Lightning injuries: neurologic complications

Douglas J Lanska MD FAAN MS MSPH (Dr. Lanska of the Great Lakes VA Healthcare System and the University of Wisconsin School of Medicine and Public Health has no relevant financial relationships to disclose.)
Originally released July 7, 2003; last updated January 29, 2017; expires January 29, 2020

Overview

For patients who survive lightning strikes, neurologic complications can be devastating. The great majority of prolonged or permanent complications involve the central nervous system. These lesions include posthypoxic encephalopathy, intracranial hemorrhage, cerebral infarction, and myelopathy. Many lightning survivors are plagued with persistent neuropsychological and behavioral problems that interfere with employment and family life. These neurologic complications are especially tragic because they often involve young healthy people who had been engaged in sports or recreation. For these reasons, individuals should be familiar with lightning safety recommendations and take prudent precautions to prevent a lightning injury. Ball lightning encephalopathy resembles the clinical condition seen in lightning-strike patients.

Historical note and terminology

Early deities and mythological gods used thunderbolts to punish their enemies and wayward humans. These early deities included Thor, the Scandinavian god; Zeus, the Greek king of gods; and Jupiter, the Roman god. The splendor and horror of lightning have been captured in the poetry and writings of many great writers, including English playwright and poet William Shakespeare (1564-1616) and English dramatist and poet Sir William Schwenck Gilbert (1836-1911).

In 1752, American scientist and diplomat Benjamin Franklin (1705-1790) made a major breakthrough in our scientific understanding of lightning when he deduced that lightning was a form of electricity. Nearly 2 centuries after Franklin's kite experiment, researchers have established that cloud-to-ground lightning is a transient, high-current electric discharge. The subsequent lightning return strokes have peak currents on the order of 20 to 40 kA (Krider and Uman 1995).

Although many authors cite French neurologist Jean-Martin Charcot (1825-1893) as the first to describe lightning-induced paralysis (keraunoparalysis), transient lightning-induced limb weakness was described earlier by English physician James Parkinson (1755-1824) in 1789 (Parkinson 1789; Morris 1989; Cherington 2004; Cherington 2006; Poirier 2013). Parkinson reported that 2 men were struck by the same lightning strike during a violent storm on July 17, 1787.

One of the men was described by James Parkinson:

[He] had been taken up to all appearance dead, and by the accounts of the neighbours, had remained in that state upwards of a quarter of an hour; but, when I saw him, the vital organs had resumed their functions, although so very imperfectly as to render the circumstance of their having been suspended, highly credible: respiration was performed with much difficulty and irregularity; and the circulation of the blood still carried on so partially as not to be discoverable at all by the pulse in the lower extremities; nor, without extreme attention, in the arteries at the wrist, although the pulsation of the carotids, at the same time, was not perceptibly different from that with might be supposed to be natural. His head was bent considerably backwards, in which state it remained immoveable, notwithstanding his endeavors, and those of his attendants, to bring it forward. His countenance was flushed; and his eyes, which he had almost lost the power of moving, were red, and, in consequence of their not being both directed to the same object, appeared wild and staring, which appearance was farther increased by the eyelids being widely opened and the pupils considerably dilated. His hands and legs resembled those of a corpse, being excessively cold, and of a dark livid colour, nearly approaching to black. A large red streak appeared on his right side, and several lesser ones on his legs, the skin in all those places being evidently scorched. He complained of a total loss of sense and motion in the lower extremities, and of much pain in the head and chest; which last was aggravated by a frequent cough, by which a considerable quantity of blood was thrown up…He was then put to bed…an universal sweat soon broke out, which was followed by an easy sleep, from which he awoke so much relieved, that, when I saw him, two hours after, his head and chest being free from pain, the spitting of blood stopped, the muscles at the back of the neck relaxed, and the use of the limbs restored (Parkinson 1789).

Parkinson also described a peculiar erythematous, painless, branching, skin pattern, which is now called “Lichtenberg figures.”

Image: Lichtenberg figures
Lichtenberg figures (German: Lichtenberg-Figuren), or "Lichtenberg dust figures", are branching electric discharges that sometimes appear on the surface or in the interior of insulating materials, including the skin. Lichtenberg figures are now known to occur on or within solids, liquids, and gases during electrical breakdown. Lightning itself is a naturally occurring 3-dimensional Lichtenberg figure. Lichtenberg figures are named after the German physicist Georg Christoph Lichtenberg (1742-1799), who originally discovered and studied them in 1777.
Image: Georg Christoph Lichtenberg (1742-1799)

Cutaneous lightning-induced Lichtenberg figures have been described by others as “branching” (Resnik and Wetli 1996), “ferning” (Resnik and Wetli 1996; Cherington et al 2007), “fern-like” (Mahajan et al 2008; Wollina et al 2015), “fern leaf” (Domart and Garet 2000; Schmidhauser and Azzola 2011), or “dendriform” (Johnstone et al 1986). Like keraunoparalysis, Lichtenberg figures are a transient lightning-induced finding (Johnstone et al 1986; Resnik and Wetli 1996; Domart et al 2000; Gupta 2001; Cherington et al 2003; Cherington et al 2007; Mahajan et al 2008; Schmidhauser and Azzola 2011; Nagesh et al 2015; Wollina et al 2015; Yigit et al 2015). Lichtenberg figures are not a burn, and skin biopsies have not demonstrated pathologic changes (Cherington et al 2007).

The second man reported by Parkinson had Lichtenberg figures:

A red streak, about two inches wide, passed down his right side, from which, on each side, several ramifications branched out, exactly representing, in figure, those vivid corrusgations, which are so frequently seen to fly off, from any little pointed elevation on the surface of an electrified insulated conductor. A similar, but lesser streak, with similar branches, appeared on his right arm, and on the fore part of each leg and thigh; from all these he felt considerable burning pain…By the next day he was entirely free from all his complaints, except the burning pain which he still felt where the lightning had so beautifully marked him; this, however, was soon lessened by the use of a saturnine [lead] lotion; the streaks becoming, in two days time, of a brownish colour, and, in a few days more, no other vestige remained than the roughness of the cuticle, which was then peeling off (Parkinson 1789).

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