Disclosures: John P. Pianka, MD: No financial relationships or conflicts of interest

Case Diagnosis: A 22-year-old male with severe Traumatic Brain Injury (TBI) with grade III Diffuse Axonal Injury (DAI) following a motor vehicle accident.

Case Description: Patient initially presented following a motor vehicle accident with grade III DAI, as well as subarachnoid and subdural hemorrhage and global cerebral edema. He underwent a decompressive craniectomy and was ultimately admitted to acute inpatient rehab on post-op day 10 in a vegetative state.The patient demonstrated what was considered to be mild paroxysmal sympathetic hyperactivity during his rehabilitation stay. He developed fevers and leukocytosis on post-op day 6; however, infectious workup was negative and these improved spontaneously. Leukocytosis recurred on post-op day 31. At this time, a repeat head CT scan disclosed a left frontal intracranial abscess with associated left frontotemporal empyema. Patient was emergently transferred to an acute care hospital and underwent surgical evacuation of the abscess. He was re-evaluated post-operatively by his same physiatry team to assess his appropriateness for continued inpatient rehab.Assessment/

Results: Patient initially presented to inpatient rehabilitation with a JFK Coma Recovery Scale-Revised (CRS) score of 3 and unfortunately remained in the 2-3 range despite intensive therapy and aggressive neurostimulant trials over 3-4 weeks. However, when re-evaluated shortly after evacuation of his brain abscess, CRS score had improved to 7.

Discussion: Given patient’s poor neurologic progression prior to discovery of the brain abscess (JFK unchanged at 2-3 for weeks), followed by his rapid improvement following evacuation (CRS 7), the abscess likely contributed to his lack of progress. Earlier recognition would have led to earlier management and functional progress.

Setting: Acute inpatient rehabilitation hospital.

Conclusion: A low threshold for re-imaging should be considered in TBI patients who demonstrate little to no progress, particularly if the patient is demonstrating signs of infection without an obvious cause.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/latent-brain-abscess-stalling-progress-in-a-vegetative-patient-a-case-report/