Meningioma\Postoperative Vegetative State

Female, 71 years old Admission record Department: Neurosurgery Ward Admission date: June 28, 15:02 History taken: June 28, 15:51 Record date: June 28, 16:51 History provided by: the patient herself Chief complaint: Meningioma discovered more than 7 months ago. Present illness: Seven months ago, the patient underwent cranial CTA at another hospital, which suggested a possible meningioma and a left posterior communicating artery aneurysm. She came to our hospital for treatment. Cerebral angiography also revealed a left dural arteriovenous fistula and aneurysm. On November 22 last year, she underwent stent-assisted embolization of the left posterior communicating artery aneurysm and embolization of the left cranial base DAVF at our hospital. She recovered well after the procedure. She was admitted to our hospital for treatment of the meningioma, with outpatient diagnosis of “meningioma.” Since onset, the patient has maintained good spirits, normal appetite, normal bowel and bladder function, and no significant weight change. Past history: General health and medical history: Usually in good health. Hypertension for over 20 years, on amlodipine besylate, valsartan, and atorvastatin calcium for blood pressure and lipid control; she reports good blood pressure control. Rheumatoid arthritis for 2 years, controlled with medication (specific drugs unknown, now discontinued). Half a year ago, head CT showed a small patchy infarct beside the left lateral ventricle. She underwent aneurysm stenting and received anticoagulation; aspirin was stopped one week before this admission. She denies diabetes or coronary heart disease. Infectious disease history: Chronic hepatitis B (active phase) for 1 year, currently on entecavir and coenzyme Q₁₀. Denies tuberculosis. Surgical history: Confirmed. Cholecystectomy; left posterior communicating artery stent-assisted embolization and left cranial base DAVF embolization on November 22 last year at our hospital. Personal history: Denies smoking or alcohol use. Physical examination T: 36.4℃ P: 78 beats/min R: 21 breaths/min BP: 137/92 mmHg Conscious, normal development, good nutrition, answers appropriately, active position, cooperative with examination, walked into the ward. No abnormalities in skin or mucous membranes, no liver palms, no superficial lymphadenopathy. No subcutaneous bleeding or rash. Head normal, eyelids normal, conjunctiva normal, sclera not icteric. Pupils equal and round, reactive to light. Ears normal, no discharge or tenderness. Nose normal, patent, septum straight, no alar flaring, no sinus tenderness. Lips not cyanotic, parotid glands not enlarged. Neck supple, no resistance, jugular veins not distended, trachea midline, thyroid not enlarged. Chest symmetric, no tenderness. Breath sounds clear bilaterally, no wheezes or crackles. Heart rate 78 beats/min, regular rhythm. Abdomen flat and soft, no tenderness, no rebound or guarding, liver and spleen not palpable, no costovertebral angle tenderness, bowel sounds 4 times/min. Anus and external genitalia normal. Spine and limbs normal, no joint swelling, no clubbing, no lower limb edema. Muscle strength and tone normal. Physiological reflexes normal, pathological reflexes absent. Specialist examination GCS 15, answers appropriately, cooperative. Pupils equal and round, 3 mm diameter, direct and indirect light reflexes normal, corneal reflex present, accommodation reflex present. Symmetric frontal wrinkles and nasolabial folds. Tongue midline. Neck supple, normal muscle tone, bilateral limb strength grade V and symmetric, deep and superficial sensation normal and symmetric. Tendon reflexes ++, no clonus. Pathological signs negative. Fundus not examined. Auxiliary examinations Cranial CT on December 9 last year at our hospital: subdural hematoma adjacent to the anterior falx. Possible small patchy infarct beside the left ventricle. Intracranial arterial atherosclerosis. Metallic shadow near the sella, status post intracranial aneurysm treatment? Preliminary diagnosis: 1. Meningioma; 2. Status post cerebrovascular intervention; 3. Hypertension; 4. Cerebral infarction; 5. Rheumatoid arthritis; 6. Hepatitis B virus infection Date: June 28

Department: Neurosurgery Ward June 28, 16:16 First progress note I. Case characteristics: Female, 71 years old, admitted with “meningioma discovered more than 7 months ago.” II. Diagnosis and basis: Diagnosis: Meningioma; status post cerebrovascular intervention; hypertension; cerebral infarction; rheumatoid arthritis; hepatitis B virus infection Basis: 1. Female, 71 years old, admitted with “meningioma discovered more than 7 months ago.” 2. Physical examination: no special findings. 3. Auxiliary examinations: Cranial CT on December 9 last year showed subdural hematoma adjacent to the anterior falx (neurosurgery review suggested possible meningioma). Possible small patchy infarct beside the left ventricle. Intracranial arterial atherosclerosis. Metallic shadow near the sella, status post intracranial aneurysm treatment? 4. Other diagnoses: Confirmed based on past history and hospital test results. III. Differential diagnosis: Differential for meningioma: 1. Meningioma: Extra-axial lesion; mass effect when enlarged; strong enhancement on imaging with possible dural tail sign. The patient shows these features. 2. Glioma: Intra-axial; may cause mass effect; enhancement and edema vary by grade. Cannot be fully excluded at present. 3. Metastasis: Often multiple lesions with marked edema and primary tumor symptoms. Unlikely in this patient. Differential for other diagnoses: Confirmed based on history and examinations. IV. Treatment plan: 1. Complete necessary preoperative tests (routine blood, biochemistry, coagulation, etc.). 2. Schedule surgery.

July 6, 09:25 Progress note Ward round today: patient in stable general condition, no complaints. The patient underwent transcatheter intracranial aneurysm stent-assisted embolization at our hospital half a year ago and was on routine oral anticoagulation afterward. Aspirin was stopped for over one week before admission for this resection; coagulation is now normal. The patient and family were informed that the tumor is small and observation with follow-up is possible, but they strongly prefer surgery. Surgery is planned. Doctor signature: *** July 8, 08:00 Preoperative progress note Preoperative history: Seven months ago, cranial CTA at another hospital suggested possible meningioma and left posterior communicating segment aneurysm. She came to our hospital; angiography also showed left dural arteriovenous fistula and aneurysm. On November 22, last year, stent-assisted embolization of the left posterior communicating artery aneurysm and embolization of the left cranial base DAVF were performed at our hospital. Recovery was good. She was admitted for meningioma treatment with outpatient diagnosis of “meningioma.” Physical examination: Aspirin stopped for over one week before admission, no discomfort. GCS 15, answers appropriately, cooperative. Pupils equal and round, 3 mm, light reflexes normal, corneal reflex present, accommodation present. Symmetric nasolabial folds. Tongue midline. Neck supple, normal tone, bilateral strength grade V and symmetric, sensation normal. Tendon reflexes ++, no clonus. Pathological signs negative. Fundus not examined. Key preoperative imaging and labs: Cranial CTA: Status post left internal carotid artery communicating segment aneurysm treatment, no definite residual aneurysm. Right posterior communicating artery and left middle cerebral artery origin slightly dilated. Intracranial atherosclerosis noted. Correlate clinically. Cranial MRI: Lacunar infarcts and ischemic foci in left cerebellum, bilateral basal ganglia, periventricular areas, and frontal lobe. Brain atrophy and white matter degeneration. Status post left internal carotid communicating segment aneurysm treatment. Possible hemosiderin deposition anterior falx? Contrast-enhanced cranial MRI: Spindle-shaped shadow anterior falx, possible chronic subdural hematoma, unchanged from prior CT (December 9 last year). Possible left frontal venous malformation. Correlate clinically. Surgical contraindications excluded: Yes Planned surgery time: July 8, 08:00 Planned procedure: Craniotomy for meningioma resection Planned anesthesia: General Preoperative discussion and summary completed: Yes Informed consent signed by patient and family: Yes

July 8, 14:30 First postoperative progress note Surgery time: July 8, 08:55 to 13:30 Intraoperative diagnosis: Meningioma (two locations: parasagittal and falcine) Anesthesia: General Procedure: Craniotomy for meningioma resection Brief operative course: 1. After induction, patient in supine position with head elevated, fixed in Mayfield head holder. 2. Small coronal incision 3 cm anterior to coronal suture. Standard prep and drape. 3. Layered scalp incision, hemostasis with clips. Five burr holes in midline and right frontal bone, craniotomy with high-speed drill to create free bone flap. 5. Dural hitch sutures at bone edge. 6. Horseshoe dural incision reflected toward midline and secured. Three large veins draining into superior sagittal sinus visible in anterior third of field, protected with Gelfoam. 7. Frontal lobe retracted into interhemispheric fissure; 0.5 cm meningioma seen at superior sagittal sinus angle, attached to sinus, well-defined, minimal vascularity, completely resected. Further retraction 2 cm deeper revealed another tumor. 8. Tumor base divided along falx. Gelfoam used to separate boundaries; total resection achieved. Careful hemostasis, hemostatic gauze applied. 10. Dura closed watertight, bone flap replaced and fixed with titanium plates. 11. Layered scalp closure, sterile dressing. Postoperative measures: Acid suppression, anti-inflammatory, antiepileptic, and fluid therapy. Postoperative monitoring: Vital signs, consciousness, speech, limb movement.

July 8, 17:00 Progress note Approximately 1.5 hours after emergence from anesthesia, patient transferred to NICU. Examination showed clouded consciousness, right hemiparesis, aphasia, unable to communicate normally. Head CT: small hyperdense shadow anterior falx—correlate clinically; postoperative frontal bone changes, intracranial air; possible small left periventricular infarct; intracranial atherosclerosis; metallic shadow near sella, status post aneurysm treatment. Compared with preoperative CT (December 9 last year): left infarct slightly larger, possible new infarction. Treatment: volume expansion, fluids, anticoagulation. Family fully informed and understands. Close monitoring in NICU with treatment adjusted as needed.

July 9, 09:08 Attending physician ward round First postoperative day after meningioma resection. Vital signs stable, T 36.6℃, BP 133/85 mmHg. Patient can produce simple sounds, improved from yesterday. Left limb strength and tone normal; right leg movement improved to approximately grade 3, right arm still grade 1. July 9 coagulation (anticoagulation panel): PT 12.10 s, INR 1.01, fibrinogen 1.140 g/L (low), APTT 24.90 s, TT 19.10 s. July 9 emergency biochemistry and electrolytes: glucose 6.4 mmol/L (high), magnesium 0.81 mmol/L, total bilirubin 18.10 μmol/L, urea 4.74 mmol/L, phosphorus 0.59 mmol/L (low), AST 49.00 U/L (high), creatinine 61.2 μmol/L, LDH 324.00 U/L (high), uric acid 414.20 μmol/L, total protein 67.60 g/L, ALP 59.00 U/L, CK 73.0 U/L, calcium 2.00 mmol/L (low), albumin 38.10 g/L, GGT 44.0 U/L, chloride 115.0 mmol/L (high), ALT 28.0 U/L, potassium 4.80 mmol/L, sodium 140.00 mmol/L, globulin 29.50 g/L (low), A/G 1.29. July 9 CBC: basophils 0.02 × 10⁹/L, 0.1%; eosinophils 0.00 × 10⁹/L (low), 0.0% (low); hematocrit 37.5%, hemoglobin 123.00 g/L, lymphocytes 1.25 × 10⁹/L, 5.4% (low); MCH 28.5 pg, MCHC 328 g/L, MCV 90.8 fL; monocytes 0.95 × 10⁹/L, 4.1%; MPV 9.7 fL; neutrophils 20.73 × 10⁹/L (high), 90.40% (high); plateletcrit 0.23%, PDW 9.9%, platelets 237 × 10⁹/L; RBC 4.13 × 10¹²/L, RDW 12.80%, WBC 22.95 × 10⁹/L (high). Treatment: 1. Continue fluids, volume expansion, anti-inflammatory, antiepileptic therapy. 2. Maintain appropriate blood pressure for cerebral perfusion. 3. Start nadroparin today, monitor coagulation. 4. Close observation. Date: July 9

July 10, 10:00 Second postoperative day progress note Second postoperative day. Chief physician ward round: vital signs stable, T 37.1℃. Patient’s speech further improved. Left limb strength and tone normal; right leg approximately grade 3, right arm grade 1. Treatment: continue anticoagulation, fluids, volume expansion, anti-inflammatory, antiepileptic; otherwise unchanged. Doctor signature: July 11, 10:17 Attending physician ward round Ward round today: vital signs stable, general condition similar to yesterday, T 37.1℃. Left limb strength and tone normal; right leg grade 3, right arm grade 1. July 11 CBC: WBC 15.68 × 10⁹/L (high), RBC 3.54 × 10¹²/L (low), neutrophils 90.10% (high), hemoglobin 106 g/L (low), lymphocytes 5.0% (low), hematocrit 31.5% (low), etc. July 11 coagulation: PT 12.70 s, INR 1.06, fibrinogen 3.384 g/L, APTT 26.50 s, TT 14.40 s. July 11 biochemistry: glucose 7.8 mmol/L (high), ... total protein 54.30 g/L (low), albumin 26.90 g/L (low), etc. Treatment: continue fluids, volume expansion, anti-inflammatory, antiepileptic; continue anticoagulation, low-molecular-weight heparin sodium to be adjusted to 0.4 ml BID subcutaneous tomorrow; otherwise unchanged. *Date: July 11

Postoperative day 1 records show the patient could produce simple sounds. Subsequent records contain no further documentation of speech or level of consciousness. However, according to family reports, the patient has remained in a vegetative state since the operation.