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Just a graze? Cephalic tetanus presenting as a stroke mimic
  1. Anisha Doshi1,
  2. Clare Warrell1,
  3. Dima Dahdaleh1,
  4. Dimitri Kullmann1,2
  1. 1National Hospital for Neurology and Neurosurgery, London, UK
  2. 2UCL Institute of Neurology, Queen Square, London, UK
  1. Correspondence to Dr Anisha Doshi, Department of Neurology, National Hospital For Neurology and Neurosurgery, Post Box 134, Queen Square, London WC1N 3BG, UK; anisha.doshi{at}nhs.net

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BACKGROUND

A 76-year-old right handed woman awoke with sudden onset of difficulty with swallowing, slurred speech and left-sided facial weakness and numbness. She had multiple vascular risk factors: hypertension, hypercholesterolaemia, impaired glucose tolerance and a 50 pack-year smoking history. Twelve days before presentation she had developed right-sided facial weakness. Ten days before presentation she had sustained a right supraorbital laceration which required suturing after falling on to pavement (figure 1). A CT scan of the head at the time of injury was normal (figure 2). On examination, there was left-sided upper motor neurone facial palsy and right lower motor neurone facial palsy, with dysarthria but no dysphasia, diminished sensation over the left maxillary and mandibular areas, and normal limb examination. Given her constellation of signs, we considered the possibility of brainstem stroke and recent right Bell's palsy.

Figure 1

Star-shaped right supraorbital laceration sustained 10 days before presentation during a road traffic accident. This is the wound from which Clostridium tetani was eventually cultured. This photograph was taken after the wound was further debrided and post decannulation, as evidenced by her tracheostomy scar.

Figure 2

Axial CT scan of head post injury shows a large extracranial soft tissue swelling overlying the frontal bones, particularly on the right side and extending inferiorly into the right periorbital region. Tiny radiopaque densities within this extracranial soft tissue swelling raise the possibility of foreign bodies. The ventricular system and basal cisterns are normal.

CT scan of head and CT angiogram showed a large right supraorbital haematoma, but no acute stroke (figure 3 …

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