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.