title: Difficulties with the neurological assessment of humans following a chimpanzee attack.
abstract: Chimpanzee attacks can be vicious, mutilating, and disabling if not fatal. Stereotypically, the hands and face are targeted, and in male victims, genitalia are mutilated. The authors present a case highlighting the difficulties with early neurological assessment following such an attack. This 55-year-old woman was attacked by a 14-year-old chimpanzee. She suffered mutilation of both hands, severe midface bony, soft-tissue, and eye injuries, and scalp degloving. An emergency tracheotomy was performed at the scene, with an unclear duration of hypoxia. The patient was unresponsive without spontaneous movements, papillary or corneal reflexes, cough, or gag. Attempts to lighten sedation were not tolerated. Brain CTs were normal. Intracranial pressure monitoring was deemed infeasible. Brain MR imaging suggested diffuse axonal injury consistent with severe shaking trauma. Diffusion tensor imaging indicated intact corticospinal tracts, confirmed by somatosensory evoked potentials. Magnetic resonance imaging suggested left optic nerve transaction, and right retinal detachment was diagnosed. Electroencephalography showed severe diffuse encephalopathy. Auditory evoked potentials showed absent auditory pathway responses except for a right delayed wave V. Visual evoked potentials indicated absent visual function. At 1 month after the attack, sedation and analgesia weaning revealed lower-extremity movement to command, but no upper-limb response. Cervical spine and brachial plexus MR imaging showed brachial plexus edema. Two months after the attack, the patient regained strength in all her extremities and verbally communicated using a Passy-Muir tracheostomy valve. Chimpanzee attacks on humans can cause extensive, life-threatening injuries. The neurological assessment of such patients is challenging, complicated by limb and craniofacial disfigurement and the need for heavy sedation. Initial assessment of nervous system integrity may rely on costly imaging and electrophysiological studies.
authors.affiliation: Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Amer
authors.initials: A
authors.lastname: Khalil
authors.forename: Alejandro M
authors.initials: AM
authors.lastname: Spiotta
authors.forename: Gene H
authors.initials: GH
authors.lastname: Barnett
mesh_terms: D000818:Animals; D002490:Central Nervous System / Q000293:injuries / Q000473:pathology* / Q000503:physiopathology*; D006259:Craniocerebral Trauma / Q000175:diagnosis / Q000473:pathology / Q000503:physiopathology; D004569:Electroencephalography; D005072:Evoked Potentials, Auditory; D005074:Evoked Potentials, Visual; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D009104:Multiple Trauma / Q000209:etiology* / Q000473:pathology / Q000503:physiopathology; D009460:Neurologic Examination; D002679:Pan troglodytes; D059348:Peripheral Nerve Injuries; D010525:Peripheral Nerves / Q000473:pathology* / Q000503:physiopathology*