Comprehensive multidisciplinary neurorehabilitation in severe traumatic brain injury. Post-decompressive craniectomy and cranioplasty: A case report

Deepak Prasad J1*, Jyothi Bai2, Adithya AS2, Ebin Shiji2, Sushmidha2

1Consultant & Incharge – Dept of Physical Medicine & Rehabilitation, Kauvery Hospital, Marathahalli, Bangalore

2Physiotherapy Team, Department of PMR, Kauvery Hospital, Marathahalli, Bangalore

*Correspondence

Abstract

Severe traumatic brain injury (TBI) accompanied by acute subdural hematoma (SDH) and diffuse axonal injury (DAI) typically presents profound cognitive, motor, and functional impairments. Management mandates a highly synchronized, interdisciplinary approach spanning acute neurosurgical intervention, specialized medical management, and rigorous, progressive neurorehabilitation. We report the case of a 23-year-old male engineer who sustained a severe TBI following a road traffic accident (RTA). Following an emergency left fronto – temporo-parietal decompressive craniectomy and subsequent cranioplasty, the patient underwent a structured 6-week inpatient multidisciplinary rehabilitation program led by Physical Medicine and Rehabilitation (PMR) Physician. The team consists of Physiotherapists, Speech & swallow therapists, Rehabilitation Nursing Team, Respiratory Therapy Team & Dietician. This comprehensive case report details his remarkable journey from profound cognitive impairment and complete functional dependence (Initial Functional Independence Measure [FIM] score: 18) to independent ambulation under supervision and significant cognitive recovery (Discharge FIM score: 84).

Key words: Traumatic brain injury (TBI); Subdural hematoma; Road traffic accident (RTA).

Introduction

Traumatic brain injury (TBI) remains a leading cause of global mortality and long-term neuro disability, frequently affecting young, productive demographics. Severe TBI characterized by mass-effecting subdural hematomas and diffuse axonal injury often necessitates emergent life-saving decompressive craniectomy. While surgical interventions address structural crisis and intracranial hypertension, the subsequent residual focal deficits such as hemiparesis, cognitive deficits, dysarthria, and severe balance degradation require early, systematic neurorehabilitation to promote neuroplasticity. This case report illustrates the vital role of a structured, phased rehabilitation protocol designed by the Neuro-Rehabilitation Team led by PMR Physician in achieving optimal functional recovery.

Case Presentation

A 23-year-old male engineer with no significant comorbidities or relevant past medical history presented to the emergency department and was later referred to the Department of Physical Medicine and Rehabilitation for Neurorehabilitation. The patient had sustained severe TBI in an alleged road traffic accident (RTA) on April 15, 2026.

Following the initial trauma, he was admitted to Kauvery Hospital, Hosur, where neuroimaging revealed a left fronto-temporo-parietal (FTP) acute subdural hematoma (SDH) with significant mass effect, a left frontal bone fracture, bilateral tentorial bleed, frontal contusions, and diffuse axonal injury (DAI) with multiple cerebral microhemorrhages. An emergency left FTP decompressive craniectomy with evacuation of the hematoma was performed on April 15, 2026. A tracheostomy was executed the following day (April 16, 2026) for securing airway management, and the bone flap was preserved in an abdominal pouch. Following clinical stabilization, the patient was transferred to our facility in Marathahalli, Bangalore, for comprehensive inpatient rehabilitation. He undergone 6 weeks of IP rehabilitation at PMR Dept. During his rehabilitation trajectory, a planned cranioplasty was successfully performed by neurosurgeon in Kauvery hospital Hosur on May 26, 2026, and was transferred to the PMR dept at Kauvery Hospital Marathahalli for further rehabilitation. Cranioplasty after decompressive craniectomy can help in facilitating neurological rehabilitation and potentiate neurological recovery when combined with early Neuro-Rehabilitation measures.[2]

Clinical Evaluation & Objective Assessment

Initial Assessment (April 2026) vs. Re-evaluation (June2026)

Neurological Status & Higher Mental Functions

Level of Consciousness: On admission, the patient’s Glasgow Coma Scale (GCS) was E3VTM1 (Eye opening to speech, verbal response non-testable due to tracheostomy, and no motor response). By June 13, 2026, the patient was fully conscious, alert, and oriented with a GCS of E4V5M6.

Cognitive Assessment

  • Mini-Mental State Examination (MMSE): On admission, MMSE cannot be tested as the patient was unconscious; MMSE was 24/30 on June 13, 2026, indicating mild cognitive impairment, with specific deficits noted in orientation to time/place, registration recall, and multi-stage commands.
  • Montreal Cognitive Assessment (MoCA): On admission, MoCA cannot be tested as the patient was unconscious; MoCA was 24/30 on June 13, 2026, confirming mild cognitive impairment with minor executive, attention, language, abstraction, and delayed recall deficits.
  • Cranial Nerves: Examination revealed involvement of the Left Optic (CN II) and Left Facial (CN VII) nerves, manifesting as facial palsy & blurred vision. Other cranial nerves were intact.
  • Sensory Examination: Superficial (pain, temperature, touch) and deep (proprioception, vibration, kinesthetic movement sense) sensations were fully intact bilaterally.

Musculoskeletal and Motor Examination

Observation & Posture: The patient initially exhibited a classic left hemiplegic posture (shoulder adducted/internally rotated, elbow semi-flexed, forearm pronated, wrist flexed, hip extended/adducted, knee semi-flexed, ankle plantarflexed and inverted).

  • External Appliances: Tracheostomy tube, Foley’s catheter, and Ryle’s tube were present on admission.
  • Palpation: Grade 1 pitting edema was initially noted over the left dorsum of the foot and ankle, which completely resolved by June 13, 2026. Grade 3 tenderness (winced and withdrew limb) was noted over the left calf musculature on admission.
  • Muscle Girth Assessment: Left calf girth measured 13 inches compared to the right side’s 15.7 inches, indicating significant muscle atrophy (2.7-inch discrepancy) in the affected left lower limb. True and apparent limb lengths were normal.
  • Tone & Brunnstrom Stages: Initially, left upper and lower limb flaccidity was noted (Brunnstrom Stage 1). Over the 6-week period, the patient demonstrated an extraordinary evolution, achieving a Brunnstrom Stage 6 (return of fine motor skills) by June 13, 2026.
  • Reflexes: Deep tendon reflexes (DTR) revealed marked hyperreflexia (+4) in the left knee and ankle jerks, indicative of upper motor neuron (UMN) involvement. Upper limb reflexes (biceps, triceps, supinator) remained normal (+2).

Range of Motion (ROM) & Manual Muscle Testing (MMT)

Passive ROM (PROM) of all joints remained fully preserved.

Joint / MovementRight MMTLeft MMT
Shoulder Flex/Ext/Abd/Add/Rot5/52+/5
Elbow Flexion / Extension5/53+/5
Wrist Flexion / Extension / Deviation5/52+/5
Hip Flex/Ext/Abd/Add/Rot4/52+/5
Knee Flexion / Extension4/52+/5
Ankle Dorsi/Plantarflexion/Inversion4/52+/5

Balance, Coordination, and Gait Analysis (Tested in June 2026)

Berg Balance Scale (BBS): Total score was 18/56, placing the patient at a severe balance impairment level with a high risk of falls. Marked deficits were noted in dynamic transitions, single-leg stance, and turning 360 degrees.

  • Coordination: Non-equilibrium testing revealed mild coordination deficits (rebound test score 3, heel-to-knee score 3). Equilibrium tests demonstrated moderate deficits during challenged standing and tandem walking.
  • Gait Profile: Exhibited a high-stepping gait pattern characterized by left foot drop. Spatial and temporal variables showed:
  • Cadence: 26 steps/min
  • Gait Velocity: 0.4 – 0.6 m/s
  • Stride Time / Step Time: 4.6 sec / 2.3 sec
  • Base of Support Width: 14 cm
  • Step / Stride Length: 28 cm / 57 cm

Diagnostic Focus and Assessment

Post-stabilization Brain MRI identified post-craniotomy changes in the left FTP region with a thick rim of hyperintense collection and intracranial air under the craniotomy flap causing medial dural displacement and mass effect. Additionally, a thin rim of SDH along the left inferior temporal convexity, a minimal midline shift, bilateral Basi frontal gliotic changes, and cystic alterations in the body of the corpus callosum along with chronic microhemorrhages were confirmed.

Clinical Diagnosis: Severe traumatic brain injury sequelae and subsequent left FTP neurosurgical interventions – Left Hemiparesis.

Therapeutic Interventions

Medical Management (by PMR Lead)

  • Cognitive Enhancement: Initiated Tab. Donepezil to address post-TBI cognitive deficits. Started with 5gm OD and gradually increased to 10mg.
  • Neuro-Behavioral Optimization: Administered Tab. Quetiapine at night to manage nocturnal agitation; environmental modifications (Dimming lights, reducing stimulation) & calming techniques were taught.
  • Orthotic Prescription: Custom left Ankle-Foot Orthosis (AFO) prescribed to prevent contracture & stabilize the ankle during ambulation.
  • Airway Clearance & Decannulation: Following clinical improvement, the tracheostomy tube was progressively downsized, successfully cleared a capping trial, and the patient was safely decannulated.

Phased Physical Therapy & Rehabilitation Protocol

Weeks 1–2 (Acute Neurorehabilitation, Bedside Mobilization, Swallow Assessment)

  • Multimodal Stimulation: Deployed sensory and cognitive stimulation techniques.
  • Orthostatic Tolerance: Initiated early mobilization via a tilt-table trial starting at 45 degrees, progressing gradually to 90 degrees.
  • Prophylaxis & Activation: Implemented regular facial stimulation, passive ROM, and deep vein thrombosis (DVT) prevention protocols (ankle pumps, positional elevation).[3]
  • Bedside Ergonomics: Structured proper alignment and positioning to avoid contractures and abnormal synergy patterns.
  • Speech & Swallow Therapy: Thermal stimulation was done.

Weeks 3–4 (Neuromuscular Re-education & Intermediate Mobility)

  • Postural Control: Administered intensive static sitting balance and trunk-stabilization exercises.
  • Weight Shifting & Assisted Mobility: Initiated standing trials with AFO support, dynamic weight-shifting in standing, and early parallel bar ambulation.
  • Closed Kinetic Chain Work: Utilized assisted stationary cycling to promote reciprocal lower-limb patterns.
  • Functional Transitions: Progressed to bed-to-chair transfer training and sit-to-stand transitions with minimal manual assistance.

Weeks 5–6 (Advanced Ambulatory, Coordination & Cognitive Integration)

  • Advanced Ambulation: Transitioned from a wheeled walker with two-person support to independent walking under supervision with single-person standby.
  • Dynamic Balance & Perturbation: Progressed to uneven surface walking, turning and directional tracking, tandem standing, and single-leg weight-bearing.
  • Advanced Functional Tasks: Stair climbing and descending training with two-person manual support.
  • Dual-Task Training: Combined advanced motor tasks with cognitive challenges (e.g., walking while counting backward by sevens or naming objects).
  • Upper Limb Dexterity & Fine Motor Skills: Administered peg-board tasks, ball-squeezing, and precise grasping activities (tripod, tip-to-tip) to target residual left-hand weakness.
  • ADL Rehabilitation: Focused task-oriented training on dressing, self-grooming, and independent toileting.

Image Source: AI generated

Treatment Outcomes and Progress

The success of the multidisciplinary PMR interventions is best demonstrated by the profound improvement captured across the admission and discharge Functional Independence Measure (FIM) [4] metrics:

FIM Domain ComponentScore on AdmissionScore at DischargeAbsolute Functional Gain
Motor Subtotal Score1353+40
Cognitive Subtotal Score531+26
TOTAL FIM SCORE18 / 12684 / 126+66

By the end of week 6, the patient achieved:

  • Independent Ambulation: Capable of walking safely over flat surfaces under standby supervision.
  • Decannulation & Tube Removal: Successful decannulatory status; regular mixed oral diet resumed following Ryle’s tube removal.
  • Functional Autonomy: Attained complete independence in bed mobility, sit-to-stand transfers, and basic upper-body ADLs.
  • Resolution of Complications: Complete resolution of left lower limb pitting edema and calf tenderness.
  • The patient was discharged with a customized home exercise program and a structured schedule for outpatient PMR follow-up.

Discussion

This case highlights that while early neurosurgical intervention (craniectomy and cranioplasty) is imperative to preserve life following severe TBI, functional survival depends heavily on immediate, comprehensive rehabilitation. The patient’s evolution from semiconscious state (GCS E3VTM1, FIM 18) to an ambulatory, communicative state (GCS E4V5M6, FIM 84) highlights the principles of neuroplasticity, which are optimally driven by early, task-oriented, and high-repetition training. The timely referral to PMR physician and the multidisciplinary team involvement served as the cornerstone for this patient’s rapid functional recovery.

Conclusion

A structured, multidisciplinary neuro-rehabilitation protocol initiated in the acute post-surgical phase is highly effective in mitigating severe motor and cognitive deficits in young TBI survivors. This case reinforces that an integrated PMR and Neurosurgery framework significantly reduces long-term disability, maximizes functional independence, and bridges the gap between major neurosurgical survival and community reintegration.

Acknowledgements

The authors would like to express their sincere gratitude to Dr Prasanth Duraiswamy MBBS MS, Mch (Neurosurgery), Consultant Neurosurgeon, Kauvery Hospital Hosur for his support.

Additionally, the authors extend their appreciation to,

  • Dr. Shiny Francis, Dr Farshin, Dr Manasa, Dr Meghana Ramesh, Dr Pallavi, Dr Thanvee, Dr Thamees Ali: Medical Officer’s Team, Kauvery Hospital, Marathahalli, Bangalore, Karnataka
  • Mr. Henry Abraham (Senior RT), Ms. Fathimath Muneeba, Mr. Muhammed Nishal, Ms. Lida Ann Jacob, Mr. Sinan Basheer, Ms. Anagha VP: Respiratory Therapy Team, Kauvery Hospital, Marathahalli, Bangalore, Karnataka
  • Ms. Sangeetha Sioniya, Ms. Swathi, Ms. Sangeetha E, Ms. Bharathi A.P, Ms. Steffy, Mr. Ravi Chandran, Ms. Rajeshwari, Mr. Jayamurthy, Ms. Savitha, Ms. Sudhamani, Ms. Annamma, Ms. Dhanamma, Mr. Surya, Mr. Midhun, Mr Saiker : Rehabilitation Nursing Team & Care Coordinators, Kauvery Hospital, Marathahalli, Bangalore, Karnataka
  • Mr Abhishek N (BASLP): Speech & Swallow Therapist, Department of PMR, Kauvery Hospital, Marathahalli, Bangalore, Karnataka
  • Dietician Team, Kauvery Hospital, Marathahalli, Bangalore, Karnataka.

References

  • Inpatient Medical Records, Department of Physical Medicine & Rehabilitation, Kauvery Hospital, Marathahalli, Bangalore, India (Case Ref: April-June 2026).
  • Iaccarino C, Kolias AG, Roumy LG, Fountas K, Adeleye AO. Cranioplasty Following Decompressive Craniectomy. Front Neurol. 2020 Jan 29;10:1357. doi: 10.3389/fneur.2019.01357. PMID: 32063880; PMCID: PMC7000464.
  • Nazwar TA, Triangto I, Pringga GA, Bal’afif F, Wardana DW. Mobilization phases in traumatic brain injury. Acute Crit Care. 2023 Aug;38(3):261-270. doi: 10.4266/acc.2023.00640. Epub 2023 Aug 1. PMID: 37652856; PMCID: PMC10497896.
  • Calderone A, Bonanno L, Rifici C, Calabrò RS. Early Functional Recovery Trajectories After Severe Traumatic Brain Injury: A Secondary Analysis of the TBIMS National Database. Brain Sci. 2026 Jan 6;16(1):73. doi: 10.3390/brainsci16010073. PMID: 41594794; PMCID: PMC12838949.

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