Reviving Consciousness: A Neurophysiotherapy Triumph in Decompressive Craniotomy Recovery

This case report presents a 54-year-old male with a history of type-2 diabetes mellitus who experienced sudden unconsciousness and vomiting, leading to aspiration and subsequent diagnosis of a hemorrhagic stroke. The patient underwent an immediate decompressive craniotomy, revealing a sizable intraparenchymal hematoma in the right basal ganglia and corona radiata. Postoperatively, the patient exhibited left-sided weakness, hyporeflexia, and cognitive impairment. A comprehensive neurophysiotherapy intervention addressed impaired mobility, strength, balance, coordination, respiratory complications, pain management, and other associated challenges. The rehabilitation protocol involved diverse strategies such as passive and active exercises, sensory stimulation, and the application of neurophysiotherapeutic approaches. The patient's progress was assessed using various outcome measures. Neurophysiotherapy plays a crucial role in the recovery of decompressive craniotomy.


Introduction
Hemorrhagic stroke, a critical neurological event characterized by bleeding within the brain, represents a profound clinical challenge necessitating comprehensive management strategies [1].This case report centers on the rehabilitation journey of an individual who underwent a decompressive craniotomy following a hemorrhagic stroke, with a specific focus on the integral role played by neurophysiotherapy in optimizing recovery.Hemorrhagic strokes arise from the rupture of blood vessels within the brain, leading to bleeding in the surrounding tissues.Causes of hemorrhagic strokes encompass various factors, including hypertensive emergencies, cerebral aneurysms, arteriovenous malformations, and anticoagulant medication usage [2].The clinical consequences of hemorrhagic strokes are severe, often resulting in neurological deficits and impaired functional abilities.Management strategies involve urgent medical interventions, including surgical procedures such as decompressive craniotomy, aimed at alleviating intracranial pressure and preventing further damage [3].Decompressive craniotomy emerges as a critical surgical intervention in the context of hemorrhagic strokes.Indicated when intracranial pressure becomes dangerously elevated, this procedure involves the removal of a portion of the skull to allow for the expansion of the brain, mitigating the risk of life-threatening complications.The decision for decompressive craniotomy is influenced by factors such as the extent of hemorrhage, mass effect, and neurological status [4].
The occurrence of aspiration pneumonia, a condition characterized by inflammation of the lungs due to the inhalation of foreign material, adds a layer of complexity to the aftermath of a hemorrhagic stroke [5].Aspiration events are particularly relevant in stroke cases, where impaired swallowing mechanisms can lead to the inhalation of oral or gastric contents.Aspiration pneumonia is a severe complication, often requiring prompt attention and targeted interventions to prevent respiratory compromise and enhance overall recovery [6].Neurophysiotherapy plays a pivotal role in the rehabilitation process following a decompressive craniotomy for hemorrhagic stroke [7,8].The multifaceted approach addresses impairments in mobility, strength, balance, coordination, respiratory function, and cognitive abilities.The physiotherapy protocol includes tailored interventions such as passive and active range of motion (ROM) exercises, balance training, respiratory exercises, cognitive rehabilitation, and sensory-motor approaches like Rood's techniques, multimodal stimulation, and Proprioceptive Neuromuscular Facilitation (PNF) [9][10][11][12][13][14][15].
Through this case report, we aim to delineate the intricate relationship between hemorrhagic strokes, decompressive craniotomy, aspiration pneumonia, and the indispensable role of neurophysiotherapy in optimizing the rehabilitation process [16].The subsequent sections will provide a detailed exploration of the patient's clinical course, the rationale behind neurophysiotherapy interventions, and the collective effort to enhance functional outcomes and quality of life (QOL).

Case Presentation
The subject of this case presentation is a 54-year-old male known for type-2 diabetes mellitus for 15 years and was on regular medication for the same.He had right-hand dominance and experienced sudden unconsciousness and vomiting in his sleep, which got aspirated in September 2023.After this, the patient got unconscious and was immediately taken to a local hospital.Due to unavailability, the patient did not get treatment and was taken for investigation the following day.Studies such as computed tomography (CT) scans of the brain revealed hemorrhagic stroke, with intraparenchymal hematoma of 72x35 mm in the right basal ganglia and corona radiata.A mass is noted over the right lateral ventricle and a midline shift of 7 mm to the left side.Biochemistry revealed increased serum cholesterol (210 mg/dl), increased high-density lipoprotein (HDL) (5.5), increased blood urea (65.1 mg/dl), and increased serum creatinine (1.58 mg/dl).
The patient was operated immediately on the same day.The patient gained consciousness in three days but was not oriented.Chest CT revealed airspace consolidation in bilateral lower limbs, mild bilateral pleural effusion, and aspiration pneumonitis.The patient's relatives complained of an inability to move the left side of the body.As mentioned in Table 1, the reflexes of joints were assessed.Hyporeflexia was noted in the left upper and lower extremities.The left upper and lower limb tones were seen as a two-layer in Table 2 using the tone grading scale.Figure 2 shows evidence of extra-axial blood density collection (Hounsfield unit (HU) +50 to +90) in the posterior falx and left tentorium cerebelli suggestive of subdural hemorrhage.There was evidence of welldefined intraaxial blood density collection (HU +50 to +80) in the left temporo-parieto-frontal lobe measuring approximately 8.4 x 5.6 x 3.4 cm with perilesional edema extending into the body of left lateral ventricle suggestive of hemorrhagic contusion with intraventricular extension.

FIGURE 1: Pre-operative computed tomography scan
The red oval shows hemorrhagic contusion in the left temporo-parieto-frontal region with intraventricular extension and mass effect

Physiotherapy intervention
The patient was given physiotherapy rehabilitation seven days a week for one hour daily, for two months.The protocol to be followed using a timeline of the rehabilitation is presented in

Outcome measures
The patient was assessed during the initial week, and progress was measured during the fourth and eighth weeks of physiotherapy rehabilitation, as shown in Table 4.

Outcome measures
Week

Discussion
The study by Grüner et al. investigates the application of Multimodal Early Onset Stimulation (MEOS) in the early rehabilitation of severe brain injury patients.Highlighting the importance of early intervention, the study focuses on a specific patient selection criterion and outlines the multimodal components of MEOS, including acoustic, tactile, olfactory, gustatory, and kinesthetic procedures.Monitoring responses through physiological and behavioral parameters, the study identifies significant changes in vegetative functions, mainly influenced by tactile and acoustic stimulation.While acknowledging controversies in therapeutic effects, the authors emphasize the individualized nature of rehabilitation and the potential diagnostic value of non-responsiveness to external stimuli.The study contributes insights into sensory stimulation and calls for further research to refine protocols and prognostic assessments [17].
This article highlights the crucial role of neurorehabilitation in the aftermath of stroke, emphasizing its significance in reducing mortality, disability, and overall healthcare costs associated with this condition.The prevalence of stroke necessitates a comprehensive approach to stroke management, with a focus on acute neurological treatment, stroke unit admissions, fibrinolytic interventions for ischemic strokes, and, notably, neurorehabilitation.Given their expertise in neuroanatomy, physiopathology, neuropharmacology, and brain plasticity, Neurologists are positioned to actively contribute to neurorehabilitation teams.The article underscores vital factors influencing the efficacy of rehabilitation, emphasizing the importance of early initiation, optimal duration, and treatment intensity.It contends that a concerted effort is essential to ensure timely and appropriately intense neurorehabilitation during inpatient and outpatient phases, as this correlates with improved functional outcomes, reduced mortality and institutionalization rates, and shorter hospital stays.Ultimately, the article advocates for integrating neurologists into multidisciplinary neurorehabilitation teams and underscores the need for strategic planning to facilitate timely and sustained neurorehabilitation for stroke patients [18].
The study by Kelly et al. investigated functional recovery in intracerebral hemorrhage (ICH) and cerebral infarction patients undergoing rehabilitation.Analyzing over 1,000 cases, they found that, despite ICH patients having greater initial impairment, they experienced more significant gains during rehabilitation than cerebral infarction patients.Surprisingly, the initial severity of disability did not predict the degree of recovery.Instead, younger age, a longer length of stay, and cognitive function at admission were identified as predictors of better outcomes.The study challenges traditional assumptions and suggests tailoring rehabilitation strategies based on stroke subtypes and individual characteristics [19].
In summary, these studies underscore the evolving landscape of neurorehabilitation, emphasizing the need for personalized, timely, and intensive interventions.They contribute to the ongoing discourse on refining rehabilitation protocols, prognostic assessments, and the integration of neurologists into multidisciplinary teams, ultimately striving for improved outcomes and enhanced quality of life for patients recovering from severe brain injuries and strokes.

Conclusions
This case underscores the critical role of neurophysiotherapy in the multidisciplinary management of a hemorrhagic stroke patient following decompressive craniotomy.The tailored rehabilitation protocol, incorporating elements of sensory stimulation and neurophysiotherapeutic approaches, demonstrated positive outcomes regarding motor function, cognition, and overall well-being.The findings emphasize the importance of early and individualized rehabilitation strategies to optimize recovery and functional independence in patients with hemorrhagic stroke undergoing decompressive craniotomy.Further research and larger-scale studies are warranted to refine and validate such rehabilitation protocols in diverse clinical settings.

FIGURE 2 :
FIGURE 2: Physical therapy rehabilitation A: Multimodal stimulation (visual); B: Multimodal stimulation (auditory); C: Sitting on a chair at the bedside.

FIGURE 3 :
FIGURE 3: Rehabilitation A: Patient wearing shoulder arm pouch; B: Patient is in supine with head end elevated to 45 degrees

Table 3 .
The patient being treated is shown in Figures2, 3.

TABLE 3 : Physiotherapy rehabilitation intervention
ROM: Range Of Motion; TENS: Transcutaneous Electrical Nerve Stimulation; PNF: Proprioceptive Neuromuscular Facilitation, QOL: Quality of Life