Case study
Here is a case study of a 34-year-old patient, an academic (PhD degree)
employed at a Polish university. The patient is a professional
laboratory diagnostician with excellent knowledge of several foreign
languages. In September 2017 he suffered a severe multiorgan injury
after his motorcycle had collided with a lorry. He suffered a traumatic
brain injury with accompanying epidural haematoma of the left frontal
region with numerous fractures of cranial bones, including calvarial,
basilar skull, and viscerocranium fractures (preliminary Glasgow Coma
Scale rating: 4 points – severe TBI). After the accident computed
tomography imaging also revealed numerous bilateral rib fractures and
spleen rupture. Immediately after the injury the patient was qualified
for surgery to remove the epidural haematoma and spleen. After the
surgery he was admitted to the Intensive Care Unit (ICU), where
artificial ventilation was continued under analgosedation, and
hyperosmotic and neuroprotective therapy was implemented. On the first
day after the injury a CT scan of the patient’s head revealed
significant enlargement of the area of contusion of the frontal lobes of
both cerebral hemispheres. There were numerous foci of intracerebral
bleeding and subarachnoid bleeding. The patient’s condition improved
after the therapy. After 23 days of the therapy contact with the patient
was established, but he was still suffering from sensory aphasia and
significant muscle weakness. As a result of injury, the patient lost
vision in his left eye. The patient stayed in the ICU for 5 months. Then
he underwent rehabilitation, which continued until August 2018.
During the rehabilitation before HBOT the patient underwent an initial
neuropsychological examination, which revealed deep cognitive
impairment. He could remember events only from one day or the previous
6-9 hours. His mood was changeable and that is why he refused to take
part in planned psychological tests. Attempts to conduct the Mini-Mental
State Examination ended with a few initial tasks. Frontal lobe syndrome
was diagnosed.
As the patient’s clinical condition was improving, he was qualified for
active rehabilitation, including psychiatric rehabilitation.
As there was a chance to improve the patient’s cognitive function after
optimising the supply of oxygen to the CNS, he was qualified for
treatment in a hyperbaric chamber.
Within five months the patient underwent a series of 42 hyperbaric
oxygen therapy sessions, each of which lasted 90 minutes. During the
first three weeks there were sessions five times a week. Next, they were
held three times a week for the next four weeks. The therapy was
discontinued for 48 days because the patient needed to have his calvaria
augmented. After the break sessions were held three times a week for
another five weeks.
After the therapy the patient’s nervous and mental functions as well as
his motor skills and coordination improved. His memory also improved
significantly, which resulted in better communication. During the
therapy his cognitive processes, memory, and concentration improved. His
excessive sleepiness passed away. His motor skills and vision in his
left eye improved. He answered questions in full sentences. In the
neuropsychologist’s opinion, the patient’s condition improved
significantly after the hyperbaric therapy. His emotional lability
disappeared and the overall level of his cognitive functions improved.
His everyday communication and performance of minor chores also
improved. The therapy reduced the symptoms of the frontal lobe syndrome,
which was diagnosed by the neuropsychologist during the first
examination.
Detailed neuropsychological assessment was possible after full HBOT. The
patient maintained verbal contact but with reduced orientation to time
and place. He scored low in tasks testing the course of cognitive
processes. His attention and stimulus selection were disordered. He
exhibited hemispatial neglect (skipped the left side of space) and
visual-spatial deficits. Unfortunately, his working memory was
disordered, which resulted in a low auditory-verbal learning level.
However, the patient’s direct auditory memory functioned well. The
analysis of executive functions revealed organisation and planning
disorders, dissociation between the patient’s knowledge and ability to
use it, and frontal amnesia. The patient’s social behaviour was
disordered. He exhibited verbal disinhibition, confabulation,
anosognosia, reduced insight and criticism. As far as other cognitive
spheres are concerned, the patient’s abstract thinking ability was
reduced and he made delusional interpretations. The patient was
characterised by high fatigability and despite his awareness of
behavioural disorders he was not able to correct them. While staying at
the rehabilitation centre the patient’s state changed dynamically. His
emotional lability disappeared, whereas his general level of cognitive
functions and compliance with behavioural standards improved slightly.
The clinical picture was dominated by visual-spatial disorders,
disorientation and behavioural disorders, which pointed to frontal lobe
syndrome. The patient’s willingness to cooperate varied depending on his
mood. He required permanent care. After rehabilitation with the HBOT his
short-term memory improved and now he can remember the topics of
conversations about 3-4 days back.