A 56-year-old man (height: 5'11'' and weight: 194lbs) was brought to the ED via ambulance after being assaulted by multiple individuals and run over by a motor vehicle. The patient was brought into our Level II trauma center as a trauma code and had CPR on entry into the trauma bay. The patient had suffered blunt trauma to the face with orbital ecchymoses and maxillary edema, traumatic brain injury (TBI) with no discrete hemorrhages but soft tissue emphysema of the anterior neck, extensive soft tissue swelling overriding the right face, Hydrocephalus, bilateral pneumothoraxes, bilateral pulmonary contusions, multiple rib fractures including right ribs 1 through 8 anteriorly; right ribs 4 through 6 laterally; left ribs 2 through 7 anteriorly; left ribs 3, 4, 5, 8, 9, 10, 11 laterally, flail chest, hypoxic and hypercapnic respiratory failure, grade I pancreatic laceration, left scapula fracture, right sacral fracture extending into right sacroiliac joint, right superior and inferior pubic rami fracture, unstable right knee, unstable left knee, left humeral fracture, hemorrhagic shock. He required emergent tracheostomy, and massive transfusion protocol. The patient was GCS 3 t. Bilateral chest tubes were placed for the bilateral pneumothoraxes. Vitals post return of spontaneous circulation were blood pressure of 90/56 mmHg and a heart rate of 89 beats per minute. Resuscitation continued until the patient's vitals were within normal limits. Bilateral occipital hemorrhages were seen on CT of the head which required insertion of an external ventricular drain. The patient was also maintained on Keppra (levetiracetam) for seizure prophylaxis. As the patient started to be weaned off of IV sedation, the opening intracranial pressures were stable and the external ventricular drain was removed on hospital day 8. A state of permissive hypertension was maintained to ensure adequate perfusion to the brain post cerebrovascular accident with pressures ranging from 140 to 181/64 to 89 mmHg. On hospital day 12, a gastric feeding tube was placed bedside in the surgical ICU. On hospital day 14 the patient was stable enough to undergo an MRI. The MRI showed possible vertebral artery dissection and neurosurgery was consulted (See Fig. 2).
Per neurosurgery, it was unlikely to be a vertebral artery dissection due to the lack of specific vertebrobasilar disruption on the initial CTA head and neck. No further studies were recommended due to the patient's injuries associated with trauma and hemodynamic instability causing potential stroke and/or embolus.
On hospital day 30, the patient developed acute acalculous, cholecystitis and a percutaneous cholecystostomy tube was placed on hospital day 31. The patient remained in a persistent vegetative state, which resulted in a prolonged hospital stay. He developed Serratia bacteremia and Vancomycin resistant Entercocci (VRE) in the urine.
On hospital day 104, the patient underwent repeat MRI and a CT of the head due to his persistent vegetative state. The CT scan showed questionable small linear areas of hyperintensity in the posterior occipito-parietal junction as well as enlarged ventricles suggesting the recurrence of hydrocephalus. The MRI of the brain showed extensive stable white matter disease without evidence of acute infarct (See Fig. 3). A plan for a permanent ventriculoperitoneal (VP) shunt was made. On hospital day 127, another CT of the head was performed which revealed a diminished attenuation within the cerebral white matter (See Fig. 4). These findings along with those from hospital day 104, could have been suggestive of PRES, however, the neurologic status of the patient made it difficult to assess any clinical correlation. On hospital day 128, the patient had a VP shunt placed.
Over the patient's 132-day long hospital course, the neurological status ranged from GCS 3 t-6 t with the only improvements observed being spontaneous opening of the eyes and brief periods of withdrawing to painful stimulus. The patient was eventually discharged to a long-term acute care facility on hospital day 132.