We present the case of a 56-year-old male, admitted to the emergency room with [TBI] secondary to a gunshot wound in the right posterior parietal area. At admission he was awake with 11 points in the Glasgow Coma Scale [GCS] (O4 V2 M5), right pupil 4 mm, left pupil 3 mm, both light reactive. The initial CT scan (Fig. 1) showed the entry zone of the projectile almost in the midline, bi-parietal intracerebral hemorrhage that was predominant in the right side, with cerebral edema in both occipital lobes. Two hours after admission, he suffered neurological deterioration to 8 points in the GCS (O1 V2 M5) and required intensive care unit [ICU] medical treatment that include: intubation, mechanical ventilation, sedation and analgesia.
We decided to place a parenchimal intracranial pressure monitor in the right Kocher point. The initial intracranial pressure was 60 mmHg, that was persistent despite optimal medical treatment. The patient was taken to the operating room and a posterior bi-parietal decompressive craniectomy was performed. After the Dural opening the intracranial pressure diminished until 42 mmHg; at the end of the surgery the intracranial pressure was 10 mmHg (Fig. 2).
Postoperatively the patient was admitted to the ICU where he was under intensive neuroprotective treatment with intracranial pressures under 15 mmHg. The 24 h postsurgical CT scan showed an adequate surgical decompression and presence of basal cisterns (Fig. 3, Fig. 4).
The patient was kept under sedation and analgesia with midazolam and propofol, maintaining a Richmond Analgesia-Sedation Score [RASS] -5, and the pupils returned to 2 mm, low reflective, he required vasopressor support (norepinephrine) to keep a mean arterial pressure between 90-100 mmHg. His diary urinary output was 1-1.2 ml/kg/h. At day 4 the sedatives were suspended to assess neurological response, however, six days after the surgery the patient underwent tracheostomy because the maximal Glasgow Coma Scale was 8 points; had diminished gag-reflex and developed nosocomial pneumonia. ICU discharged the patient to Neurosurgery service 12 days after, where he completed antibiotic treatment, started rehabilitation and physical therapy. At discharge of our service, at day 16 of hospitalization the patient was with 11 points in the GCS (O4, V1, M6), pupils were 3 mm both adequate light responsive, the surgical wound did not presented any complications, the strength in the 4 extremities was 4/5, reflexes ++, and sensibility was conserved in all of its modalities. Six months after the initial trauma the patient underwent cranioplasty with autologous bone graft.