Cautionary case: Low Glasgow coma scale scores, brainstem involvement, decompressive craniectomy, full recovery, and one more reason for advocacy/collaboration

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Case study of a 21-yr-old premed college student with severe traumatic brain injury (TBI) describes an exceptional outcome that may have been facilitated by decompressive craniectomy (DC), while highlighting need for caution in development of potentially overly restrictive presurgical selection criteria. Presurgical selection criteria for DC treatment of severe TBI remain controversial. Proposed criteria to improve outcomes include high admission Glasgow Coma Scale (GCS) scores (≥7) and exclusion of patients having brainstem involvement. The patient, who initially had a GCS score of 3, left fixed dilated pupil, and brainstem signs, had emergency DC following a motor vehicle crash. Nine years after the trauma, she was employed full time as a physician, and only residual symptom, an occasional headache, remained. The authors conclude that caution is necessary in the development of DC presurgical selection guidelines, as this case had excellent long-term functional outcome that may have been facilitated by DC despite initial low GCS scores and signs of brainstem involvement. Also, this case highlights one more reason for multispecialty physician advocacy, collaboration, and comparative effectiveness research.

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