17-year-old, boy with type 1 diabetes mellitus, presents after having a RTA resulting in bilateral femoral and L1 spine burst fractures with mesenteric contusions. On scene, he had a self-resolving loss of consciousness followed by GCS 14 in ER with some confusion and unremarkable CT head. Had gradual improvement throughout the day, being more conversant within 24 hours. Later, he suddenly developed paroxysmal sympathetic hyperactivity with GCS 7 and normal CT head, followed 2 hours later by episodes concerning for decorticate posturing, requiring Lorazepam and Levetiracetam load with maintenance. He underwent internal fixation and intubated subsequently the next day. MRI brain obtained within 48 hours showed “starfield pattern” on DWI sequence, characteristic for CFE. Echocardiography showed patent foramen ovale. Mental status improved gradually over two-weeks with ability to follow simple commands. Managed supportively, underwent tracheostomy and peg-tube placement and transferred to a rehab hospital.