Decompressive craniectomy in a neonate.

A nearly 41 week female infant was born by emergency c-section for decreased movement/fetal distress.  APGARs were 2, 2, 5, 6 and 6.  Initial venous blood gas was 7.29/27/54/13.1 with base deficit 13. Lactate was 109. AST peaked in the mid 200’s.  She was not intubated. She was treated with a total body cooling protocol.  Amplitude integrated EEG showed marked asymmetry with suppression of left hemisphere.  There was onset of left hemispheric frequent seizures <12 hours after birth.  She required levetiracetam, phenobarbital and fosphenytoin to manage seizures. MRI first done at 4 days showed large left hemisphere stroke involving entire MCA and PCA territories.  ACA territory spared.  The stroke affected the entire left basal ganglia and thalamus and some midbrain involvement.  There was significant mass effect with 7 mm midline shift and uncal herniation. There was no visible hypoxic-ischemic injury to the right hemisphere. She underwent decompressive left hemicraniectomy.

MRI with T2 weighted imaging at 4 days shows massive left hemisphere hypoxic-ischemic injury with midline shift.

MRI with diffusion weighted imaging at 4 days of age.

T2 MRI at 9 days of age following decompressive craniectomy shows resolution of midline shift and evidence of evolving hypoxic-ischemic injury to the left hemisphere diffusely.

MRA at 9 days of age shows attenuation of the left internal carotid artery and absence of the left middle cerebral artery.  There is hemorrhagic change in the left cerebral hemisphere.