Fellow University of Minnesota Eagan, Minnesota, United States
Case Diagnosis: Traumatic Brain Injury case that required Neurosurgical interventions for frontotemporal SAH, Subdural hematoma, and fracture of the temporal bone complicated with pneumocephalus and Syndrome of the Trephined.
Case Description: 38-year-old female with TBI, sustained a left frontotemporal SAH, Subdural hematoma, and fracture of temporal bone requiring decompressive craniectomy.
During Inpatient Rehabilitation, required hyperbaric oxygen therapies for skin flap integrity. Upon a week of Rehabilitation, the team noted a new right facial droop and Right arm weakness; imaging revealed Pneumocephalus. Hyperbaric oxygen therapies were stopped, and Neurosurgery recommended high-flow oxygen therapy with occlusive dressing to the skin flap, subsequently required transfer to Neurosurgery, where there was a resolution of pneumocephalus with said treatment.
The patient required cranioplasty takedown for concerns of infection and started antimicrobial therapy. Subsequently presented with a sunken flap and worsening Right-sided weakness, consistent with Syndrome of the trephined. Cranioplasty was not desired due to infection. The team had to develop potential solutions. In the end, positional changes improved the patient’s symptoms, and was able to be scheduled for definite cranioplasty upon completion of antibiotics.
Discussions: Pneumocephalus is a common complication challenging to diagnose clinically. CT is the preferred imaging, and a prompt resolution is warranted to prevent serious outcomes. Syndrome of the Trephined is a serious complication that warrants cranioplasty for resolution; when unable to do cranioplasty, different options can be tried, including external cranioplasty and, in this case, positional changes.
Conclusions: This is the first case report of Pneumocephalus and Syndrome of the Trephined occurring in the same patient. Both complications can be observed after surgical interventions that can rapidly progress and be fatal unless corrected. It is essential to recognize these conditions as they can present in our practice during the Acute inpatient Rehabilitation stay.
