Bilateral decompressive craniectomy in a predominantly hypoxic brain damage

Introduction: We report a case of a 3 year old patient with general hypoxic ischemic brain damage and following malignant brain swelling and threatening herniation, treated by bilateral craniectomy.

Case: Three years old girl after accidental fall out of a window from fourth floor. Initially GCS 3, insufficient breathing. Because of insufficient breathing and seizure, she got resuscitation and intubation after emergency doctor arrived. She was admitted to our hospital after stabilisation. CT scan of the brain showed subdural haematoma, no fracture. Additional problems like pneumothorax, vertebral bone fracture and spleen and liver injury. MRI of the head showed bihemispheric hypoxic brain damage. We meassured increased intracranial pressure by an intraparenchymal pressure sensor under conservative intensive treatment. On day three malignant brain swelling occurred and was treated by bihemispheric decompressive craniectomy.

Intracranial pressure was stabilized and extubation was possible. After few days the patient was awake and showed a pleasing improvement.

After rehabilitation for six weeks the patient was readmitted for bilateral bone flap replantation because of increasing bilateral subdural hygroma.

Neurological examination showed deficit in fine motor skills, moderate ataxia and weakness. Glasgow outcome scale 5

Discussion: Despite signs of general hypoxic brain damage, after bilateral decompressive craniectomy we have seen an amazing good clinical outcome with minimal neurological deficit. Expanding the indication of craniectomy to include malignant brain swelling due to hypoxia following drowning or strangulation is, what should be considered.