Date of Medical Observation: march 2007
A 35 year-old male was referred to the neurosurgery service due to slurring
of speech, left hemifacial muscle twitching and left sided motor weakness on both upper and lower
extremities.
Cranial CT scan was done and revealed a peripherally enhancing space occupying
lesion on the right frontoparietal area.
He was a diagnosed case of congenital heart disease at 11 month old at Chinese
General Hospital and had a history of methamphetamine abuse.
Our working impression was a Space Occupying Lesion probably Brain abscess
vs. Tumor, right temporoparietal area. We then suggested a possible craniotomy with
evacuation of abscess.
Risk stratification was done for operation and was assessed to have poor surgical
risk to undergo craniotomy for 1-2 hrs under general anesthesia due to congenital heart disease with multichamber
enlargement.
A small interdepartmental meeting was conducted to talk about the strategic
treatment approach that can be offered to the patient. It was attended by representative residents and consultants of the
Department of Internal Medicine, Anesthesia and Surgery together with the patient relatives.
I happened to be the one together with my chief resident who attended
the so called meeting.
The patient has serious neurological condition requiring an immediate surgical
intervention however his failing heart precludes with the plan.
We analyzed keenly the patient condition and presented our differing ideas as
far as the treatment options are concerned.
The Anesthesiology Department opted to defer the operation because the patient
has poor surgical risk and has dilated cardiomyopathy.
We presented our situational analysis and proposed modes of treatment to the
patient relatives together with its carried advantages and complications.
The relatives then decided to try medical management initially and consented
for a planned surgery if it deemed necessary.
We agreed to try antibiotics for at least one week then to repeat the CT scan
thereafter. In case of deterioration in patients’ neurologic status an emergency craniotomy must be performed.
After a week a repeat Cranial CT-Scan with contrast was done and revealed an
increase in the size of the septated peripherally enhancing right frontoparietal
space occupying lesion.
Patient was scheduled to undergo craniotomy with evacuation of abscess. The
patient tolerated the operation well and now on his way to full recovery.
INSIGHT
- Physical, Ethical, Psycho-social
- Discovery, Stimulus, Re-enforcement
How do we approach patient with brain abscess with concomitant cyanotic heart disease?
Again it’s just another difficult case posing a management dilemma.
If we do not operate on him, the chance of recovery is very dim and outweighed by the greater possibility
of deterioration.
However, if we opted to push thru with the planned surgery, there is a high possibility
that the patient will have post anesthesia cardiac complications which is very fatal.
A matter that should be keenly analyzed weighed and discussed upon.
I commend the effort of the IM resident who made everything successful in the management of this
patient. In deed, she made the patient walk again away from danger
I would like to praise the good relationship and communication established by each resident and
consultant involved in this particular case.
This is an example of a true team work.
