BrainAndCo

Physician Assistant

Case Report

A right-handed 40-year-old female was found unconscious and partially disrobed in a parking lot mid-morning. She appears to have survived attempted homicide following a sexual & physical assault. Per EMS, she is agitated and minimally following commands in the field.

Exam on Arrival:

• GCS 7 (E1-V2-M4)
• No longer following commands
• Pupils: 3 to 4 mm; equally reactive
• Brainstem reflexes are present

Labs:

• PT/INR/PTT: normal
• etOH: 0.19 g/dL
• Cocaine: positive
• NA: 129 mg/dL

Head CT shows multiple left temporal lobe hemorrhagic contusions, complete effacement of most of the basal cisterns, and 11 mm of left-to-right midline shift. She undergoes emergent decompressive hemicraniectomy.

Follow-Up:

Fig. 3 shows head CT on POD#1 with improved midline shift and patency of the basal cisterns. So far, so good. But we don’t treat the scan, we treat the patient. The crani flap is full and she is now following commands.

Three months later (fig.4), she walks into the clinic for evaluation for cranioplasty with nearly intact speech and comprehension.

Discussion

This discussion will be about traumatic brain injury (TBI). What are the indications for and controversies surrounding surgical management? What is your prognosis for a case like this? What factors are key in optimizing the care of patients with TBI?

For help with structures, see fig. 5, and for more MedEd, see the link in our bio.