Differential Diagnosis for Post Decompressive Craniotomy for SDH with No Improvement in GCS

• Single Most Likely Diagnosis
  • Rebound intracranial hypertension or worsening cerebral edema: This is a common complication following decompressive craniotomy for subdural hematoma (SDH), where the initial relief of pressure does not lead to sustained improvement due to ongoing brain swelling or re-accumulation of hemorrhage.
• Other Likely Diagnoses
  • Residual or recurrent SDH: The hematoma may not have been fully evacuated during the initial surgery, or there could be re-bleeding, leading to continued increased intracranial pressure (ICP) and lack of improvement in Glasgow Coma Scale (GCS).
  • Cerebral vasospasm: This can occur after subarachnoid hemorrhage (which might be associated with SDH) and can lead to decreased cerebral blood flow, causing worsening neurological status.
  • Seizures: Post-traumatic seizures can occur after head injury and may not always be overt, leading to a decreased level of consciousness without obvious seizure activity.
• Do Not Miss Diagnoses
  • Brainstem herniation: Although less likely if there's no improvement rather than deterioration, it's critical to consider due to its high mortality rate. Signs might be subtle, including changes in pupil reactivity or respiratory patterns.
  • Infection (meningitis or cerebral abscess): Post-surgical infections can lead to severe complications, including decreased consciousness, and require prompt diagnosis and treatment.
  • Hydrocephalus: Obstruction of cerebrospinal fluid (CSF) pathways can lead to increased ICP and decreased level of consciousness, which might not be immediately apparent post-operatively.
• Rare Diagnoses
  • Cerebral venous sinus thrombosis: This is a less common complication that can occur after head injury or surgery, leading to increased ICP and decreased level of consciousness.
  • Fat embolism syndrome: Although more commonly associated with long bone fractures, it can occur after any significant trauma and leads to a petechial rash, respiratory distress, and neurological decline.
  • Hypoxic-ischemic brain injury: If the patient had a period of hypoxia or hypotension post-operatively, this could lead to brain injury and a failure to improve neurologically.