Ischemic stroke following operated head trauma in children: Discussion of a rare clinical case

INTRODUCTION: Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children. TBI in children are responsible for a range of clinical symptoms and signs that are comparable to those in adults, but present several differences in both physiopathology and management. Many postoperative complications may occur, ischemic stroke among others, which is generally related to an injury of an intracranial artery. Out of this case, it may be more difficult to find a suitable explanation to this complication. CASE PRESENTATION: We report the case of a child aged years old, who was collided by a car causing a polytrauma with head and chest injury. On body scan, she had a fracture of the sixth left rib, and a frontal cranio-cerebral wound. The patient was operated for debridement of the wound, and tight closure of the injured dura mater. Initial postoperative course was uneventful, but 5 days after first surgery patient presented an acute onset of a right hemiplegia followed by an alteration of her state of consciousness, and a left anisocoria. Follow up CT scan showed a stroke of the whole left carotid territory. The patient was re-operated through a left decompressive craniectomy. Following the second surgery, she showed an improvement of her level of consciousness and a normalization of the size of her pupils, but aphasia and a right hemiplegia persisted. 2 weeks after surgery, the patient had a progressive necrosis of the surgical scar, followed by an exposure of the underlying cerebral cortex. Despite of intensive local care, a plastic surgery to recover the wound and antibiotics, the patient presented a meningitis, followed by a septic shock and death. CLINICAL DISCUSSION AND CONCLUSIONS: Ischemic stroke is probably the most harsh and unpredictable complication that may occur after TBI, mainly in children. Only rigorous surgical approach followed by stringent post-operative care may prevent such outcomes.