Emily Hon, MD
Physician Fellow
Mount Sinai Hospital
New York, New York, United States
Aliza Perez, DO
PGY-2 Resident Physician
Icahn School of Medicine at Mount Sinai
New York, New York, United States
Jason Wang, BA
Medical Student
Rutgers Robert Wood Johnson Medical School
Bridgewater, New Jersey, United States
Megan E. Andrews, MD
Attending Physician
Mount Sinai Hospital
New York, New York, United States
Alyssa M. Volmrich, MD
Assistant Professor
Icahn School of Medicine at Mount Sinai
New York, New York, United States
Miguel X. Escalon, MD
Program Director
Icahn School of Medicine at Mount Sinai
NY, New York, United States
Hydrocephalus in a patient with dual diagnosis TBI and SCI
A 28 year-old-male with no past medical history suffered a fall from a height while intoxicated, resulting in a subdural hematoma, subfalcine herniation, and multiple thoracic burst fractures. He underwent right-sided hemicraniectomy and thoracic spine decompression and stabilization. Nearly three months later, he was admitted to acute rehabilitation for his traumatic brain injury (TBI) and spinal cord injury (SCI). On the admission physical exam, he had a T6 ASIA A SCI and was oriented only to self, despite optimization of medical management. Further imaging revealed significant left-sided hydrocephalus, for which neurosurgery placed a ventriculoperitoneal shunt (VPS). His immediate postsurgical cognition improved to where he was oriented to person and place.
Comorbid severe TBI and SCI are notoriously complex cases to address. Here, the patient’s improvement in cognition unexpectedly plateaued in the acute rehabilitation setting, prompting workup to assess for contributing causes. Although the classic symptoms of urinary incontinence and gait disturbances were absent in this case due to SCI, hydrocephalus remained on the differential as a reversible cause of cognitive decline. When hydrocephalus was identified on imaging, VPS was placed and cognition fortunately improved. Improving cognition in patients with comorbid SCI and TBI is critical in the rehabilitation setting. First, cognition impacts a patient’s ability to reliably follow commands. Second, successfully educating the patient about SCI-related aspects of care (e.g., bowel management) requires the patient to carry over information between sessions.
Maximizing cognition in patients with comorbid TBI and SCI improves TBI outcomes and influences SCI ones. Here, identifying and treating hydrocephalus – a reversible cause of cognitive deterioration – resulted in immediate changes in his physical exam that impacted the remainder of his acute rehabilitation course.
