Under Pressure: Chloe’s Cautionary Tale
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The Gut Instincts of an Emergency Physician and Lifesaving Treatment by a Neurosurgeon Restore the Life of a Misdiagnosed ‘Psychiatric’ Patient
Chloe Kral had been placed on an involuntary mental-health hold and was headed to a psychiatric ward when she arrived in the Emergency Department at Cedars-Sinai Marina del Rey Hospital one night in March. Judged a danger to herself and others, the 23-year-old was confused, disoriented and out of control.
“She had been restrained overnight and was having nonsensical, rambling speech and bizarre behavior,” said emergency physician Elizabeth Mitchell, MD, who took over Chloe’s care the next morning. “She had already been accepted at a psychiatric hospital and was just waiting for transfer.”
Chloe was unable to answer most of Mitchell’s questions, except to say that she hadn’t been using drugs or alcohol, and Mitchell decided her case deserved a closer look. Mitchell’s gut instinct led to a quick transfer to Cedars-Sinai Medical Center, where neurosurgeon Ray Chu, MD, performed a procedure that gave Chloe her life back.
Early Signs of Trouble
Chloe’s confusion and bizarre behavior were signs of hydrocephalus, a buildup of excess fluid in her brain that had gone undiagnosed for years. She had been experiencing poor balance, another hydrocephalus symptom, since her teens.
“She used to be a very proficient skier when she was 8, 9 and 10,” said Chloe’s mother, Alison Kral. “And then at around 13 or 14, her balance wasn’t as good, and she didn’t want to ski anymore. But it was just so gradual we didn’t think much of it.” Chloe’s family also poked gentle fun at the way she couldn’t seem to walk in a straight line and would veer into people walking beside her.
This was due to a partial blockage that prevented cerebrospinal fluid (CSF), which protects the brain and spinal cord, from draining out of chambers called ventricles in the right and left hemispheres of Chloe’s brain. The fluid would normally be reabsorbed into the bloodstream, but with nowhere to go, it built up, causing the ventricles to expand and compress Chloe’s brain tissue against the inside of her skull.
As the fluid buildup and pressure on her brain worsened, Chloe’s symptoms worsened as well.
In 2015, she left home in Rolling Hills Estates to attend the Fashion Institute of Technology in New York. But when her parents visited a few weeks later, Chloe had gained weight and was tearful, depressed and struggling in her classes.
“All throughout high school, I was really focused,” Chloe recalled. “And then once I got into college, it was just this complete change.” She had trouble managing her schedule and couldn’t seem to motivate herself to do even the simplest tasks.
“The frontal lobes of her brain, which are responsible for things like decision making, planning and executing steps in order, were being compressed,” said Chu, associate professor of Neurosurgery at Cedars-Sinai. “This is why Chloe began having trouble with things like remembering to attend classes and complete assignments, and eventually even to do simple things like bathe herself.”
To those around her, however, Chloe just looked like a student having trouble adjusting to college life. During the holiday break, her parents took her to a therapist, who prescribed antidepressants.
The Pressure Takes Its Toll
The treatment seemed to work. Chloe’s second semester was better than the first, and her second year in school was off to a good start. But in October of 2016, Chloe called Alison, pleading to come home. Alison flew to New York.
“I had never seen anything like it,” Alison said. “She was like a small child. She couldn’t function. She was so depressed she hadn’t been getting out of bed.” The pair returned to L.A., where over the next four years, Chloe’s symptoms continued to worsen.
“I was just kind of wasting the day away,” Chloe recalled. “I didn’t have anything that I wanted to do. Nothing motivated me or made me excited. It was just the same thing every day, and I didn’t see anything changing.”
Alison, meanwhile, was exhausted caring for her daughter. “She’d follow me around all day, every day, like a 2-year-old,” she said. “Chloe had developed derealization, where everything seems unreal, and didn’t recognize us as parents.”
In September of 2020, Alison called Chloe’s psychiatrist to ask for more help, and Chloe entered a residential psychological treatment center. She had developed urinary incontinence, another common sign of hydrocephalus, but remained undiagnosed. Treated instead for psychological problems, she again seemed to slowly improve.
Then one night in March, Chloe suddenly became violent, threatening herself and others, and staff at the facility called the police.
The following morning, Alison received two calls from Cedars-Sinai Marina del Rey Hospital’s emergency department. The first, at 9:30 a.m., was to inform her that Chloe was there and scheduled to be transferred to a psychiatric hospital. At 11 a.m., another call came, this one from Mitchell.
“Did you know your daughter has hydrocephalus?” Mitchell asked Alison.
“I don’t even know what that is,” Alison responded. Told that her daughter needed brain surgery, she packed a bag and rushed to the hospital.
A Lifesaving Surgery
Earlier that morning Mitchell had ordered a CT scan of Chloe’s head, and the results astonished her.
“Her poor brain didn’t have enough room to properly function—there was so much fluid in the ventricles. I’ve never seen a CT scan with that degree of hydrocephalus,” said Mitchell, who immediately called to arrange Chloe’s transfer to Cedars-Sinai. “It was very important that we get her to a hospital with neurosurgical capabilities as soon as we could,” she said.
Within days of Chloe’s arrival, Chu performed a minimally invasive procedure called an endoscopic third ventriculostomy (ETV) to relieve the pressure on Chloe’s brain. Making a small opening in one side of Chloe’s skull, he used an endoscope—a lighted instrument about the width of a pen—to inflate a small surgical balloon that opened space and created a permanent path allowing the CSF to drain.
A surgeon less practiced in ETV might have instead placed a shunt, a hollow tube for the fluid to drain through, but Chu said this has drawbacks. “You can imagine having a foreign body in place in your brain, and the risk of blockage or infection,” Chu said. “That can mean follow-up surgeries later on.”
The day after Chloe’s surgery, Alison answered a call to her phone and was shocked to find that the caller was Chloe, completely lucid, speaking normally and asking for magazines to read. By her three-month follow-up appointment, “she was totally independent, back to driving, working and applying to design school,” Chu said. “There are people whose hydrocephalus places so much pressure on the brain that it causes irreversible problems. Fortunately, Chloe is not one of them.”
Chloe is now living on her own in San Francisco, where she is studying fashion at Academy of Art University.
“She’s doing the things that she should have been doing but couldn’t do before,” Alison said. “If [Dr. Mitchell] hadn’t done that scan, Chloe would have gone to that psychiatric facility and she would have continued to be treated as a psychiatric patient. I’m so incredibly thankful for her and for her intuition. She deserves a medal.”
“This is a perfect example of how Cedars-Sinai’s regional hospitals and the resources available at our academic medical center can come together,” said Keith Black, MD, chair of the Department of Neurosurgery. “A young woman has her life back because of this dedicated emergency physician and the expertise of our neurosurgery team.”
Chloe said that finally having an explanation for all of her strange symptoms has given her a new outlook. “I was wondering, like, why is this happening to me? What’s wrong with me?” she said. “Now I know I am capable of having a job and doing classwork and doing normal things that people my age are doing.”
Read more on the Cedars-Sinai Blog: Seeing the Light—Neuroendoscopy Revolutionizes Skull Base Surgery