After being treated for bipolar disorder and depression for years, 23-year-old Chloe Kral suddenly became aggressive, threatening to harm others and kill herself—but when she arrived at Cedars-Sinai Marina del Rey Hospital in the back of a police car, an emergency physician's "gut instinct" led to a shocking diagnosis, Sandra Boodman writes for the Washington Post.

Expedite patient diagnosis

Years of misdiagnosed symptoms

In August 2015, Kral moved from her home near Palos Verdes, Calif. to start college at New York's Fashion Institute of Technology. The adjustment was challenging for her, and during Thanksgiving break, a therapist prescribed antidepressants, which which initially seemed to help, Boodman writes.

As Kral's sophomore year approached, "[s]he couldn't wait to get back," according to her mother, Alison Houghton Kral. However, by late October 2016, Kral called her mother, asking to come home.

Her mother flew to New York and discovered that Kral had not left her bed for six weeks, was skipping all her classes, and seemed unusually vacant, Boodman writes.

After she returned home, Kral enrolled in community college and went back to her therapist. "I felt very depressed," she said, "but I don't remember what I felt depressed about."

In addition, Kral struggled to remember basic instructions and tasks, forcing her to withdraw from school—a stark contrast from her time as a high school student, when she was focused and organized.

To boost her daughter's mood, Kral's mother got her involved in yoga. But even in the most basic positions, Kral was wobbly and unsteady—the latest sign of physical changes that began in her early adolescence.

Then, in early 2018, Kral was taken to an ED after she fainted. Unfortunately, no cause was found, and when Kral's mother followed up with her pediatrician, they responded by saying, "Some people faint a lot."

In late 2018, testing revealed that Kral had a mild case of attention-deficit/hyperactivity disorder along with severe anxiety. Even with therapy and various combinations of medications, Kral's condition did not improve.

In 2019, she started experiencing what appeared to be bipolar episodes. She would go from acting uncharacteristically aggressive to following her mother around the house for hours like a toddler, Boodman writes.

In the summer of 2020, Kral's mother noticed that she started to drag her right foot when she walked. And by fall 2020, Kral's condition worsened.

According to her mother, she was spending every day on the living room sofa, almost completely inactive. She would forget to bathe or brush her teeth, and she also once urinated on herself while riding in her mother's car, Boodman writes.

In September 2020, Kral was admitted to a facility that provided intensive psychotherapy. "I told them all about the dragging of the foot, the urination, I gave them everything," Kral's mother said. "They told me they noticed her odd gait."

"They said 'Oh, maybe she has a UTI,'" Kral's mother recalled. But when Kral tested negative for a urinary tract infection, the doctors did not investigate further.

Kral spent six months at the facility, which cost $180,000. "It was our savings plus some of her college fund," Kral's mother said. "It just stripped us, but what choice did we have? I remember thinking that if this doesn't work, I don't know what we're going to do."

'Water in the brain'

After six months in the treatment facility, Kral had improved and was about to move to transitional housing when she suddenly became aggressive, threatening to harm staff and kill herself. 

As a result, she was transported by police in four-point restraints—with her hands and feet strapped to a gurney—to Cedars-Sinai Marina del Rey Hospital on an emergency psychiatric order.

In the ED, emergency physician Elizabeth Mitchell recalled Kral "mumbling about Rosa Parks" when they met. Although Kral was mostly incoherent, she managed to tell Mitchell that she hadn't used drugs or alcohol.

However, Mitchell said something infallible, "maybe gut instinct" honed by almost two decades of practice, prompted her to order a CT scan of Kral's head to better evaluate her mental status.

When Mitchell saw the results of Kral's CT scan, she was shocked. "I had never seen anything like it," she said. She gathered her colleagues and "made everyone in the whole [ED] come look."

"I was speechless," she said. "All I could think was 'How did no one figure this out?'"

The CT scan revealed that Kral had what Mitchell called "the most severe case of hydrocephalus [she had] ever seen."

According to Boodman, hydrocephalus, commonly referred to as "water on the brain," is caused by the accumulation of cerebrospinal fluid in cavities known as ventricles. Excess fluid was compressing Kral 's frontal lobes—responsible for memory, decision-making, and emotions. If left untreated, hydrocephalus can result in permanent brain damage, coma, or death.

Mitchell was shocked as Kral's mother listed off her symptoms—all telltale symptoms of hydrocephalus, including poor balance, gait problems, personality changes, confusion, fainting, memory lapses, and involuntary urination.

"I cannot believe that no one ever ordered a CT scan," Mitchell said. "That's what I thought was very weird."

Kral was immediately sent to the hospital's neuro-ICU for brain surgery.

'People get pigeonholed'

An MRI scan revealed that Kral's condition was caused by aqueductal stenosis, a narrowing between the ventricles that caused an obstruction, Boodman writes.

In Kral's case, the obstruction was partial, allowing her brain to compensate until it no longer could, said neurosurgeon Ray Chu, who treated Kral at Cedars-Sinai.

According to Chu, if Kral had developed other hydrocephalus symptoms like headaches, double vision, or nausea, she might have been diagnosed sooner.

"It's a cautionary tale," Chu observed. "People get pigeonholed" when they have a psychiatric diagnosis. "If there's anything funny going on it doesn't hurt to get brain imaging," he added.

After a five-day hospital stay, Kral returned home. According to Chu, Kral is now "a totally different person." She has since started driving again, gotten a job, and is headed to college in San Francisco.

Without the CT scan, Mitchell thinks Kral "would have wound up in a locked psych facility" until she had a seizure "and then I hope someone would have figured it out," she said. "But I'm not sure." (Boodman, Washington Post, 2/12)