CT of lightning injury.

A 20-year-old man was on a fishing trip in a boat on Delaware Bay. At one point during an ensuing storm, he rai sed his head above the rigging and was immediately stru ck by a lightning bolt that also momentaril y stunned his companions. They recovered to find him unconscious on th e bottom of the boat with blood-tinged fluid emanating from his left ear . After a brief examination at a nearby hospital where his vital signs were found to be stable, he was transferred to our institution. Physica l examination revealed movement of all four limbs to painful stimuli; the right ex tremities showed a diminished range of motion. A small , c ircular burn with associated soft-ti ssue swelling was noted over the occipital area, and a second area of burned skin was over the right anterior chest. Routine skull radiographs revea led no abnormality. A CT examination showed evidence of subarachnoid hemorrhage and intraparenchymal hemorrhage in the left basal ganglia with extension into th e left ventricu lar system. Mild midline shift to the right was noted (fig . 1). The subsequent hospital course was characteri zed by progressive neurolog ic and cardiorespiratory deteriorat ion; ventilator support and vasopressor infusion was instituted on hospi tal day 6 . A persistent cerebrospinal fluid leak from the left ear was noted . Repeat CT on hospital day 5 revealed minimally inc reased midline shift, with no other change. An elec troenceph alogram on hospital day 11 showed elec trocerebral silence. Card iac arrest occurred 13 days after admission. An autopsy was performed. This showed the brain surface to be blood-stained, with the brain itself desuibed as soft and mushy in consistency. Two small , irregular areas at th e base of each middle c ranial fossa were in terpreted as skull fractures. Brain sect ion ing confirmed basal ganglia hemorrhage with involvement of the anterior rim of the internal capsule and intraventricular ex tension .