Dhanyashri was brought to Apollo Hospital (Tondiarpet) in a very critical condition with severe brain injury and other minor fractures and injuries, after a man fell on top of her from the second floor of an apartment building. She was shifted to Apollo Children’s Hospital in an extremely critical condition.
The high-impact concussion resulted in Dhanyashri’s brain becoming rapidly swollen and, despite instituting the highest levels of neuro-protective care in the Pediatric ICU at Apollo Children’s Hospital, the brain swelling progressed (malignant cerebral edema). The restrictive effect of the surrounding bony skull against the swollen brain resulted in a dangerously high brain pressure, known as elevated intracranial pressure (ICP). The ICP is normally less than 15mmHg, whereas Dhanyashri’s Intracranial Pressure (Brain pressure) rose to 30 to 35mmHg despite institution of all medical measures.
Uncontrolled high ICP levels can result in the brain “herniating”/ squeezing right out of the skull, thus damaging many vital centres which sustain life, such as centres that control breathing and circulation. Brain herniation is a near-terminal condition that if not reversed, usually results in a state known as “brain-death”. Therefore, if medical treatment doesn’t help to normalize ICP, doctors must quickly institute the next level of surgical treatment, which is emergency decompressive craniectomy: this is a life and brain-saving surgery, where experienced neurosurgeons remove parts of the skull bone, thus permitting the swollen brain to expand without the constricting effect of the skull.
This was the exact sequence in Dhanyashri’s neuroprotective care. Her brain swelling and ICP was initially managed by medical treatment in the pediatric ICU. When the brain swelling progressed despite maximum medical treatment, she was moved up to the next level of ICP control necessitating emergency brain decompressive craniectomy.
Explaining the procedure further, Dr. Suchitra Ranjit, Senior Consultant PICU said, “As part of intensive treatment of traumatic brain injury, intracranial pressure (ICP) is monitored with a delicate and precise pressure-monitor placed within the brain. Intensive medical treatment, including general anesthesia in the ICU is necessary when the ICP is greater than 15mmHg. Brain pressure between 25mmHg to 30 mmHg brain in a child is critically high and potentially fatal, because it causes compression and subsequent death of brain tissue, and cessation of vital centres that control life”
She added, “The PICU team and the Neurosurgeon decided that emergency decompression was the only way to save Dhanyashri and was performed 48 hours after admission, when the ICP was at its peak. Decompressive surgery is a neurosurgical procedure in which a part of the skull is removed to allow a swelling brain more room to expand without being squeezed. The swollen brain tissue expanded out of the gap created by the craniectomy in the skull, and the ICP immediately subsided, thus preventing fatal brain herniation. In the next few days, Dhayashri’s neurological function had improved, and we could wean Dhanyashri from the ventilator and other PICU therapies. Dhanyashri’s recovery is satisfactory, and will be discharged soon.”
