Traumatic-Brain-Injury-Case-Mr Du

Case: Mr Du from China

Nationality：

China

Age：

31 years old

Diagnosis：

Traumatic Brain Injury

Admission Date：

Nov. 2014

Background

Mr. Du, a 31-year-old Chinese male, suffered from the sequela of traumatic brain injury. On February 4, 2002, he fell from a high place after getting drunk, leading to brain injury, coma, and incontinence. Sent to a local hospital for unknown symptomatic treatment, two days later he was admitted to Nanyang Central Hospital. Image exams showed right frontal contusion and laceration, intracerebral hematoma breaking into the right lateral and 3rd ventricles. He had emergency right lateral ventricle hematoma drainage. The operation was successful, but he didn't wake up immediately. After hyperbaric oxygen and other treatments, he woke up on the 40th day post-operation with his mouth, eyes, and neck leaning left and left-side body movement disorder. He's been doing rehabilitation and physical therapy since then. His left limb touch sensation improved and left lower- limb muscle strength gradually recovered, but his left hand can't stretch and his left upper limb is stiff. He was finally diagnosed with the sequela of traumatic brain injury and admitted to our hospital in Beijing in Nov. 2014.

Pre-Treatment Condition（Before Stem Cell Treatment）

The corner of his mouth, the corner of his eyes, and his neck deviated to the left.
The muscular tension in his left upper limb was elevated. As a result, his left upper limb remained rigid and in a bent position. His left hand couldn't stretch freely and was constantly clenched into a fist.
His left lower limb and left foot were slightly in an internally rotated state.

Treatment Plan

One course of stem cell therapy
Surgical method: Lumbar puncture+Stereotactic brain surgery
Efficacy monitoring plan over 1 to 12 months post-treatment

After the First Course ofTreatment ( 1 day)

He noticed that his left shoulder joint had regained free mobility.

After the First Course ofTreatment ( 3 day)

1. The involuntary turning of the corner of his mouth, corner of his eyes, and neck has been significantly improved.
2. The muscular tension in his left upper limbs has been markedly alleviated, enabling him to move his left upper limb at will.
3. The internal rotation condition of his left lower limb and left foot has been greatly improved.

After the First Course ofTreatment ( 30 day)

His facial expressions now appear natural. During feeding, there is no leakage from his mouth, and the abnormal turning of his neck has improved even more.
The muscle tension in his left upper limb has been further reduced. He can now voluntarily stretch and bend his left upper limb, and the clenched - fist state of his left hand has slightly improved.
The internal rotation of his left lower limb and left foot has been further alleviated. He can now walk naturally and with more strength.

Symptom	Improvement
Facial/Neck Deviation: Corner of mouth, eyes, and neck deviated to the left.	Improved Facial/Neck Alignment: Involuntary turning of mouth, eyes, and neck significantly reduced. Facial expressions appear natural; no leakage during feeding.
Left Upper Limb: Elevated muscle tension caused rigidity, bent positioning, and clenched fist (unable to stretch).	Left Upper Limb Mobility: Muscle tension markedly reduced; voluntary stretching/bending of arm and slight improvement in clenched fist.
Left Lower Limb/Foot: Internally rotated posture.	Left Lower Limb/Foot: Internal rotation greatly alleviated; natural walking with increased strength.

Progress Summary & Future Outlook

The patient has made remarkable progress. Looking ahead, with continued treatment and rehabilitation, the remaining issues like the fisting of his left hand are likely to improve further. He may regain full functionality of his left-side limbs, allowing for seamless daily activities. His enhanced walking ability may lead to more independent mobility, and overall, his quality of life will see significant elevation.