Abstract
This case reports a 74-year-old female from eastern China presented with memory loss, dyscalculia, language disorders, diagnosed with Alzheimer's disease and underwent deep cervical venous lymphatic anastomosis. After rigorous preoperative evaluation, surgical treatment, and postoperative care, the patient had no postoperative care-related complications and showed obvious improvement in her language and self-care skills. The patient's Mini-Mental State Examination score improved three months after surgery compared to the preoperative period (5 versus 0). This case illustrates the potential of related surgery in the treatment of Alzheimer's disease and emphasizes that proper medical and nursing care are essential for better recovery.
Keywords
Introduction
Alzheimer's disease (AD), the most common form of dementia, affected approximately 50 million people worldwide. 1 The global economic burden of AD and related dementias is estimated about to reach 16.9 trillion US dollar by 2050. 2 Therefore, how to standardize treatment has become a key concern in the medical community. 3 While existing pharmacological strategies can delay cognitive decline, effective therapeutic strategies alter the disease's progression remain unavailable. So that, making symptomatic deterioration of the disease remains inevitable.
One of the biggest challenges facing AD lies in effectively preventing the abnormal accumulation of toxic proteins such as amyloid-β (Aβ) and tau protein. Recent studies have found that the glymphatic and meningeal lymphatic systems as key mechanisms for clearing central nervous system waste, offering new insights into brain waste removal. 4 Based on this, Professor Qingping Xie and his team in China firstly proposed the idea of treating and improving symptoms by performing deep jugular lymphaticovenous anastomosis (DJLA) in AD patients to reduce brain lymphatic pressure and promote the clearance of metabolites like tau protein. 5 In addition, Professor Xia Li's team developed the Cervical Shunting to Unclog cerebral Lymphatic Systems surgical procedure, demonstrating promising outcomes. 6 However, these studies simply reported the results without detailing the surgical process. As a new treatment method, perioperative care of DJLA is undoubtedly crucial to recovery outcomes. Since 2024, Professor Wang's team from Zhengzhou Central Hospital started to carry out DJLA for patients with end-stage AD, leading to notable improvements in language, mood, activity, and cognition. 7 Therefore, this paper is to report a case of a patient who underwent DJLA, detailing the surgical process, perioperative care, and clinical outcomes, aiming to provide a reference for the standardizing perioperative care in this procedure.
Case report
Patient information
A 74-year-old female from East China began experiencing memory issues in 2021, showing forgetfulness. Over time, she developed dyscalculia and, by December 2022, her cognitive function declined further, resulting in a loss of the ability to cook, difficulty remembering recent actions, and even failing to recall familiar names. She eventually showed symptoms of apraxia, wearing multiple pairs of underwear or bras, or wearing underwear as outerwear. By December 2023, her symptoms became more severe than before. Finally, she was diagnosed with Mixed Dementia and hospitalized at Zhengzhou Central Hospital in May 2024.
Her medical history included 30 years of hypertension and hyperlipidemia, along with cataract surgery in both eyes in 2022. She was allergic to sulfonamides, and no family history of AD or similar conditions. Initial drug treatment, including sodium mannitol capsules, donepezil hydrochloride tablets, and memantine hydrochloride, proved ineffective. Her husband and son, as primary caregivers, faced great financial and mental pressure in managing her daily needs.
Clinical findings
The patient's MD is characterized by a gradual onset and progressive memory and language impairments, which worsened significantly six months prior.
Diagnostic assessment
According to Chinese guideline for the diagnosis and treatment of Alzheimer's disease dementia (2020), diagnosis is based on patient history and cognitive or behavioral symptoms confirmed by examination. 8 Neurologic examination on May 28 revealed declines in short-term and long-term memory, calculation skills, orientation to time and place, and judgement. Her cerebrospinal fluid analysis on May 30 showed an elevated level of α-synuclein reaching 15,628.07 pg/ml, 9 the amyloid-β (Aβ)1–42 at 19.89 pg/ml, Aβ1–40 at 125.92 pg/ml, 10 and tau protein at 0.93 pg/ml. Magnetic resonance imaging (MRI) on May 29 showed bilateral lacunar infarctions in the basal ganglia and hippocampal atrophy (Figure 1). Positron emission tomography-computed tomography on May 28 showed decreased fluorodeoxyglucose metabolism in the left precuneus, left inferior parietal lobe, left superior parietal lobe, left posterior cingulate gyrus, left frontal lobe, and right precuneus, along with white matter demyelination (Figure 2). Her scores on standardized cognitive assessments are shown in Table 1.
Patient's MRI results before surgery. MRI: Magnetic resonance imaging.
Patient's PET-CT results before surgery. PET-CT: Positron emission tomography-computed tomography.
Patient's scores of neurocognitive test pre and post operation.
MMSE: Mini-Mental State Examination; ADCS-iADL: Alzheimer's Disease Cooperative Study-instrumental Activities of Daily Living; DGS: Digit Span.
Therapeutic intervention
The patient underwent surgery, with an informed consent form signed by her family. The DJLA was approved to treat AD by the Ethics Committee of Zhengzhou University Central Hospital (No: ZXYY202472).
Preoperative care
To ensure patient safety, she was asked to be accompanied by her family members before the surgery. She completed a series of preoperative laboratory tests, including blood routine, urine routine, myocardial markers, coagulation function, liver and kidney function, glycosylated hemoglobin, and immune tests without abnormal results. Her electrocardiogram showed sinus rhythm.
Surgery information
The patient received surgery on June 5. Under general anesthesia, she received an injection of indocyanine green for fluorescent detection. A skin incision was made along the sternocleidomastoid muscle, and the lymph nodes and afferent lymphatic vessels were identified under a microscope. The lymphatic vessels were separated from the subcutaneous tissue of the sternocleidomastoid muscle, and matching veins were located. The matching vein was detached from the subcutaneous tissue, and a non-absorbable microsuture was used to anastomose the proximal lymphatic vessel to the distal end of the vein. Afterwards, the wound was sutured and dressed. The entire surgery lasted about 4 h.
Postoperative care
After surgery, the patient was transferred back to the ward and was given 6 h of electrocardiogram monitoring and 3 liters/minute of oxygen inhalation. Her postoperative vital signs are shown in tables (see Table 2). Two hours after surgery, a Kubota water drinking test indicated normal swallowing function. Six hours post-surgery, she was allowed to eat liquid food, gradually transitioned to a low-salt, low-fat, low-cholesterol, high-vitamin diet. To reduce the risk of venous thromboembolism and stroke, she was encouraged to get out of bed that night and do ankle pump exercises three times a day. Her wound appearance, pain level, and infection signs were monitored.
Patient's vital signs post-surgery.
Outcomes and follow-up
On the first day after surgery, the patient's eyes were able to track, she spoke more, repeated less, and reacted faster than before the surgery.
On the third day after surgery, she began to have the desire to express herself and her words were clear. On the fifth day after surgery, she was able to recognize her families. Her condition was stable, and she was discharged.
After discharge, she returned to the hospital regularly for follow-up.
One month after surgery (July 2024), she could speak more and no longer repeated sentences or mumbled to herself; she could put on her outerwear faster, from half an hour before the operation to a few seconds at that time; she could do some housework such as washing the dishes; she was able to take the initiative to express herself and speak in longer sentences and her sleep duration had increased. Her Mini-Mental State Examination (MMSE) score (Chinese version, range from 0 to 30) was 2 and her Alzheimer's Disease Cooperative Study-instrumental Activities of Daily Living (ADCS-iADL) score (Chinese version, range from 14 to 56) was 41.
Three months after surgery (September 2024), her MMSE score rose to 5 points and her ADCS-iADL score dropped to 40 points. Table 1 shows the changes in her neurocognitive test.
Discussion
This case represents the first reported instance of perioperative care for DJLA in an AD patient. In this case, with meticulous perioperative care, the patient underwent DJLA surgery safely and improved her ability to take care of herself. The preliminary outcomes of the surgery are encouraging: within one-week post-surgery, the patient's speech and responsiveness improved significantly, and further cognitive improvements were observed within three months.
Given that AD is characterized by the abnormal accumulation of Aβ and hyperphosphorylation of tau protein, both of which disrupt normal brain cell function, 11 facilitating the clearance of these proteins through lymphatic drainage may offer a novel therapeutic pathway. The surgical technique described here employs ultramicrosurgery to anastomose deep cervical lymphatic vessels with superficial cervical veins, enabling intracranial lymphatic fluid to return to the venous system, thereby addressing intracranial lymphatic hypertension and abnormal protein metabolism. 4 This might be part of the reason why this surgery could restore cognitive function. However, as this surgery is not currently included in the treatment guidelines for AD, the decision to proceed must be made with careful consideration.
For this new surgical method, perioperative care played a significant role in ensuring patient safety and treatment outcomes. Any surgical procedure can lead to complications, the essence of the operative risk is usually attributed to a patient's overall health. 12 Previous studies have shown that frailty rates in dementia patients was more than 50%. 13 Therefore, the assessment from the anesthesiologist before operation is important and necessary. If this patient is not able to tolerate the surgery, she would be inadvisable to proceed in order to prioritize life safety, as the potential risks could outweigh the potential benefits. In view of her possible risks of thrombosis, delirium and stroke, she was given medication prevention and postoperative exercise guidance. These measures could reduce her chances of postoperative complications and enhance her recovery after surgery. 14 After the operation, through measures such as vital signs monitoring and early activities, her wound recovered well and her self-care ability improved.
In conclusion, our case report presents a case of an elderly female with AD who had failed to respond to medication and other treatments and underwent deep jugular venous lymphatic surgery with some success. However, given that the pathogenesis of AD remains unclear, we cannot be certain that this procedure will only provide symptomatic relief without therapeutic effect. In addition, although this patient demonstrated a favorable recovery, this does not indicate that this will be the case for all patients. Further large-scale, long-term observations studies are needed in the future to demonstrate the effectiveness of the procedure. We believe that this brings new hope to the patient of AD.
Supplemental Material
sj-docx-1-alr-10.1177_25424823251342487 - Supplemental material for Perioperative care and recovery outcome of deep jugular venous lymphatic anastomosis in Alzheimer's disease: A case report
Supplemental material, sj-docx-1-alr-10.1177_25424823251342487 for Perioperative care and recovery outcome of deep jugular venous lymphatic anastomosis in Alzheimer's disease: A case report by Li Chen, Lang Peng, Xiaojing Guo, Wumei Liu, Qian Shi, Meiying Zhao, Feiyun Wang, Mingzi Li, Chunhong Li and Yaqin Zhang in Journal of Alzheimer's Disease Reports
Footnotes
Ethical considerations
The deep jugular lymphaticovenous anastomosis was approved to treat AD by the Ethics Committee of Zhengzhou University Central Hospital (No: ZXYY202472).
Consent to participate
The patient and her family have received information and reminders about the surgery from the doctor and an informed consent form was signed by patient's husband to agree to underwent surgery.
Consent for publication
An informed consent form was signed by patient's husband for the publication of her information in this report.
Author contributions
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Zhengzhou Science and Technology Innovation Guidance Program in Healthcare (grant number: 2024YLZDJH261). The funding source had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
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References
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