Patient: Gao Moumou, female, 32 years old,
Tianjin Baodi District, present address: Beiyuan Home, Chaoyang District, Beijing
Complaints: 2.5 months after aneurysm clamping and 1.5 months of intermittent fever after hydrocephalus shunt.
I. Medical history before admission to the cerebrospinal fluid department of the Aviation General Hospital.
The patient had a sudden severe and unbearable headache 2.5 months ago (i.e., November 4, 2013) and went to Beijing Tiantan Hospital for a cranial CT suggestive of subarachnoid hemorrhage (Figure 1), followed by a cranial CTA examination to confirm the diagnosis of a right anterior communicating artery aneurysm. (Figure 2)
Figure 1: Brain CT on November 4, 2013: bilateral fissure and longitudinal fissure hemorrhage with suspected ventricular dilatation
Figure 2: CTA of the brain on November 4, 2013: the aneurysm was unclear
On the same day, “right anterior communicating artery aneurysm clamping” was performed under general anesthesia. The surgeon considered intracranial hypertension according to the patient’s preoperative CT performance, so continuous external drainage of the lumbar pool was given on the same day. On the 4th postoperative day, i.e., 4 days after lumbar pool drainage, a repeat cranial CT showed patchy hypointense shadow in the right basal ganglia area and a smaller ventricle due to lumbar pool drainage (Figure 2).
Figure 3: CT 4 days after surgery: right basal ganglia hypodense shadow and smaller ventricle than before surgery
On the basis of the patchy hypointense shadow in the right basal ganglia and the smaller ventricle than before, the doctor thought that the former was related to ischemia in the anterior cerebral artery and the latter was related to cerebral swelling or/and lumbar pool drainage, and then added nimodipine to control vasospasm and blood pressure, and continued lumbar pool continuous drainage treatment. Respiratory distress, an immediate cranial CT review was performed and revealed signs of severe brain swelling (Figure 4). The physician thought that the brain swelling was mostly due to high cranial pressure, and added treatment with mannitol, albumin, tachypnea and hormones to strongly lower the cranial pressure; the physician performed a transnasal tracheal intubation for the patient because of respiratory distress; to prevent drug-related hypotension and cerebral ischemia, nimodipine was discontinued. The next day, 2013-11-12, the patient’s condition improved. At this time, the physician considered that long-term external drainage of the lumbar pool had the risk of causing intracranial infection, so the external drainage tube of the lumbar pool was removed; the physician considered that the cranial pressure-lowering measures were too strong, so he discontinued albumin, tachypnea and hormone therapy and switched to hypertonic saline to lower the cranial pressure.
Figure 3: CT 7 days after surgery: brain swelling was obvious, and the midline was mildly displaced to the left
On 2013-11-18, the 14th postoperative day (the 6th day after the removal of the external lumbar pool drainage tube), the patient’s consciousness turned clear, and he could write with his right hand, but there were swallowing disorders, dysarthria, and weakness of the left limb. A repeat cranial CT (Figure 4) indicated that the edema was reduced and the ventricles were slightly dilated. The physician considered that the patient was in the recovery period and the ventricles could gradually return to normal, and transferred the patient to the general ward for further treatment.
Figure 4: CT 14 days after surgery: reduced cerebral edema and slightly dilated ventricles
Within the next 14 days, the patient gradually developed dull expression, unresponsiveness and lethargy. On 2013-12-2, 28 days after aneurysm clamping, a repeat cranial CT showed increased ventricular dilatation and significant periventricular edema (Figure 5).
Figure 5: 28-day postoperative CT: ventricular dilatation and periventricular edema were more pronounced than before
The local physician considered the presence of hydrocephalus and performed a lateral ventriculoperitoneal shunt under general anesthesia on 2013-12-4. On the first day after the shunt, the patient’s consciousness was better than before, and the time to open the eyes was significantly longer than before the operation, and he could make a fist as instructed. However, on the second postoperative day, the patient developed fever, with a maximum temperature of 38.5
℃. The local physician considered that the patient might have a possible post-shunt infection and immediately added vancomycin and ceftazidime combination anti-infection treatment. The patient’s condition continued to deteriorate gradually afterwards, and on 2013-12-10, 8 days after the shunt (6 days after anti-infective treatment), the patient again became lethargic with a temperature of 38.5
The repeat cranial CT suggested that the ventricular dilatation was not smaller or still more severe than before surgery (Figure 6).
Figure 6: CT 8 days after shunt: the ventricle was not significantly smaller than before surgery
The local physician diagnosed intracranial infection and continued anti-infective treatment with vancomycin and ceftazidime combination. However, during this anti-infective treatment, complications of swelling of the left lower extremity occurred again, and ultrasound suggested deep vein thrombosis in the lower extremity, and treatment with subcutaneous injections of over-low molecular heparin was given. With such anti-infective treatment, the patient’s body temperature gradually returned to normal, but his consciousness still did not improve significantly and he was in a comatose state. On 2013-12-13, i.e. 11 days after the shunt, the cranial CT was reexamined (Figure 7): the ventricles were still significantly dilated.
Figure 7: CT 11 days after shunt: the ventricle was not significantly smaller than before
The local doctor considered that the shunt pressure was too high and adjusted the pressure of the “shunt pump” from 2.0 to 1.5, and measured the pressure of 110 mmH2O by lumbar puncture, which proved the effectiveness of the “pump pressure adjustment”. After the pressure regulation, the patient’s consciousness gradually changed to clear, and he was able to speak and write softly, but his reaction was still sluggish.
Figure 8: CT 22 days after shunt: the ventricles were smaller than before and the periventricular edema was reduced
Based on the results of the cranial CT on 2012-12-24 and the improvement of symptoms, the local physician considered that the patient’s disease had been cured and recommended transfer to the hospital for rehabilitation. The following day, 2013-12-25, the patient was transferred to Beijing Xuanwu Hospital for inpatient rehabilitation. However, on the second day of admission, 2013-12-26, the patient presented with right lower abdominal pain and hypothermia with signs of localized pressure pain and rebound pain, and no significant abnormalities were seen on abdominal CT. Based on the previous medical history, the neurosurgeon considered a possible abdominal infection or peritonitis and gave a combination of vancomycin, ceftazidime, and ornidazole for anti-inflammatory treatment. Within 3 days of such anti-infective treatment, the patient had persistent abdominal pain although he was conscious and had fair verbal skills. The patient’s condition began to deteriorate on 2013-12-31, the 6th day after transfer, with drowsiness, high fever (maximum temperature 29
On 2014-1-1, the patient was transferred to the neurosurgery department of Beijing Anzhen Hospital for inpatient treatment, and on 2014-1-2, the first day after transfer (day 31 after shunt), a repeat cranial CT (Figure 9) showed an increase in ventricular dilatation and periventricular edema.
Figure 9: CT 31 days after shunt: ventricular dilatation and increased periventricular edema
The neurosurgeon of Beijing Tiantan Hospital consulted and considered that the intracranial infection was still uncontrolled, which eventually led to abdominal infection, and gave a combination of vancomycin and fudaxin for anti-inflammation. On the second day after the administration, the patient’s abdominal pain disappeared; the pressure of lumbar puncture was 110 mmH2O, and the cerebrospinal fluid leukocytes were 29*10^6/L. On 2013-1-13, the 12th day after hospitalization in Beijing Anzhen Hospital (the 42nd day after shunt), the patient’s body temperature returned to normal, and the lumbar puncture leukocytes were 39*10^6/L, so the dosage of Fudaxin was reduced to 1/3. Fudaxin was used in this dosage for 3 days, i.e. 2013-1-16. Three days later, on the afternoon of 2013-1-16, the patient suddenly developed lethargy, high fever of 39.2
On the following day, January 17, 2013, a cranial CT (Figure 10) showed that the ventricles were dilated again, the lumbar puncture pressure was 140, and the cerebrospinal fluid leukocytes were 1100. The doctors at Anzhen Hospital considered that this was related to the reduction of Fudaxin, so they resumed the “high dose” of Fudaxin and added oral cotrimoxazole.
Figure 10: CT 46 days after shunt: the ventricles were dilated again
On the second day of this “high dose” of Fotaxin, i.e., the night of 2013-1-18, the patient’s body temperature returned to normal, consciousness returned to clear, he could eat liquid food but had difficulty opening his mouth and could not extend his tongue, he was unresponsive, and he occasionally spoke but his speech was unclear.
The patient’s family was so confused and helpless that they made many inquiries and personally checked the Internet to determine a change in the direction of consultation and immediately brought the patient to the cerebrospinal fluid department of the Aviation General Hospital for consultation.
II. Treatment and results in the cerebrospinal fluid department of the General Aviation Hospital.
(I) Situation on arrival.
The patient presented on admission (January 20, 2014, Figure 11): clear consciousness, but unresponsive, difficulty in opening the mouth, inability to extend the tongue, inability to eat through the mouth, and inability to speak. He was uncooperative on examination and could move his limbs correctly on command but with minimal movements; a curved surgical incision scar of approximately 375 px in length could be seen on the right frontotemporal area (aneurysm clamping surgery had been performed); a longitudinal surgical incision scar of approximately 125 px in length could be seen on the right occipital area (a ventriculoperitoneal shunt had been performed). The neck was tense. Bilateral pupils were unequal, pupils: 3.5mm on the left and 3.0mm on the right, with blunted reflex to light. Muscle strength: grade IV in the left limb and grade IV in the right limb. Muscle tone: the muscle tone of the bilateral limbs was basically normal.
Figure 11: Performance on the day of admission
A cranial CT performed on the day of admission showed significant ventricular dilatation and marked periventricular edema (i.e., interstitial cerebral edema or transventricular meningeal edema) (Figure 12).
Figure 12: 2014-1-20: Significant ventricular dilatation with marked periventricular edema
Approximately a few hours after the day of admission, the patient underwent emergency surgery: removal of the original ventriculoperitoneal shunt (right) + external drainage of the lateral ventricles (left).
The patient’s symptoms improved significantly and rapidly on the postoperative day: simple speech was possible, but still difficult to discriminate because of the tiny vocalizations; a small amount of liquid food could be consumed through the mouth; and a repeat cranial CT showed that the ventricles were smaller than before, the original ventriculoperitoneal shunt was removed, and the ventricular end of the lateral ventricular external drain was well positioned (Figure 13).
Figure 13: 2014-1-20: reduced ventricular dilatation
Bacterial culture of the cerebrospinal fluid taken at the time of admission for surgery returned results of Staphylococcus epidermidis three days later. Three consecutive bacterial cultures of cerebrospinal fluid within three days of admission, all of which subsequently returned negative, indicated that the patient’s intracranial infection-causing organisms had been eradicated. One week after admission, the patient was eating more, and his speech, voice and behavioral responses improved significantly.
On the 7th day of admission, 2014-1-27, the patient underwent drainage prior to a left ventriculoperitoneal shunt with preservation of the right lateral ventricular external drain. Postoperative cranial CT review on the same day showed good position of the ventricular end of the shunt, with reduced ventricular dilatation and periventricular edema (Figure 14).
Figure 14: CT on the 7th day of admission, i.e., January 27, 2014: after external placement of the lower segment of the ventricular shunt
Two days after surgery i.e. on January 29, 2014, the patient had further symptomatic improvement and the cranial CT was reviewed, which showed more controlled hydrocephalus (Figure 15).
Figure 15: CT 2 days after surgery i.e. January 29, 2014: reduction of the ventricles
After the CT, the lateral extraventricular drainage tube was removed from the patient’s right side. The patient’s ability to eat, open and extend his mouth, vocalize and speak, answer questions, turn in bed and other behavioral responses improved significantly within 9 days after the removal of the extraventricular drain (Figure 16). Cerebrospinal fluid color treatment improved at this time (Figure 17).
Figure 16: Performance at 9 days after the removal of the extraventricular drainage tube on February 7, 2014, i.e., compliance with tongue extension
Figure 17: Performance at 9 days after the removal of the extraventricular drainage tube on February 7, 2014: the color of the cerebrospinal fluid has become clearer
The patient underwent a ventriculoperitoneal shunt on 2014-2-19, 12 days after continuing treatment.
A cranial CT review was performed on the 12th day after the shunt i.e. 2014-3-3, the day before discharge, and showed good results for both ventricular size and shunt tube location (Figure 18). The patient’s behavior returned to essentially normal in all areas (Figure 19).
Figure 18: 2014-3-3 cranial CT: reduced ventricle size and well positioned shunt canal
Figure 19: 2014-3-3 Patient’s behavior returned to normal