A 19-year-old woman was admitted comatose at the Emergency Department after a fall from a motorbike (reported low speed but no helmet) with severe TBI. She presented with a GCS of 5/15 (by component: Eyes 1, verbal 2, and motor 2) and 3 mm non-reactive pupils bilaterally. The computed tomography (CT) brain scan at admission showed few left frontal and temporal contusions, a small left frontal epidural hematoma and diffuse brain edema [Figure 1] and the decision was for nonsurgical management.
The patient was intubated and admitted to the intensive care unit (ICU) after placement of an intraparenchymal catheter for measuring and managing of intracranial pressure (ICP) [Figure 2]. The patient was treated conservatively and her condition remained stable with ICP readings of 7-17 mmHg for the following 6 days.
On the afternoon of the 7th post-injury day, while in ICU care, the patient presented an increase in ICP (>25 mmHg with surges of >30) and bilateral non-reactive mydriasis (7 mm). Initial decision was for conservative treatment using mannitol, hyperventilation, and barbiturate coma that controlled the ICP in a range of 17-27 mmHg, but despite that, mydriasis was resistant for >12 h. A reassessment of the patient's condition led to a decision for a final attempt at salvaging the patient by performing decompressive craniectomy.
The pupils were checked immediately before the operation, but no recovery was observed. The patient was then operated using a wide decompressive craniectomy that encompassed bilaterally frontal and temporal areas, and extended as far as possible in the parietal bone. No bony bridge was left above the superior sagittal sinus in the area of the craniectomy; undercutting and smoothing was also performed at the edge of the parietal bone. Furthermore, due to excessive swelling of the underlying brain, we decided to perform dural incisions instead of flap durotomy [Figures 3 and 4].
While immediately postoperatively the patient pupils did not change, the patient's condition presented gradual improvement over the period of the next 3 weeks. She was able to be decommitted from mechanical ventilation, be transported back to the neurosurgical ward and commence physiotherapy, and active kinesiotherapy. The patient's tracheostomy was removed and the patient's outcome at 1 month post-injury was at Glasgow Outcome Scale (GOS) 4 (moderate disability), reaching a GCS of 13/15 (by component: eyes 4, verbal 3, and motor 6). A 1-month post-injury magnetic resonance imaging (MRI) scan also showed significant improvement of the intracranial lesions [Figure 5].
The patient's significant improvement was halted by complications in the form of delayed recurring refractory infections (pulmonary and systematic sepsis) and her clinical status gradually deteriorated, leading to her death due to sepsis after 3 months (ultimately GOS 1) despite combined management with the hospital's infections team.