Pediatric Critical Care Medicine:

May 2014 - Volume 15 - Issue 4_suppl - p 79

doi: 10.1097/01.pcc.0000449063.13568.af

PARADOXAL HERNIATION IN TRAUMA BRAIN INJURY AFTER DECOMPRESSIVE CRANIECTOMY

Mangia, C.M.F.; Macedo, R.G.; Santos, P.B.B.; Oliveira, M.B.; Viana, M.P.; Bergamo, V.C.; Sposito, R.; Vaisberg, P.H.C.

ABSTRACT

Background and aims: The herniation paradoxal is consequence of the trephined syndrome that is a subacute complication of large craniectomies.

Aims: We report a case of a 4-year-old male child who presented major trauma brain injury after motor vehicle accident versus pedestrian.

Methods: He had a crushing lesion on the right side of the skull. Glasgow Coma Score (GCS) was 11T at the hospital admission. His initial CT scan showed frontal comminuted fracture of the right facial bones, frontal, temporal, parietal and nasal bones. Plus skull base fracture throught the temporal floor, soft tissue edema and large pneumocephalus. TBI guidelines was used and intracranial pressure monitoring. After 4 days he presented an uncontrollable intracranial hypertension and signs of severe infection of the brain. A new CT showed reducing size of the lateral ventricles, sulci and cisterns, mildline shift and transcalvarial herniation of the right temporal lobe. The decompressive craniectomy and dural repair was performed. His skul frontal, temporal and parietal right bones were necrotic and were removed. The ICP was controlled on post injury day 7. After 3 weeks his medical condition deteriorated with tachycardia, tachypnea, fever, worsening of nasal cerebrospinal fluid leak and decerebrate posture. CT scan showed paradoxal herniation with uncal herniation, brainstem compression and midline shift.

Results: The medical management was to increase intracranial pressure by placing into Trendelenburg positioning and increasing hydratation.

Conclusions: Our proposal was to bring attention to early diagnosis of paradoxal herniation whose outcome is severe acute neurological deterioration and death.