In March, Robert Hewitt began to notice difficulty speaking. He also was losing strength and sensation on the right side of his body. Over the next two days, his condition worsened. Thinking he was having a stroke, he went to an emergency department near his home in South Carolina.
But the award-winning landscape architect and university professor, who also maintains a residence in Sacramento, wanted to receive care at UC Davis Medical Center. He flew to Sacramento, where he could be near family and exceptional specialty care.
Prompt diagnosis in the emergency department
A detailed history and evaluation at UC Davis Medical Center by Nicolas Sawyer and the emergency medicine department team discovered that the patient had previously been treated for a skin cancer on the top of his head. Now, they found a large infected wound in that same area and an abscess. Imaging showed the infection penetrated through the scalp, skull and dura, the lining of the brain, compressing the brain surface and its draining veins. This pressure and effects of the infection were causing loss of speech, strength and sensation.
“This was a rare case,” said Sawyer who has been practicing emergency medicine for the past eight years. “I’ve only seen something like it once before. Surgery was needed right away to remove the infected issue, repair the damage and save his life.”
Complex surgery by multispecialty UC Davis team
Griff Harsh, professor and chair of neurological surgery, and Lee L.Q. Pu, professor of plastic and reconstructive surgery, led a team of six surgeons in a 10-hour operation.
The senior surgeons combined have 50 years of experience treating complex cases over careers that span decades. Harsh specializes in developing innovative treatments of tumors of the brain, pituitary gland and skull base. Pu specializes in reconstructive microsurgery and is one of the few with specific expertise in complicated scalp and skull reconstruction.
“We had good communication on the case, discussing right way the best treatment plan for the urgent microsurgery to reconstruct the skull and scalp,” Pu said of his collaboration with Harsh and the surgical team.
The neurosurgeons first removed infected tissues of the scalp, skull and inner lining of the brain. They then removed the solid abscess compressing the brain surface and the major veins that carry blood out of the brain.
With the damaged tissue removed and brain compression relieved, Harsh and his team closed the three-inch opening in the brain lining with a collagen patch of artificial dura. Pu and his team then filled the five-inch skull defect with artificial bone matrix. Using a portion of the patient’s back muscle, overlying skin and blood vessels, Pu repaired the scalp, connecting the transplanted section of tissue with an artery and vein of similar size from in front of the left ear. They also used a skin graft from the left thigh to cover the open wound in his back.
After surgery, Hewitt spent five days under the care of neurocritical care specialists Ryan Martin and Lara Zimmermann and the Neurosurgical Intensive Care Unit nurses.
Despite the current concerns about the novel coronavirus, patients need health care providers to deliver essential services.
“We have well-established and proven protocols that safely care for patients before, during and after surgery, which have been in place well before the current pandemic arose,” Pu said. “Our post-op care, for example, allows doctors and nurses to monitor the healing process and health of transplanted tissues using devices that measure important conditions, such as blood flow, fluid levels and drainage to and from the treated areas.”
Today, the patient is doing well, recuperating at home.
“Mr. Hewitt has made a dramatic recovery,” Harsh said. “His speech returned, and he regained normal strength and sensation in his right arm and leg.”
“I had a brilliant team of doctors. They saved my life,” Hewitt said.