Patient: Liu Moumou, female, 32 years old,
Taiyuan City, Shanxi Province
Date of admission: August 18, 2011
Complaint: About 2.5 months after craniocerebral trauma, diagnosed hydrocephalus with left-sided limb weakness and delayed reaction for about 1.5 months, sudden onset of high fever and lateral ventricular external drainage for about 1 month.
I. Medical history before admission to the cerebrospinal fluid department of the Aviation General Hospital.
The patient was knocked down by a car while riding a bicycle on June 2, 2011, and was unconscious at that time. He visited the neurosurgery department of the local hospital in Taiyuan, namely the Second Hospital of Traditional Chinese Medicine of Shanxi Province, and underwent an emergency right frontotemporal craniotomy for decompression on the same day after a brain CT examination revealed a right subdural hemorrhage and brain contusion (Figure 1).
On the first day, he became clear and showed no abnormal movement of the limbs, but from the second postoperative day, he developed fever up to 39 degrees. On the third postoperative day, June 5, 2010, a brain CT review was performed (Figure 2), and the drainage tube was removed after the drainage fluid from the subcutaneous flap was left in place and a bacterial culture was performed. The brain CT was reviewed on the 5th postoperative day (Figure 3) and showed no significant abnormalities. However, the fever remained high and unresolved.
Figure 2: June 5, 2011
Figure 3: June 7, 2011
After the bacterial culture result of the incisional drainage fluid was found to be “Acinetobacter baumannii” infection, intravenous treatment with antibiotics of Sulphen was started immediately according to the drug sensitivity test result, and the temperature was controlled soon afterwards. This anti-infective treatment continued until the third week after surgery, until the bacterial culture of the incisional drainage fluid turned negative, i.e. “no bacterial growth”. Mental and physical activity gradually recovered, and two brain CT examinations were performed, both of which revealed no significant abnormalities (Figures 4 and 5).
Figure 4:5 Brain CT on June 13, 2011
Figure 5: CT brain on June 15, 2011
The patient started hyperbaric oxygen therapy around the middle of July 2011, after the intracranial infection was controlled and the condition gradually improved. However, after a few days of hyperbaric oxygen therapy, the patient started to show scalp enlargement at the site of the cranial window, as well as weakness of the left limb, inability to stand, unresponsiveness, poor appetite, and slow speech. The lumbar pool drainage was performed on the third day, but there was no drainage and the bulging brain became worse again (Figure 7).
Figure 6: July 3, 2011
Figure 7: Brain CT on July 6, 2011
The patient was transferred to the Shanxi Provincial People’s Hospital on July 18, 2011, after about a week of ineffective drainage of the lumbar pool. However, on the third day of this hospitalization with mannitol and other cranial pressure lowering drugs, abnormal manifestations of sudden onset of fever reaching more than 39 degrees, shallow and rapid respiratory confusion, low hematocrit, and rapid blood pressure instability appeared, so emergency resuscitation was given: blood transfusion, lateral ventricular external drainage (Figure 8) and anti-inflammatory treatment with intravenous infusion of sulphen drug.
Figure 8: Brain CT on July 21, 2011
The patient’s condition gradually improved from the beginning until 15 days after the external ventricular drainage, and was reviewed by brain CT on day 5 (Figure 9), day 8 (Figure 10), day 11 (Figure 11), and day 15 (Figure 12), respectively, all of which showed varying degrees of control of hydrocephalus.
Figure 9: July 26, 2011
Figure 10: July 29, 2011
Figure 11: August 1, 2011
Figure 12: August 5, 2011
However, during this 15-day period of ventricular drainage, the patient continued to have intermittent fever, inability to stand, unresponsiveness, and abnormal speech delays. Because the cerebrospinal fluid culture was reported as “Acinetobacter baumannii”, the patient was recommended to Tsinghua University Yuquan Hospital in Beijing for treatment.
On August 11, 2011, the patient was transferred to the Yuquan Hospital of Tsinghua University. The hospital quickly performed a flexible ventriculoscopic third ventriculostomy and intracerebroventricular “plaque flushing”. However, the patient presented with more severe hydrocephalus after surgery: the scalp flap that had been operated on was more severely inflated (Figure 13). The patient was alert, but he developed psychiatric symptoms again.
Figure 13: August 15, 2011
After repeated “investigations” and personal knowledge of the treatment plan, the patient’s family was transferred to the cerebrospinal fluid department of the General Aviation Hospital on August 18, 2011.
II. Treatment and results in the Cerebrospinal Fluid Department of Aviation General Hospital.
(I). Stages of treatment for hydrocephalic brain bulge complications.
The patient presented a very frightened demeanor when he was transferred to the cerebrospinal fluid department of the Aviation General Hospital, and kept calling out a hallucination: “An old monk planted three trees on my head, which could not be pulled out”; uncontrollably called out to his family: “Help me pull out these three trees”. The bulge of the surgical flap on the right side of the head was very serious, as if it was going to burst, and the left limb was in a state of paralysis: the upper limb was more paralyzed than the lower limb. The body temperature fluctuated around 38.5°C. Therefore, according to the results of the brain MRI that had been performed at the Yuquan Hospital of Tsinghua University before admission (Figure 13), emergency treatment to relieve severe hydrocephalus and its associated intracranial hypertension was immediately performed, and the cerebrospinal fluid was taken for the corresponding laboratory tests.
On the second day of admission, August 19, 2011, the bulging brain was still severe (Figure 14), and a CT brain examination was performed, which showed that the severe bulging brain and hydrocephalus had been somewhat controlled (Figure 15).
Figure 14: Significant cerebral bulge remained under extraventricular drainage on the day after admission
Figure 15: CT on August 19, 2011: the bulging brain and hydrocephalus were under control
After more than ten days of treatment, the body temperature was quickly and completely controlled. After continuing treatment for nearly two months, the patient recovered significantly from the previously paralyzed left limb and underwent a cerebrospinal fluid shunt for permanent control of hydrocephalus on October 17, 2011, after a preoperative CT examination (Figure 16).
Figure 16: Pre-shunt CT of the brain on October 17, 2011: satisfactory control of hydrocephalus and brain bulge
However, after the hydrocephalus shunt, the patient gradually showed signs of increased paralysis again in the left paralyzed limb, as well as severe scalp flap invagination; at this time, CT examination showed invagination of the scalp flap and the underlying brain parenchyma (Figure 17).
Figure 16: November 1, 2011: post-shunt sexual cephalic flap and brain parenchymal invagination
(b) Stage of treatment for complications of cephalic flap invagination after hydrocephalus shunt.
After a month of continued observation of scalp flap subsidence, a cranial repair was performed for the patient on December 5, 2011. However, on December 7, 2011, the second day after the cranial repair, the patient showed persistent high muscle tone with wheezing-like breathing in the left limb throughout the day, and at this time, the emergency head CT examination revealed an epidural fluid and a small amount of air accumulation in the cranial repair area, and a significant displacement of the midline structures to the opposite side (Figure 18).
Figure 18: Head CT on December 7, 2011: epidural fluid and gas accumulation in the operated area, with leftward midline shift
A bedside percutaneous percutaneous epidural fluid puncture and drainage was given on an emergency basis. The next day, the third day after the skull repair (December 8, 2011), the patient’s respiration improved to stable, and the muscle tone of the left limb was also reduced. The day after this epidural fluid drainage, i.e., the 4th day after the skull repair (December 9, 2011), another head CT was performed: the epidural fluid and air accumulation in the operated area were significantly reduced, and the degree of leftward shift of the midline findings was reduced (Figure 19).
Figure 19: Head CT on December 9, 2011: the epidural fluid and gas accumulation in the operated area decreased, and the leftward shift of the midline was reduced
Thereafter, the patient’s left limb mobility gradually improved, and the “three trees on the patient’s head” were also removed at this time. On the 8th (Figure 20) and 14th (Figure 21) days after the skull repair, two head CT examinations were performed, both of which showed that the epidural fluid in the operated area had begun to gradually absorb.
Figure 20: Head CT on December 13, 2011: the epidural fluid began to be absorbed
Figure 20: CT head on December 19, 2011: significant absorption of epidural fluid
Two weeks after the cranial repair, the patient’s paralyzed left lower extremity began to improve and returned to the ability to walk with assistance, but the left upper extremity still showed a stiff and flexed posture. On the day before discharge, i.e., the 34th day after the skull repair (January 8, 2011), a head CT examination showed that the epidural fluid and gas accumulation in the operated area basically disappeared, and the midline structures were well reset (Figure 21).
Figure 21: Head CT on January 8, 2012: the epidural fluid and gas accumulation disappeared and the midline was well repositioned
The patient was discharged on January 9, 2012, 4 months after hospitalization, but at this time the left paralyzed upper limb still showed flexion cerebral palsy (Figure 22).
Figure 22: At the time of discharge on January 9, 2012: speech and thinking returned to normal, but the left upper limb was still flexion paralyzed
Post-discharge follow-up results.
On March 10, 2012, two months after the patient’s discharge, the patient was followed up by telephone: the patient’s speech was clear and his thinking was normal. According to the patient’s description, he could walk 300 to 500 meters unaided, and could do simple household chores such as cooking and laundry independently, and planned to participate in work within a short period of time.
On October 19, 2012, 9 months after discharge from the hospital, the patient was accompanied by her family to the outpatient clinic for a follow-up examination, and the left paralyzed upper limb was completely restored to normal and reached the ability to move as normal (Figure 23).
Figure 23: Full recovery of normal human mobility
The head CT reviewed at this time showed that the ventricular system and brain structures were basically normal (Figure 24).
Figure 24:Head CT on October 19, 2012: the ventricular system and brain structures were basically normal