Improvement in Coma Recovery Scale-Revised Score Following Trendelenburg Positioning in Syndrome of the Trephined: A Case Report

Philadelphia, PA

Disclosures: None

Setting: Inpatient Rehabilitation Facility

Patient: 44-year-old woman status post decompressive hemicraniectomy with suspected syndrome of the trephined.

Case Description: The patient sustained a non-traumatic brain injury secondary to ruptured right posterior communicating artery aneurysm. She required aneurysm coiling and right decompressive hemicraniectomy. Her course was complicated by right hemispheric strokes, seizures, and hydrocephalus requiring ventriculoperitoneal shunt (VPS) placement. She was admitted to inpatient rehabilitation for a specialized disorder of consciousness (DOC) program 6 weeks after the initial bleed. Her initial Coma Recovery Scale-Revised (CRS-R) score was a 3 of 23 indicating unresponsive wakefulness syndrome (UWS).

Assessment/Results: Patient remained in a UWS after a week of inpatient rehabilitation and there was concern that syndrome of the trephined was contributing to her failure to progress. The CRS-R was performed both supine and in Trendelenburg position to assess for a positional component to her scoring. The CRS-R score supine was 11 indicating minimally conscious state (MCS). The CRS-R score in Trendelenburg position was 13 with new functional and accurate communication indicating emergence from MCS. Subsequent CRS-R score supine was 9 indicating MCS. She was referred to neurosurgery and underwent cranioplasty. Upon readmission to inpatient rehabilitation her initial CRS-R score was 23 indicating emergence from MCS.

Discussion: For patients in a DOC it can be challenging to assess for syndrome of the trephined due to poor baseline neurologic examination. Temporizing measures that increase intracranial pressure can mitigate symptoms of syndrome of the trephined such as intravenous fluids, Trendelenburg position, and increasing VPS settings, but definitive treatment is cranioplasty. This case highlights the use of Trendelenburg position to demonstrate subtle clinical improvement to support the diagnosis of syndrome of the trephined.

Conclusion: Assessing for improvement in standardized neurobehavioral assessments in Trendelenburg position should be considered for DOC patients with suspected syndrome of the trephined.