Zhang Yifan

Name: Zhang Yifan

Gender: Female

Age: 7 years and 5 months

Admission Information:

The patient was diagnosed with cerebral developmental delay for over 5 years. About 5 years ago, the parents noticed delayed closure of the fontanelle, slow development in language and intelligence, and sought treatment at the local hospital where the diagnosis of "cerebral developmental delay" was made. Currently, the patient is in the first grade, capable of brief communication, but with slightly reduced cognitive ability, limited understanding, and some difficulty in logical thinking. The patient has amblyopia in both eyes, with the right eye exhibiting exotropia. There is a slight imbalance in limb movement. The patient is capable of self-care in terms of diet and bowel movements.



Admission Diagnosis:

Cerebral developmental delay

Treatment Process:

Patient Zhang Yifan, female, 7 years and 5 months old, underwent robot-assisted frameless stereotactic surgery for cerebral developmental delay under general anesthesia on April 10, 2023, at 12:40 PM. The surgical procedure was as follows: After successful anesthesia, marker points were placed on the head, followed by a head CT scan and importing of the data into the Remebot robot. The left frontal lobe was selected as the target, accessed through the left frontal region to establish the surgical pathway. The patient was placed in a supine position, with a molded pillow securing the head, and underwent routine disinfection. A local scalp incision was made, a bone hole drilled, and a sharp needle punctured the dura mater. Initially, an electrode needle was used to detect brain tissue impedance, followed by using an RF needle for gentle electrical stimulation therapy at the target point on the left side. The surgery on the left target point was completed. Then, the right basal ganglia was chosen as the target point, with the same surgical approach. The surgery proceeded smoothly, with approximately 3 ml of postoperative bleeding. The needle was removed, and the skin was sutured locally with pressure bandaging. Postoperative head CT showed no obvious bleeding, and the target point was accurately located. The patient safely returned to the ward, receiving routine intravenous fluids, oxygen therapy, and cardiac monitoring. Medical staff closely monitored the patient's vital signs and provided timely symptomatic treatment as needed. The family was informed of the surgical procedure.

Discharge Summary:

The patient's condition is currently stable with no specific discomfort, no headache, nausea, or vomiting. The patient has a good appetite. There is no bleeding or swelling at the surgical wound, normal bowel movements, and good dietary and sleep habits.

Physical examination findings showed stable vital signs, clear consciousness, and good mental status. The patient can engage in brief communication, although there are abnormalities in intelligence and orientation. Pupils are equal and reactive to light, eye movements are normal, hearing is normal, pharyngeal reflex is present, no atrophy or tremors in the tongue muscles, nasal-labial folds are symmetric, tongue protrusion is central, neck is soft, normal muscle strength in all four limbs (grade V), normal muscle tone, normal tendon reflexes, no involuntary movements, negative finger-nose test. Negative Brudzinski sign and Kernig sign indicating no meningeal irritation. No lower limb edema, and normal gait.

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.