Case Stusies

Liu Caijun

Gender: Male

Age: 6 years and 2 months

Admission condition:

The child has been diagnosed with autism for over 3 years. At around 3 years old, due to a lack of communication skills, he was treated at Jinan Children's Hospital, Jinan Qilu Hospital, and Peking University Sixth People's Hospital, where autism was confirmed. Subsequently, the child received about 1 year of rehabilitation therapy at a local rehabilitation institution in Dezhou and is currently attending a special school for education.

Present symptoms include hyperactivity, inability to sit still, liking to run and jump, poor concentration, lack of safety awareness, stereotyped behavior, language regression, no spontaneous language expression but only passive calls like "mom" and "dad." The child has limited cognitive understanding, can perform simple instructed actions, but has poor emotional control, self-harm tendencies, occasional drooling, chewing and swallowing difficulties, poor fine motor skills, although overall gross motor skills are normal. The child is aware of bladder and bowel functions but has difficulty falling asleep.

Physical examination shows clear consciousness, but there is language regression, and intelligence is relatively lower compared to peers. Both pupils are equal and round, reacting to light, normal eye movements, normal hearing, presence of gag reflex, soft neck, normal muscle strength in all limbs, normal tendon reflexes. There are no involuntary movements observed, and the child did not cooperate fully with some examination procedures. No obvious neurological or motor abnormalities were found. Normal gait, no edema in lower limbs.

Overall, the child requires comprehensive rehabilitation and special education to promote language development, behavioral adjustments, and social skills enhancement. Treatment should focus on emotional management, self-care abilities, sleep issues, and regular follow-up assessments to monitor progress.

Admission Diagnosis: Cerebral developmental delay, autism

Treatment Process

On July 25, 2023, at 10:30, the patient underwent robot-assisted frameless stereotactic surgery under intravenous combined anesthesia. Prior to anesthesia, markers were applied to the head for navigation, followed by a head CT scan. The data was then imported into the Remebot system for the surgical procedure. The surgery began by targeting the left internal capsule, entering through the left frontal area, and establishing the surgical trajectory. The patient was placed in a supine position with head fixation, standard disinfection, and draping were performed. The scalp was incised locally, a single bone hole was drilled, the dura mater was punctured with a sharp needle, and then brain tissue resistance was probed with an electrode needle. Radiofrequency needle was used for gentle electrical stimulation at the target point for neural modulation therapy, completing the surgery on the left side. The same procedure was repeated for the right basal ganglia region. The surgery proceeded smoothly with approximately 3ml of blood loss. Postoperatively, the needle was removed, the surgical site was sutured and dressed, and a head CT scan showed no significant bleeding with accurate targeting. The patient was awake, alert, with equal and round pupils, normal light reflex, and no involuntary movements. Limb movements were normal without self-initiated movements. Postoperative care included regular IV fluids, suction, and cardiac monitoring, along with close observation of vital signs and timely management of symptoms. The patient was safely transferred back to the ward.

Discharge Summary:

On the second day after surgery, the patient's condition remained stable with no symptoms such as headache, nausea, or vomiting. Appetite was normal, bowel movements were regular, and sleep and diet were good. The surgical wound showed no signs of bleeding or swelling, and physical examination findings were consistent with previous ones.

During rounds, the attending physician noted that the patient did not exhibit any specific adverse postoperative reactions. After 2 days of anti-infection treatment, medications can be discontinued today. It is important to continue observing the surgical wound, keep it dry, change dressings on time, and prevent accidents such as falls or choking. Close monitoring of the patient's condition is necessary, and if no abnormalities are detected after evaluation tomorrow, discharge can be considered.

Discharge Instructions:

1、Keep the wound dry after discharge and remove stitches after 5 days.

2、Rest well, avoid vigorous head movements, and strengthen protective measures.

3、Follow up with rehabilitation training based on the child's condition after discharge.

4、Seek medical attention promptly if there are any discomforts.