Delayed recovery from severe refractory intracranial hypertension due to expansion of skin and pericranium stretch after decompressive craniectomy.

purposeDecompressive craniectomy immediately reduces intracranial pressure by increasing space to accommodate brain volumes. Any delay in reduction of pressure and signs of severe intracranial hypertension requires explanation. CLINICAL FEATURES: We present the case of a 13-yr-old boy presenting with a ruptured arteriovenous malformation resulting in a massive occipito-parietal hematoma and increased intracranial pressure (ICP) refractory to medical management. This patient ultimately underwent a decompressive craniectomy (DC) for alleviation of increased ICP, despite which the patient's hemorrhage continued to worsen to the point of brainstem areflexia suggestive of possible progression to brain death. Within hours of the decompressive craniectomy, the patient displayed a relatively sudden, marked improvement in clinical status, most notably a return in pupillary reactivity and significant decrease in measured ICP. A review of postoperative images after the decompressive craniectomy suggested increases in brain volume that continued beyond the initial postoperative period.

conclusionWe urge caution to be taken in the interpretation of the neurologic examination and measured ICP in the context of a decompressive craniectomy. In the patient described in this Case Report, we propose that ongoing expansion of brain volume following a decompressive craniectomy beyond the initial postoperative period, possibly secondary to the stretch of skin or pericranium (used as a dural substitute for expansile duraplasty), can explain further clinical improvements beyond the initial postoperative period. We call for routine serial analyses of brain volumes after decompressive craniectomy to confirm these findings.