Case Stusies

Wang Zhiqiang

Gender: Male

Age: 10 years and 4 months

Admission condition:

The patient was found not to communicate with peers at the age of 3. He was subsequently diagnosed with autism at Jining People's Hospital but did not receive specialized treatment. He has been undergoing rehabilitation therapy at a local rehabilitation institution since then. Currently, the patient exhibits intellectual impairment, unclear speech with a vocabulary of 5-6 words, along with noticeable hyperactivity and irritability. At times, he engages in self-harm or requests head pinching. The patient enjoys playing with shoes and elastic toys. To further diagnose and treat his condition, the patient was referred to our hospital. Since the onset of the condition, the patient has remained alert, with a clear mental status, normal eating and sleeping patterns, and regular bowel and bladder habits. There have been no significant changes in weight.

Admission Diagnosis: Cerebral underdevelopment, Autism

Treatment Process

Patient Wang Zhiqiang, male, currently 10 years and 4 months old, underwent robot-assisted frameless stereotactic surgery for cerebral underdevelopment and autism under general anesthesia on April 10, 2023, at 3:00 PM. The surgery began by placing marker points on the head and performing a head CT scan. The scan data was then imported into the Remebot robot. The left basal ganglia was chosen as the surgical target, and a surgical path was established through the left frontal region. The patient was placed in a supine position with a molded pillow for head fixation. After standard disinfection, a local scalp incision was made to drill a single skull hole. A needle electrode was used to measure brain tissue resistance, followed by gentle electrical stimulation therapy using a radiofrequency needle at the target point for nerve modulation. The surgery on the left target point was successfully completed. The same procedure was then performed on the right frontal lobe as the target point. The surgery proceeded smoothly with approximately 3 ml of blood loss. Postoperatively, the needle was removed, and the skin was sutured and dressed with compression. A postoperative head CT scan showed no significant bleeding, confirming accurate targeting of the desired areas. The patient was transferred safely back to the ward and received routine intravenous fluids, oxygen therapy, and cardiac monitoring. Vital signs were closely monitored with prompt management of any emerging issues. The surgical procedure and outcomes have been communicated to the patient's family.

Discharge Summary:

The patient's discharge condition is good: the condition is stable with no specific discomfort, and general condition is good. Sleep and diet are normal, and bowel and bladder habits are regular with no abnormalities. Physical examination shows stable vital signs, clear mental status, and good mental condition. Pupils are equal, round, and reactive to light. Lung auscultation reveals no abnormal sounds, and heart rhythm is regular with no murmurs. Babinski sign is negative. The surgical incision is free of infection and healing well, therefore discharge is recommended.

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.