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Mike-Sequelae of Brain Injury(American)

Author Zhangqi Views Posted at 2015/12/04

Name: Mike 
Sex: Male
Age:28 Years
Diagnosis:Sequelae of Brain Injury
Date of Admission:October 23, 2015
Treatment hospital/period: Wu Medical Center/19 days

Before treatment:
Mike had a car accident 18 months ago and then felt intocoma afterwards.Thebrain CT shows diffuse axonal injury, right frontal bone fracture and fractureoffloor of both orbits. He received tracheotomy and nasal feeding. The subdural effusion was treated. He woke up 7 months later but unconscious.He limbs had involuntary movements and stiffness.His parents move his body regularly. 10 months ago, thefeeding tubewas removed and he ate onsemi-liquid diet. He developedepilepsy.When it attacks, his limbs would becomestraighten; his headon one side and his jaw were shaked. So he took Levetiracetam and clonazepam to control it. His limbs could move a little, but uncoordinated.The muscle tension was higher and couldn’t speak at all. He couldn’t take care of himself at all. His family member wanted a better life so he was brought to our center and diagnosed as sequelae of brain injury

His spirit and diet were nromal, he slept 14-15 hours a day, when he was sleeping, his eyeballs moved from side to side. He had urine incontinence and constipation; someone helps him to defecate every 2 days.

Admission PE:
BP: 116/79mmHg; HR: 58/min, temperature: 36.7 degree, Br: 22/min. the skin and mucosa were normal, with no yellow stains or petechia. He had slow shallow breathing, the respiratory sounds in both lungs were weak with no signs of dry or moist rales. The cardiac rate was normal, with no obvious murmur in each valves. The abdomen was flat and soft. The liver and spleen were nromal. There was no swollen in both lower limbs. The skin temperature below his knees were cold. SAT was 90-94%.

Nervous System Examination:
Mike was alert but bad spirit, unconscious with complete aphasia. He always open his mouth. Both pupils were equal in size and round, the diameter was 3.0mms. Both pupils were sensitive to light stimulus. The ability to converge was bad. His eyeballs move quicklyin level during sleep or when closed. He slept 14-15 hours each day, he didn’t cooperate with other cranial nerves examinations. The muscle power of four limbs’ was at level 2, the muscle tension was a little higher, and both feet were slightly pendulous. Both side tendon reflex were active, both side abdominal reflexes were absent. Sucking reflex and low jaw reflex were positive. The palm jaws reflex and both side Babinski sign were positive. He was not able to do the other coordinate movement examinations. He had slight neck rigidity. His Kernig sign and Brudzinski sign were negative. Accessory examnation: Skull CT(2014.4.24): diffuse axonal injury, right frontal bone and both side orbital floor were fractured. Skull CT(2014.4.28): there were deteriorative cerebral edema in right frontal lobe, temporal lobe and brain stem. The MRI of head(2014.6.20): both side subdural effusion, there were bruise in both side frontal lobe, pons, midbrain and left cerebral peduncle. Electroencephalograms(2015.8.28): abnromal. Non-specificity mild diffuse slow and disordered brain wave, there was diffuse ectocinerea functional impairment, no focal sign or epilepsy sign. Skull CT(2015.3.18): right frontal bone had old depressed fracture(healed), right frontal lobe with infarction, left subdural effusion.

We diagnosed Mike as sequelae of brain injury. The patient received 4 times of neural stem cell injection and 4 times of mesenchymal stem cell injection to activate the cells, nourishes neurons, fix the damaged cells, improve circulation and immunity. He also had physical rehabilitation and was under mechanical ventilation.

He then received treatment to nourish the neurons, improve his blood circulation after sometime.He was on non-invasive ventilator to improve his breath. He also had physical rehabilitation. He had a fever during his treatment.The body temperature was between 36.7-37.5 degrees.There was no evidence of infection.

After 19 days of treatment, Mike’s breath was better. He had better movement of thorax, both side respirations were clear, and SAT was 96-98%. He had less nystagmus. The muscle tension was lower than before, his body rigor was less.He opened his mouth less. He was moreconscious and understood better than before.He could do some examinations that he could not do at first.He had less epileptic attack.


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