, brachial plexus involvement is a
complication that has never been described before. In fact, the
exceptional severity of our present case was probably due to
the prolonged, multiple stimulation and its direct application
to Erb’s point.
Disclosure of interest
The authors declare that they have no competing interest.
r e f e r e n c e s
[1] Vilke GM, Bozeman WP, Chan TC. Emergency department
evaluation after conducted energy weapon use: review of
the literature for the clinician. J Emerg Med 2011;40(5):598–
604.
[2] Lee BK, Vittinghoff E, Whiteman D, Park M, Lau LL, Tseng ZH.
Relation of TASER (electrical stun gun) deployment to
increase in in-custody sudden deaths. Am J Cardiol
2009;103(6):877–80.
[3] Welsh J. Electroshock torture and the spread of stun
technology. Lancet 1997;349:1247.
M. Bonnan*
J.-L. Zerbib
B. Barroso
L.-M. Puvilland
S. Demasles
R. Marasescu
E. Krim
Service de neurologie, centre hospitalier de Pau, 4, boulevard
Hauterive, 64000 Pau, France
*Corresponding author.
E-mail address: mickael.bonnan@ch-pau.fr (M. Bonnan)
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Available online at
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www.sciencedirect.com
Received 28 September 2017
Received in revised form 30 December 2017
Accepted 4 January 2018
Available online 4 October 2018
https://doi.org/10.1016/j.neurol.2018.01.374
0035-3787/# 2018 Elsevier Masson SAS. All rights reserved.
Locked-in syndrome following
meningitis with brainstem
abscess
Brainstem abscess complicating bacterial meningitis is a rare
entity, and even more so in those with no risk factors. The
purpose of the present report is to describe the case of a
patient who presented with typical locked-in syndrome due to
brainstem abscess.
A 75 year-old male patient with no significant preexisting
medical conditions was admitted to our emergency department
for febrile confusion. He presented with a typical
meningeal syndrome, but with no focal neurological signs.
Cerebrospinal fluid (CSF) culture was positive for Grampositive
cocci, eventually identified as methicillin-sensitive
Staphylococcus aureus, thereby confirming the diagnosis of
acute bacterial meningitis. Initial brain magnetic resonance
imaging (MRI) excluded encephalitis and showed no abscesses.
Broad-spectrum antibiotics (ceftriaxone, amoxicillin,
gentamicin) were immediately started, together with adjunctive
dexamethasone therapy.
Thorough physical examination failed to find any portal of
entry for pathogens. Transesophageal echocardiography was
normal, and several blood cultures showed no S. aureus
bacteremia. Yet, the patient’s condition rapidly worsened with
coma, requiring orotracheal intubation, sedation and admission
to the intensive care unit (ICU). In the absence of
intracranial hypertension, a neurological wake-up test was
performed on day 5. The patient unexpectedly presented with
the classic locked-in syndrome: tetraplegia with anarthria,
respiratory-center disruption and preservation of consciousness.
Brain and cervical MRI was then performed, and
identified brainstem and cervical cord abscesses, ependymitis
and epiduritis (Fig. 1). Due to the lesions’ localizations, nature
and clinical impact, surgical evacuation was discussed, but
excluded by our neurosurgical team. In the face of this
unfavorable local evolution despite the apparently properly
conducted treatment, our decision was to switch antibiotics
for a combination of linezolid and fosfomycin, known to be
effective against potentially undetected methicillin-resistant
S. aureus (MRSA), for several days. However, there was no
clinical improvement and, thus, in accordance with the
patient’s and family’s wishes, it was agreed to withdraw care
on day 20, leading to the patient’s death.
S. aureus meningitis is a rare entity, constituting only 1% of
all cases of bacterial meningitis worldwide [1]. However, it is
associated with a high mortality rate (around 50%). Three
pathogenic mechanisms have been described:
 postoperative meningitis secondary to neurosurgical procedures
or a CSF shunt device;
 post-traumatic, and;
 hematogenous/spontaneous meningitis caused by S. aureus
bacteremia after staphylococcal infection outside of the
central nervous system.
Hematogenous meningitis usually affects patients with
severe underlying conditions (cardiovascular, chronic kidney
or liver disease, diabetes mellitus) and intravenous drug users.
Fig. 1 – MRI of the brain and medulla on (left) T2-weighted and (right) fat-saturated T1-weighted sequences show brainstem
abscess, ependymitis (arrows) and epiduritis (arrowhead) with (right) cervical compression of the medulla.
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