“Mielinolisis pontina secundaria a traumatismo craneoencefálico severo

Abstract

Deaths to traumatic brain injury are still among the main causes of mortality and disability, with the affections of the nervous system and hemorrhagic shock becoming its main contributors. The patient with traumatic brain injury (TCE) is forming a complicated group of patients that can present different types of brain injury, as a result of a closed lesion or an open lesion. TCEs are more frequent in males in all age groups. The causes of the TCE are related to the age of the subjects who suffer them, thus, falls are the most frequent etiology and traffic accidents correspond to the second cause in frequency. The central pontine myelinolysis is a rare pathology, characterized by a neurological alteration of undetermined etiology linked to various conditions such as serious diseases, in more than 50% of cases manifested in patients with chronic diseases with malnutrition or hydroelectrolytic disorders, being frequent, when Sodium levels rise too fast. The damage basically consists of the destruction of the myelin sheaths, leaving the cylinders undamaged, affecting part or the entire base of the protuberance symmetrically. There are a variable percentage of patients in brain death situations who have developed diabetes insipidus. To continue the clinical case is about a male patient of 14 years of age, who while doing extreme sports (Downhill), without a helmet, he suffers a fall of his bicycle in motion, with displacement of approximately 2 meters and frontal impact of his skull against a rocky surface (stones), then ECU 911 transfers him to the Pediatric Emergency Service of the IESS Ambato General Hospital. On physical examination, the positive: the patient with a tendency to sleep, disoriented, with pain, Glasgow Scale: 13/15 (O: 3, V: 4, M: 6). Head: evident hematoma in the frontal region, with left palpebral edema, localized ecchymosis, palpable bone crax in the frontal region, pupils: mydriatic, hyporeactive. CT was performed immediately, showing a fracture line at the level of the frontal bone, extending from the frontoparietal suture to the left orbit, with signs of an epidural hematoma, deciding to admit it for hospital management because he has a severe traumatic brain injury. Neurosurgery is consulted, they indicate that at the moment he does not require surgical resolution, so he decides clinical management, with advanced airway management, sedoanalgesia and later is admitted to the Intensive Care Unit Evolution in the ICU: Hemodynamically unstable, brain MRI is performed where it is evident: signs of pontine myelinolysis, results of examinations are obtained revealing the following: hypernatremia + low density + low urinary sodium + urinary hypoosmolarity + plasma hyperosmolarity related to Diabetes Insipid Central, with poor clinical evolution, he does not respond to treatment and he dies.