Neurological and functional recovery despite persistent skull defect after decompressive hemicraniectomy: a case report

BACKGROUND: Decompressive hemicraniectomy is a life-saving procedure for malignant cerebral infarction with severe edema. Although cranioplasty is performed to enhance neurological recovery, longitudinal descriptions of recovery with a persistent skull defect remain scarce. In such patients, syndrome of the trephined (SoT) may impact neurological function during upright activity. We present a patient who showed neurological and functional improvement beyond 6 months after stroke onset despite a persistent skull defect following bone flap removal due to infection. OBJECTIVE: To describe longitudinal neurological and functional progression beyond 6 months after stroke onset in a patient with a persistent skull defect after decompressive hemicraniectomy. CASE DESCRIPTION: A 60-year-old man with right internal carotid artery occlusion underwent decompressive hemicraniectomy with extensive internal decompression. Cranioplasty performed on hospital day 40 was complicated by infection, necessitating removal of the bone flap. INTERVENTION: Intensive inpatient rehabilitation included postural control training, transfer practice, activities of daily living training, and cognitive-perceptual interventions, with monitoring. OUTCOMES: Beyond 6 months after stroke onset, consciousness, cognition, and mobility improved. No reproducible posture-dependent neurological worsening suggestive of clinically manifest SoT was observed during upright activity. From admission to the inpatient rehabilitation unit to discharge, the Glasgow Coma Scale score improved from 12 to 14, the Hasegawa's Dementia Scale-Revised score from 13 to 23, the Behavioral Inattention Test score from 20 to 72, and the Scale for Contraversive Pushing score from 2.5 in sitting and 3 in standing to 0.25 in both positions. At discharge, wheelchair transfers and toileting required minimal assistance. CONCLUSION: Neurological and functional improvements were observed beyond 6 months after stroke onset, despite extensive cortical resection and a persistent skull defect. Although the contributions of biological recovery and rehabilitation could not be distinguished, this case illustrates adaptation of rehabilitation goals and priorities in response to evolving clinical and functional barriers.