• Jack Horan, Sean Tromp, and Ncedile Mankahla.
• Department of Neurosurgery, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa. Electronic address: jackhoran27@gmail.com.
• World Neurosurg. 2019 Jun 1; 126: 560-563.

BackgroundLocked-in syndrome (LIS) is a rare neurologic disorder characterized as quadriplegia with anarthria. The diagnosis of LIS is challenging and requires a high index of suspicion. The syndrome is typically caused by an infratentorial lesion to the ventral pons, regardless of etiology. LIS secondary to supratentorial injury is extremely rare, and to our knowledge, this is the first reported case.Case DescriptionWe report the case of a 26-year-old woman who sustained a gunshot to the left suboccipital area, with supratentorial extension. A diagnosis of incomplete LIS was made on the day of admission, with eye movement preservation. Imaging studies confirmed bilateral injury of the motor homunculus. The clinical course was that of progressive improvement, aided by intensive care unit (ICU) supportive care and early physiotherapy rehabilitation. Her condition improved, and she was discharged to a rehabilitation facility at the end of week 7 postadmission.ConclusionsThis is a unique case of incomplete LIS after supratentorial injury. Initial ICU care and early rehabilitation likely played a major role in the full recovery of this patient. The influence of etiology and site of injury on outcome prognosis is also suggested. Although severe diffuse brain injury may occur in the face of an unremarkable computed tomography (CT) scan, the emerging role of magnetic resonance imaging in optimally evaluating traumatic brain injury with discordant clinical and CT information is highlighted and is useful in cases of LIS where prognosis prediction is important.Copyright © 2019 Elsevier Inc. All rights reserved.

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