Case Stusies
Gong Junyao
Gender: Female
Age: 3 years and 7 months
Admission condition:
The patient was admitted approximately two years ago at the age of about 1 and a half years old when parents noticed a lack of language ability. She received diagnosis and rehabilitation treatment at a local hospital for autism and developmental delay. Currently, the patient still lacks language ability, has communication barriers, and shows limited response to external stimuli. Additionally, her cognitive and understanding abilities are poor, making it difficult to complete command actions. The patient exhibits hyperactivity, poor emotional control, and is prone to shouting loudly but does not display aggressive or self-injurious behaviors. Sleep quality is poor with difficulty falling asleep. The patient can feed herself but is unaware of her toileting needs. Limb movements are normal. To further diagnose and treat her condition, it is planned to transfer the patient to our hospital for surgical treatment. Since the onset of the illness, the patient has remained alert, with clear consciousness, normal appetite and bowel habits, and stable weight without significant changes.
Admission Diagnosis: Cerebral dysplasia, autism, epilepsy
Treatment Process
Patient Gong Junyao, female, 3 years and 7 months old, underwent robot-assisted frameless stereotactic brain surgery on January 15, 2023, at 14:30 due to cerebral dysplasia, autism, and intellectual disability. The surgery was performed under general anesthesia and proceeded smoothly. After successful anesthesia, the head was marked, followed by a head CT scan and data importation into the Remebot robot. The left temporal lobe was selected as the target point, and the surgical pathway was set through the left frontal area. The patient was placed in a supine position with the head fixed, and a local scalp incision was made to drill a cranial hole and penetrate the dura mater. Subsequently, electrode needle detection and implantation of brain monitoring electrodes were performed. After identifying the epileptic lesion, radiofrequency ablation was conducted, followed by re-implantation of monitoring electrodes to confirm the disappearance of the lesion.
Finally, gentle electrical stimulation was applied for neuroregulation treatment at the target point on the left side. The surgery on the left target point was successfully completed with a bleeding volume of 3ml. Postoperatively, the skin was sutured and compressed, and the patient was safely returned to the ward. Routine intravenous fluids, oxygen inhalation, and cardiac monitoring were provided, with close observation of vital signs and prompt treatment of any discomfort. The surgical details have been thoroughly explained to the patient's family.
Discharge Summary:
The patient's current condition is stable with no headaches, nausea, or vomiting. Her appetite is good, and there are no signs of bleeding or swelling at the surgical site. Bowel and bladder functions are normal, and she is eating and sleeping well. Physical examination shows stable vital signs, clear consciousness, and good mental status. The patient has no abnormalities in language, intelligence, or orientation. Pupils are equal in size and round, approximately 3mm in diameter, with intact light reflexes and normal eye movements. Hearing is normal, and throat reflexes are present. There are no signs of tongue muscle atrophy or tremors, and facial features are symmetrical. The patient's limbs have normal muscle strength (grade V), normal muscle tone, and normal tendon reflexes. There are no involuntary movements, and she does not cooperate with the finger-nose test, heel-knee-shin test, or Romberg's sign. Bilateral Babinski sign is negative, and signs of meningeal irritation such as Kernig's sign are absent. No edema is observed in the lower limbs, and gait is normal.
Discharge Instructions: