The Importance of Neuroimaging

K.B. was found lying on the kitchen floor with the telephone still in her hand. Since K.B. had a history of migraine headaches she assumed the sudden weakness and sharp pain she experienced in her head were simply another one of her migraines. When emergency personnel reached K.B., her Glasgow Coma Scale (GCS) was a 15, which indicated a normal level of alertness (i.e. able to respond to pain, open her eyes, verbalize and follow simple motor commands). However, while in the hospital, K.B.'s GCS rapidly deteriorated to a 5, indicating a significant decline in alertness and awareness.

A CT scan was taken of K.B.'s brain, which indicated a ruptured anterior communicating artery (ACA) aneurysm which led to a subarachnoid hemorrhage (bleed located below the arachnoid layer of her brain). An aneurysm occurs when the wall of an artery swells to the point where it appears like a balloon. As an aneurysm grows, it becomes thinner and weaker and often times will leak or rupture, which releases blood into the brain (i.e. a subarachnoid hemorrhage). K.B.'s doctors cut a hole in the right frontal-temporal area of her skull (i.e. a frontotemporal craniotomy) in order to gain access to the aneurysm and clip it, preventing it from causing further damage.

Following the surgery to clip her aneurysm, K.B. had significant memory deficits, which included decreased attention, slowed speed of processing, poor problem solving, and visual-perception difficulties. Supervision is required for all activities due to impulsivity and decreased safety awareness.

Approximately, one month after surgery to clip K.B.'s anterior communicating artery aneurysm, she was admitted to Centre for Neuro Skills® (CNS). CNS is a post-acute, residential brain injury program with 30 years of experience in rehabilitating individuals with brain injuries.

Upon admission to CNS, K.B. required 24-hour supervision due to significant confusion and balance problems. She had decreased balance and endurance, lack of insight into her disability, decreased memory and attention, depression, impaired range of motion in her upper and lower extremities, decreased verbal fluency and decreased self-care skills. K.B. was involved in physical, occupational, educational and speech therapies, as well as counseling. After being at CNS for approximately 4 months, K.B. suffered a fall. Although she was not injured, shortly thereafter therapists began to report that she had increased episodes of confusion, increased incontinence, nausea, impaired balance and coordination, increased daytime drowsiness and frontal pressure headaches. Given this information, K.B.'s physician at CNS ordered an MRI of her brain in order to determine the cause of her increased symptoms.

The MRI of K.B.'s brain revealed that she had hydrocephalus, or enlarged ventricles. Ventricles are fluid filled spaces in the brain that can become enlarged due to increased production of cerebral spinal fluid or increased pressure. A comparison was made with the CT and MRI scans that K.B. had shortly after her aneurysm. Her ventricles had doubled in size since her initial neuroimaging scans. K.B was admitted to the hospital for a ventriculoperitoneal shunt, which would drain fluid from her ventricles.

K.B. was admitted back to CNS to continue her rehabilitation following her shunt surgery. Remarkable progress was observed by both K.B. and her therapists in the areas of attention, balance, alertness, affect and memory. When asked how K.B. was feeling, she stated she felt that she had been "asleep for six months and was just now waking up." K.B. had insight into her disability and was able to recognize that she still had some memory impairments, which was not possible prior to her shunt surgery.

A few months following K.B.'s hydrocephalus diagnosis and treatment she was discharged home with her husband from Centre for Neuro Skills®. At that time, she was independent with all activities of daily living, with the exception of driving. K.B. was preparing to take a driving evaluation to be cleared to drive and was planning on returning to work or volunteering. Although, K.B. still had attention and visual-perceptual deficits, she was no longer a risk for falls, was able to ambulate independently, and no longer needed supervision or assistance with functional daily activities.

K.B.'s story illustrates the importance of neuroimaging in both the acute and postacute rehabilitation settings. Although, K.B. had scans of her brain done while she was in the acute setting being treated for her ruptured aneurysm, repeat neuroimaging was warranted due to a change in her cognitive and physical status after she fell. If a tumor, lesions or hydrocephalus is suspected, neuroimaging (a CT or an MRI scan) should be ordered to rule out these conditions that can interfere with the rate and amount of progress that is made with rehabilitation.