Clinical and rehabilitative considerations in a complex case of spastic tetraplegia, mixed aphasia, secondary encephalopathy – post severe traumatic brain injury with hemorrhagic and ischemic lesions – with favorable late evolution and post-symptomatic st

Abstract

Introduction.  The traumatic brain injury remains a current research topic considering the severity and the increased incidence of this pathology. Both physical and neuro-psychological sequelae require a complex rehabilitation program.

Material and methods. We describe the evolution of a 20-year-old case, victim of a severe traumatic brain injury due to physical aggression, with spastic tetraplegia, extended ischemia in the left cerebral hemisphere, mixed aphasia, post-traumatic encephalopathy, left eyelid ptosis, right paresis of nerve III, post remitted status of left subdural hematoma, post remitted status of right fronto-parietal subarachnoid hemorrhage, severe joint stiffness (right elbow and fist, bilateral hips and knees), cachexia and SARS-COV-2 infection. In our clinic the patient followed medical, complex kinetotherapeutic treatments and was functionally assessed using the following scales: modified Ashworth, Penn Spasm Frequency Scale ( Penn), Life Quality Assessment ( QOL ), Montreal Cognitive Assessment ( MoCA ), FAC International Scale, Glasgow Outcome Scale-Extended (GOS-E), modified Rankin scale (mRS ).

Results. During the hospitalization, the patient presented a favorable late evolution with a great improvement of motor and neurological deficit, aphasia in remision, improvement of eyelid ptosis and joint stiffness, fact also confirmed by the increasing scores from the evaluated scales.

Conclusions. Consequently in traumatic brain injury the proper medication, personalized rehabilitation program, ergotherapy, speech therapy, a great deal of involvement and documentation of current information is required to improve the patient's quality of life.