Detailed Treatment Process
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Female, 47 years old Discharge record Department: Neurosurgery Admission date: May 28 Discharge date: May 29 Condition on admission: Left-sided limb numbness and weakness for more than four months. Temperature: 36.4℃, pulse: 62 beats/min, respiration: 20 breaths/min, blood pressure: 123/75 mmHg. The patient was alert and oriented, with clear speech and appropriate responses. She followed commands well. Bilateral frontal wrinkles were symmetrical. Both pupils were equal and round, measuring 2.5 mm in diameter, with brisk light reflexes. Extraocular movements were full without nystagmus. Nasolabial folds were symmetrical, the tongue was midline, the uvula was centered, and the gag reflex was intact. The neck was supple without resistance. Muscle strength and tone in all four limbs were normal. Deep tendon reflexes were present and pathological signs were absent. On May 28, cranial CT showed: 1. Abnormal signal in the brainstem, suggestive of cavernous hemangioma with possible hemorrhage; cranial CTA was recommended for further evaluation. 2. Subcortical white matter hyperintensities in bilateral frontal and parietal lobes (modified Fazekas grade I). 3. Degenerative changes of the cervical spine: central disc herniations at C3/4 to C6/7, with spinal cord compression at C4/5 without signal change. 4. Right maxillary sinusitis. Admission diagnosis: Brainstem hemorrhage (cavernous hemangioma); cervical disc herniation. Treatment course: After admission, additional examinations were completed. Abdominal ultrasound showed no significant abnormalities in the liver, gallbladder, spleen, or pancreas. A hyperechoic mass was noted in the left kidney, considered likely a hamartoma. The right kidney and bladder appeared normal. Chest X-ray showed no abnormalities in the heart, lungs, or diaphragm. Symptomatic treatment included dehydration to reduce intracranial pressure and intravenous fluids. The patient’s family requested transfer to a higher-level hospital. They were informed of the risks during transport but insisted on discharge and signed the relevant forms. Discharge was arranged accordingly. Discharge condition: Persistent left-sided limb numbness and weakness, without nausea, vomiting, seizures, chills, or fever. Discharge diagnosis: 1. Brainstem hemorrhage (cavernous hemangioma?); 2. Cervical spondylosis. Discharge instructions: Transfer to a higher-level hospital for further treatment, follow up on CTA results, and ensure safety during transport.
MRI Report Examination time: June 4, 22:11:50 Department: Neuro-oncology Surgery Scans performed: Functional MRI (including SWI), cervical spine plain scan, brain plain scan + DWI + head MRA Clinical diagnosis: 1. Brainstem hemorrhage (cavernous hemangioma?); 2. Cervical spondylosis. Brainstem hemorrhage; cervical spondylosis. Findings: A mass-like abnormal signal was seen in the pons, with ill-defined borders, measuring approximately 23 mm × 21 mm × 21 mm. On T1WI the lesion showed central high signal with slightly high signal at the periphery. On T2WI and T2-FLAIR it demonstrated mixed central high and low signal with a surrounding ring of low signal. DWI showed focal slightly high signal suggesting restricted diffusion. On SWI the center was high signal and the periphery low signal, with linear low-signal structures inside. Mild perilesional edema was present with ill-defined borders. Scattered punctate and patchy abnormal signals were noted in the subcortical white matter of the bilateral frontal and parietal lobes and periventricular regions; these were isointense on T1WI and hyperintense on T2WI and T2-FLAIR, without restricted diffusion on DWI. The remainder of the brain parenchyma showed no abnormal signals. The ventricular system was not enlarged, sulci and fissures were normal, and the midline was centered. No bone destruction was seen in the skull. Mild mucosal thickening was present in the bilateral ethmoid sinuses. Orbits and mastoids were unremarkable. Both vestibulocochlear nerves were normal. Nasopharyngeal mucosa showed no thickening. The bilateral anterior, middle, and posterior cerebral arteries followed normal courses with good opacification, smooth walls, and homogeneous luminal signal without significant stenosis. The internal carotid arteries and vertebrobasilar arteries were also well visualized. No aneurysmal dilatation or vascular malformations were identified intracranially. Cervical lordosis was straightened without vertebral slippage. Marginal osteophytes were present on some vertebral bodies. Bone marrow signals within the vertebrae were normal. Intervertebral disc spaces were maintained. On T2WI, disc herniations were seen at C3/4, C4/5, C5/6, and C6/7, directed posteriorly, resulting in spinal canal stenosis at C3/4, C4/5, and C5/6 levels. The ventral spinal cord showed mild compression with indentation but no abnormal signal. No intraspinal mass lesions. Posterior elements were intact and paravertebral muscles showed normal signal. Impression and recommendations: 1. Probable pontine cavernous hemangioma with hemorrhage (possibly subacute stage); clinical correlation and follow-up imaging recommended. 2. Scattered multifocal small degenerative foci in subcortical white matter of bilateral frontal and parietal lobes and periventricular regions (white matter hyperintensities, modified Fazekas grade 1); mild bilateral ethmoid sinusitis noted. 3. No definite abnormalities of the cerebral arteries. 4. Degenerative changes of the cervical spine; central disc herniations at C3/4, C4/5, C5/6, and C6/7 with bulging at C3/4, C4/5, and C5/6, resulting in spinal canal stenosis at C3–6 levels, mild spinal cord compression, and normal cord signal. Report time: June 5, 19:00:29
Following inquiry by the author, the patient provided the chief complaint and the doctor’s verbal recommendations. Chief complaint: Mild numbness in hands and feet for nearly six months, with numbness and weakness for two months. This morning the doctor offered three treatment options: first, craniotomy; second, laser or infrared treatment for the intracranial bleeding site, though the hemangioma size (approximately 2–3 cm) greatly exceeded the suitable range for this approach; third, conservative management and leaving it to resolve on its own.