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[MUSIC PLAYING] Back in February, we had a 15-year-old boy, otherwise super healthy, young high-school athlete, actually avid baseball player, present with what seemed to be a rather abrupt onset of weakness on half of his body and just really bad headaches that were not getting better.

When he arrived to MUSC, which was very early on-- I believe it was a Saturday morning, kind of from an overnight transfer, he was an acting right.

His speech was very staccatic-- so very kind of-- not with any kind of fluid motion, almost as if he was answering questions based on a typewriter.

You could tell, just with the interaction with him, that his brain wasn't functioning correctly.

And his imaging showed that he had a really bad infection inside the skull, all around his brain.

None of the infection had gone into the physical brain tissue yet.

And so at this point, the question was, where is this infection coming from?

His parents started to say that, yeah, over the last few weeks, he has been complaining more of headaches.

And everyone sort of attributed it just to a regular old sinus problem.

Most of us that have been doing this for a while have seen infections in the brain and around the brain multiple times in the past.

I've never seen one this extensive before.

And I did send it off to a bunch of my colleagues around the country, just over the course of his whole hospitalization, because it got very complicated.

And they'd never seen anything this extensive before either.

So these are not-- they're not typical infections.

In general, people don't tend to get infections in the brain.

But when they do, they don't present this far out, with the infection having literally coated the entirety of the brain-- both halves of the brain, in between, on the back side, underneath, just very, very extensive infection around the brain.

When infection is this extensive on the surface of the brain, it makes the blood vessels on the surface of the brain very fragile and prone to bleeding.

And so if you do too much, you can actually cause more injury than good.

And so there's sort of this fine balance of how much do you do and when do you do it.

And in his case, it ended up that as time went on, we sort of created, what we call inside, our sniper-style surgeries that addressed the biggest problem at that time, knowing that eventually we're probably going to have to do multiple surgeries.

And we're probably going to have to do a lot of different things to him to get him through this phase because once the brain starts to swell and become encephalopathic, it doesn't just get better right off the bat.

It goes through a whole process that only thing you can do is support the patient at that point.

In his case, as we continued on with the treatments, we had to get more and more aggressive with surgeries, eventually getting to a point where everything we did was still not enough to create enough room for the brain pressure that was filling his head.

So we ended up having to take off half his skull to allow for the brain to do its swelling, again, which is not a typical type of surgery to do for infection.

A lot of times, we'll do that for trauma cases because the brain gets damaged from an impact.

And then it swells, and that's not an atypical thing.

Or in stroke cases, where the brain strokes, half the brain strokes, and it swells from a stroke.

Again, removing the skull is very common.

In infection, that's not very common.

This was over the course of about one to two months of just, again, kind of sniper treatments.

Can't overdo it.

You can't underdo it.

You've got to be in that balance.

This was a huge team effort, by the way-- our partners in the pediatric ICU, the infectious disease doctors, my partner at pediatric neurosurgery.

The operating room-- the number of times we went emergency to the operating room with him is extensive.

I think he ended up with 11 neurosurgical procedures.

Once we got to a point where we had done basically everything possible surgically and now we're just waiting for the brain swelling to continue, now, honestly, it's the hardest part because there's nothing else you can physically do.

You've done what you can surgically.

Now you have to manage medically.

And this was a huge partnership with ICU and managing his brain pressures to a point where he never had a stroke.

He never had bleeding in the brain.

Our efforts actually allowed for all the swelling and his brain pressures to be two to three times normal for almost a month.

And yet his brain never suffered a single hit as far as a ischemia, where you get lack of blood flow.

And I think that's the reason why he made the recovery.

The infection was so extensive.

But the treatments allowed his brain to go through that very long process and come out the other side unscathed.

When I say team effort, it really was.

You got to put your ego aside and your pride aside and just take care of the patient.

And when things are this rare and this severe, you got to get other people's opinions.

So I think that helped a lot because at the end of the day, our goal is to figure out how to get him through the next 24 hours, 48 hours, when it's that sort of a critical situation.

And the more minds you have, the better.

So I think that that's probably why he got better, is because we just had so many people working on him from a brain standpoint.

Amongst us in pediatric neurosurgery, we're sort of taught in general to be aggressive.

But there's a point at which you feel like, oh, there's nothing else you can do.

And I want to say that I would tame that stoic attitude of, well, we've done everything we can.

I think that when we say we've done everything we can, it's when the brain itself has demonstrated it's just not going to recover.

Now, in a case like this or in other infection cases, I would say, as long as the brain looks good, as long as the imaging demonstrates that the brain itself is surviving-- the numbers that we see on pressure monitors and the 15 things that are attached to the patient and all this kind of stuff might make it seem completely bleak.

But at the end of the day, if you can get someone through and their brain recovers, that's what your goal is.

And so I would say, be as aggressive as you can, appropriately aggressive for the time and what's needed.

Remember that the brain is a very fragile thing.

And trying to be overly aggressive is probably also not good.

But if you can figure out ways to get people stepwise through these critical care situations and really treat for brain recovery and not making the imaging look better or worry about numbers, I think that you can get these kids through.

And in general, kids recover.

If you can get them through something and they don't succumb to that, even if it takes three months, they tend to recover.

Now, older kids don't recover as well.

So this was one of the things we had talked about with him is, at what point do we give up and realize that there's nothing else we can do?

But I think at every one of those decision-making tris, we all together, the whole team that was taking care of him, came back to, but the brain looks good.

There's been no stroke.

There's been no hemorrhage.

What else can we do to get the brain through the next phase?

And we're just lucky that we were able to do that at every moment.

So that was good.

[MUSIC PLAYING]

Video

Rare and Extensive Brain Infection Prompts Massive Collaboration to Save Teenager’s Life

Pediatric neurosurgeon Ramin Eskandari, M.D., discusses an extremely rare and extensive brain infection in a teenage patient and shares the lessons learned by medical and surgical teams working to save the patient’s life and brain function.

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Ramin M. Eskandari, M.D..

Ramin M. Eskandari, M.D.

EducationWayne State University School of Medicine ResidencyUniversity of Utah FellowshipStanford University SpecialtiesPediatric Neurosurgery Clinical InterestsHydrocephalusBrain tumors in childrenSpine abnormalitiesCraniosynostosisEpilepsy surgery

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