Atypical Presentation of Post-traumatic Hydrocephalus After Traumatic Brain Injury: A Case Report

Case Diagnosis: Fecal incontinence as an atypical presentation in a traumatic brain injury patient with post-traumatic hydrocephalus.

Case Description or Program Description: 67-year-old male with a medical history of laryngeal phrenectomy with subsequent LaryTube that had a fall from a ladder resulting in a right subdural hematoma and subarachnoid hemorrhage which was managed by a right craniotomy and partial temporal lobectomy. On admission, the patient was noted to have a poorly localized headache due to his communication barriers secondary to a prior laryngectomy requiring using of an electrolarynx and poor coordination from his traumatic brain injury. The patient had urinary incontinence in acute care which was unchanged on admission to rehabilitation. During his rehabilitation course, several medications were trialed for his headaches with minimal relief. He also developed loose incontinent stools for which the cessation of his bowel regimen and the addition of a bulking agent were not helpful. However, the patient had an episode of lethargy along with 7 incontinent loose bowel movements in a 24-hour period which prompted a Computed Tomography of his head which revealed a diffuse interval increase in ventricular caliber concerning for developing hydrocephalus. Neurosurgery was consulted and the patient underwent a ventriculoperitoneal shunt.

Setting: Inpatient rehabilitation unit.

Assessment/Results: Post-operatively, the patient had improved headaches, decreased bowel frequency, and incontinence. Functionally, the patient had improved therapy participation as well as neurological progression and was able to discharge home at a moderate level of assistance with family.

Discussion (relevance): The incidence of fecal incontinence is rare in hydrocephalus. To our knowledge, this is the first reported case of bowel incontinence in a case of post-traumatic hydrocephalus.

Conclusions: In the traumatic brain injury population, atypical symptoms, such as worsening or frequent bowel incontinence should be considered in the clinical evaluation of post-traumatic hydrocephalus. Other common symptoms, including headaches and gait instability, overlap with sequelae of traumatic brain injury and can confound the diagnosis.