Detailed Treatment Process
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Male, 54 years old. The years mentioned below refer to the year of surgery unless otherwise noted. The patient was admitted for surgery because of a brain glioma. Neurosurgery Operative Record Gender: male Age: 53 years Date of surgery: March 17 (as recorded) Anesthesia: general anesthesia Preoperative diagnosis: left frontotemporal glioma Postoperative diagnosis: left frontotemporal glioma Procedure: craniotomy and resection of left frontotemporal glioma Operative findings: The patient underwent endotracheal intubation under general anesthesia and was placed in the supine position with the head slightly turned to the right and fixed in a head frame. A left modified pterional approach was used. After routine skin preparation and draping, the scalp and subcutaneous tissues were incised, and a scalp flap was elevated. A 4 × 5 cm bone window was created. The dura was tacked up and opened in a circumferential fashion. Brain tension was mildly elevated; after hyperventilation, it was reasonably controlled. After incising the cortex for about 1 cm, the tumor was encountered. The tumor was soft in consistency with rich blood supply. It was dissected along the edematous plane. The tumor was found to be located mainly in the temporal pole, with a portion extending to the lateral aspect of the basal ganglia. The temporal pole was completely resected. To protect motor function in the limbs, the portion of the tumor in the basal ganglia was not aggressively removed. After thorough hemostasis of the tumor cavity, the dura was repaired with artificial dura mater. A negative-pressure drain was placed in the epidural space. The skull was repaired with titanium plates, the scalp was closed, and the wound was dressed. The patient was transferred to the NICU after emergence from anesthesia.
Pathology Report Department: Neurosurgery Date of submission: February 17 Specimen: gray-white brain-like tissue, 2.5 × 2 × 1.5 cm Clinical history: One episode of sudden epilepsy one month earlier Preoperative diagnosis: left frontotemporal glioma Gross appearance: gray-white brain-like tissue, 2.5 × 2 × 1.5 cm Microscopic findings: Round-nucleated tumor cells distributed at moderate density, with perinuclear halos and marked nuclear atypia. Immunohistochemistry: Tumor cells GFAP(+), Olig2(+), IDH1(+), P53(−), NeuN(−), β-catenin(−), MGMT(−) MIB-1 (2%) Conclusion: (Left frontotemporal) oligodendroglioma (WHO grade II) Chromosome 1p/19q LOH testing is recommended. Please inform the patient’s family to contact the neuropathology department. Report date: February 23
Neurosurgery Operative Record Date of surgery: February 24 Anesthesia: general anesthesia Preoperative diagnosis: 1. Status post resection of left frontotemporal glioma; 2. Intracranial hematoma Postoperative diagnosis: 1. Status post resection of left frontotemporal glioma; 2. Intracranial hematoma Procedure: Evacuation of intracranial hematoma and decompressive craniectomy Operative findings: The patient underwent endotracheal intubation under general anesthesia with head fixation. The original incision was reopened and the flap elevated. Upon opening the dura, a hematoma was found within the original tumor cavity along with a small amount of fresh bleeding, with an estimated volume of about 200 ml. After complete evacuation, an oozing point was identified on a sylvian fissure vessel, which was controlled with bipolar cautery. The cavity was packed with gelatin sponge. After satisfactory hemostasis, the dura was closed under tension, a decompressive craniectomy was performed, and a negative-pressure drain was placed in the epidural space. The wound was dressed, and the patient was transferred to the NICU with the drain in place.
After the two operations, the patient remained in a vegetative state. More than a year later, he died in the inpatient ward. The family requested a medical malpractice assessment. The assessment report describes the treatment course as follows: Four, Summary of Diagnosis and Treatment On February 10, the patient was admitted for “intermittent epileptic seizures for more than three months.” According to the admission history: The patient had experienced a generalized tonic-clonic seizure at the end of October the previous year, with loss of consciousness and whole-body convulsions lasting one minute. Another seizure occurred in January. Head CT and MRI performed at an outside hospital showed a left frontotemporal mass, most likely a glioma. Specialist examination: Alert, GCS 15, pupils equal and round at 3.0 mm with normal light reflexes. Other cranial nerve examinations were unremarkable. Limb muscle tone and power were normal. Sensory examination was intact. Bilateral pathological reflexes were negative. Preliminary diagnosis: left frontotemporal glioma. After admission, preoperative evaluations and preparations were completed. On February 17, the patient underwent craniotomy and resection of the left frontotemporal glioma under general anesthesia. Intraoperatively, a 4 × 5 cm bone window was created, the dura was tacked up and opened circumferentially. Brain tension was mildly elevated and reasonably controlled after hyperventilation. After incising the cortex about 1 cm, the tumor was encountered. It was soft with rich vascularity and was dissected along the edematous plane. The tumor was located mainly in the temporal pole with extension to the lateral basal ganglia. The temporal pole was completely resected. To protect limb motor function, the basal ganglia portion was not forcibly removed. After thorough hemostasis, the dura was repaired with artificial material and a negative-pressure drain was placed epidurally. The patient was transferred to the NICU after anesthesia recovery and received dehydration, hemostatic, and anti-infective supportive treatment. Pathological diagnosis: left frontotemporal oligodendroglioma (WHO grade II). On the 22nd, the patient was alert and in good spirits but had a fluctuating fever above 38°C. Given the deep location of the surgical site, a lumbar puncture was performed and 6 ml of clear fluid was sent for examination. Cerebrospinal fluid analysis showed: pale yellow (reference: colorless), turbid (reference: clear), Pandy test ± (reference: negative), red blood cells 1800 (0–10 × 10⁶/L). At 22:00 on the 23rd, the patient became drowsy and lethargic and complained of headache. Examination: GCS 11, pupils equal and round at about 2 mm with sluggish light reflexes. Urgent head CT showed brain edema in the surgical area with a small amount of hematoma. Enhanced dehydration and hemostatic therapy were given, and the patient was transferred to the intensive care unit. At 03:00 on the 24th, the patient’s consciousness deteriorated further to GCS 4. Repeat head CT showed significant enlargement of the hematoma in the surgical area with midline shift greater than 1.5 cm and compression of one lateral ventricle. After informing the family of the critical condition and obtaining consent, at 04:00 the patient underwent evacuation of intracranial hematoma and decompressive craniectomy under general anesthesia. Intraoperatively, brain swelling was noted. The original tumor cavity contained hematoma with some fresh bleeding, which was completely evacuated. Bleeding was controlled with bipolar cautery, and the cavity was packed with gelatin sponge. After satisfactory hemostasis, the dura was closed under tension, a decompressive craniectomy was performed, and an epidural negative-pressure drain was placed. The patient was transferred to the NICU with the drain in place. Postoperative care included anti-inflammatory, hemostatic, and dehydrating measures. Vital signs stabilized, but the patient remained comatose and received anti-infective, hepatoprotective, and nutritional support. On January 16 of the following year, the patient’s vital signs began to fluctuate. He suddenly developed rapid breathing and heart rate, decreased oxygen saturation, and falling blood pressure, and aggressive supportive measures were instituted. At 10:15 on the 20th, breathing and heart rate ceased, blood pressure and oxygen saturation became unmeasurable, and the ECG showed a flat line. Clinical death was declared.
Intraoperative pathology showed grade II; final paraffin pathology showed grade II or higher. The operative record indicates that the tumor was located mainly in the temporal pole, with another portion in the basal ganglia. Not all of the tumor was resected; residual tumor remained in the body. After the second surgery, the patient remained in a long-term vegetative state and died in the ward two years later, owing the hospital more than $500,000 in self-paid medical expenses.