A 28-year-old man, with history of chronic alcohol abuse was found unconscious, with approximately 24 h after a traumatic brain injury (TBI) of unknown mechanism. He was admitted to our hospital for neurologic assessment and management. As recommended by the American College of Surgeons, his treatment followed the Advanced Trauma Life Support Management of severe brain injury protocol. A neurological examination revealed a Glasgow Coma Scale score of 6 and left anisocoria. He underwent brain computerized tomography (CT) that showed left hemispheric swelling associated with a temporo-parietal linear fracture and an acute subdural hemorrhage.
He was immediately transferred to the operating room and, after balanced standard general anesthesia, he received a left question mark incision and a fronto-temporo-parietal craniectomy. After a durotomy and acute subdural drainage, he underwent dura mater reconstruction using galea aponeurotica. After standard subcutaneous tissue and skin closures, the extracted bone flap was bisected via osteotomy and both parts were subcutaneously stored in his left abdomen.
Immediately after the procedure, the patient underwent postoperative CT scanning before his intensive care unit (ICU) admission. This revealed an acute epidural hematoma, so he was returned to operating room for further neurosurgery. After standard balanced general anesthesia, the question mark incision was reopened and the hematoma was removed. No active bleeding site was identified. After careful hemostasis, the skin flap was sutured shut, and the patient was transferred to the ICU.
Because the patient presented diffuse brain edema, he was postoperatively sedated for 2 days, at which point CT scanning confirmed that his condition had improved. However, he was mildly sedated during the time of extubation. He developed pneumonia due mechanical ventilation, so he was tracheostomized and discharged from ICU without mechanical ventilation. Seven days before his hospital discharge, his tracheostomy cannula was withdrawn.
The patient underwent repeated neurological examinations in the ICU. His pupils were anisocoric throughout his hospitalization. His Glasgow Scale score improved to 10T in the ICU and progressed until 15 after his ICU discharge. No motor deficits were identified at discharge.
At his hospital discharge, which happened 33 days after the first procedure, he was orientated and alert but still had a left third cranial nerve deficit.
One hundred and four days after craniectomy, the patient underwent a cranioplasty with his two abdominally stored autologous bone flaps. His head was positioned in a horseshoe-shaped restraint and the question mark incision was antiseptically reopened. A dissection was made between the galea and the dura mater to isolate the craniectomy's border. The abdominal incision was reopened to withdraw the bone flaps.
During evaluation, signs of bone resorption were detected at the bone flaps temporal parts, but no corrections were made due to the poor esthetic results typically obtained from acrylic mold. Figure 1 shows the result obtained immediately after the cranioplasty. No adverse events were identified, though the patient received prophylactic cefuroxime for 48 h.
Ten months after the craniectomy and 7 months after the cranioplasty, the patient returned to the trauma clinic with secondary bone defects related to near complete. It reached almost 95% of bone flap resorption, as proven in CT scan in Figures 2 and 3. External results can be observed in Figures 4 and 5.
The patient is waiting for secondary cranioplasty with allogenic material and has made a seemly good neurological recovery considering the primary situation he had score 6 in Glasgow Outcome Scale - Extended.