Case Stusies

Zhai Zihan

Gender: Female

Age: 5 years and 5 months

Admission condition:

The patient was admitted to Linyi District People's Hospital at the age of 1 year and 11 months due to a lack of language expression ability, lack of eye contact, and unresponsiveness to external stimuli, with a preliminary diagnosis of "suspected autism." Subsequently, at the age of 2 years and 10 months, due to no improvement in symptoms, she was further diagnosed with "autism" at Linyi District Central Hospital and has since received rehabilitation treatment. Currently, the patient exhibits hyperactivity, has difficulty sitting still for long periods, frequently engages in stereotypical behaviors such as tearing paper, has weak language abilities, only produces 2-3 syllables when needed, with unclear and non-imitative speech. She has some cognitive flexibility but poor comprehension, only capable of completing simple command actions. The patient experiences significant mood swings, shouts loudly when excited, and exhibits self-harming behaviors such as pinching. In terms of gross motor skills, the patient is functional, but coordination is poor, unable to stand on one foot, and lacks fine motor skills in both hands. Her diet, bowel, and bladder movements are normal, with no significant recent weight changes. Due to the need for further diagnosis and treatment, the patient was transferred to our hospital for further management. Since the onset of the condition, the patient has been alert and mentally stable.

Admission Diagnosis: Cerebral developmental delay, autism spectrum disorder

Treatment Process

Patient Zhai Zihan, a 5-year and 5-month-old female, underwent robot-assisted stereotactic brain surgery under general anesthesia on October 17, 2023, at 08:00.

The surgical procedure was as follows: Initially, the head was marked, followed by a head CT scan. The data were then imported into the Remebot robot, selecting the target point in the left internal capsule anterior limb, entering through the left frontal region, and setting the surgical path. The patient was placed in a supine position with the head fixed and underwent routine disinfection and draping. The scalp was locally incised, a single bone hole was drilled, the dura was punctured with a needle, brain tissue resistance was measured with an electrode needle, and gentle electrical stimulation therapy was applied at the target point for nerve modulation. The left-side target point surgery was completed successfully. The same method was applied to select the right basal ganglia area as the target point. The surgery proceeded smoothly with approximately 3 ml of intraoperative bleeding.

After surgery, the needle was removed, and the skin was sutured and bandaged. Postoperative head CT revealed no significant bleeding, with accurate target localization, and the patient safely returned to the ward. The patient remained alert, mentally stable, with equal and reactive pupils, normal limb movements, and no involuntary movements. The surgical wound dressing was clean and tidy. Postoperatively, the patient received routine fluid therapy, oxygen therapy, cardiac monitoring, and close observation of vital signs for timely intervention. Detailed information about the surgery was provided to the patient's family.

Discharge Summary:

The patient's condition is currently stable, with improved walking in the left lower limb (no longer dragging) and maintained upper limb motor function. There has been a significant improvement in mood compared to before surgery, with extended sitting times and reduced excitability. Physical examination shows stable vital signs, clear consciousness, good mental status, equal and reactive pupils, and normal light reflex. No abnormal breath sounds were heard in the lungs, heart rate was 86 beats per minute, with a regular rhythm and no murmurs heard. Postoperative head CT showed reduced swelling and absorption, compared to October 19, 2023. Dr. Tian Zengmin, the attending physician, analyzed the postoperative edema situation and recommended discharge with a follow-up visit.

Discharge Instructions:

1、Rest properly, strengthen protection, and avoid vigorous head movements.

2、Engage in rehabilitation training based on the child's language and motor recovery status after discharge.

3、Please schedule a follow-up visit at the outpatient department before April 24, 2024.

4、Maintain regular follow-up visits after discharge.