The 23-year-old patient arrived in the back of a police car and was in four point restraints — hands and feet strapped to a gurney — when emergency physician Elizabeth Mitchell saw her at a Los Angeles hospital early on March 17.
Chloe R. Kral was being held on a 5150, shorthand in California for an emergency psychiatric order that allows people deemed dangerous to themselves or others to be involuntarily confined for 72 hours.
She had spent the previous six months at a private treatment center receiving care for bipolar disorder and depression. Chloe had improved and was set to move to transitional housing when she suddenly became combative and threatened to harm staff and kill herself. Police had taken her to the emergency room at Cedars-Sinai Marina del Rey Hospital before a planned transfer to a mental hospital.
Chloe, Mitchell recalled, was “mumbling about Rosa Parks” when they met. She managed to tell the doctor that she hadn’t used drugs or alcohol, but was otherwise incoherent. “We get a lot of psychiatric patients, and they’re just waiting for placement,” Mitchell said.
But something indefinable — Mitchell characterized it as “maybe gut instinct” honed by nearly two decades of practice — prompted her to order a CT scan of Chloe’s head to better assess her mental status.
When she pulled up the image, Mitchell gasped. “I had never seen anything like it,” she said. She rounded up her colleagues and “made everyone in the whole ER come look.”
“I was speechless,” she said. “All I could think was ‘How did no one figure this out?’ ”
That question resonated more deeply after she spoke to Chloe’s mother. It was then that Mitchell learned about the stunning oversight that had resulted in years of needless anguish for Chloe and her family.
Rocky college start
To life coach Alison Houghton Kral, the initial plan to send her daughter to a locked ward was a shattering coda to the preceding six years.
Chloe had left her parents’ home near Palos Verdes, Calif., in August 2015 to start college at New York’s Fashion Institute of Technology. Her first semester was rocky — hardly unusual for a college freshman. “I struggled a lot, and I was very homesick,” Chloe recalled. Over Thanksgiving break she saw a therapist who prescribed antidepressants, which seemed to help.
“She couldn’t wait to get back” for sophomore year, her mother recalled. But in late October 2016, Alison was visiting her native Australia when Chloe called. “She said, ‘Mom, I can’t do this. I want to come home.’ ”
Alison flew to New York to discover that Chloe had been in bed for six weeks, wasn’t going to class and seemed oddly vacant.
“She couldn’t understand things like, ‘Can you pack that box?’ I’d have to say, ’Take the books off the shelf, then put them in the box, then seal the box.’ She was completely out of it,” said Alison, who attributed the behavior to severe depression.
Once home, Chloe returned to the therapist. “I felt very depressed,” she said, “but I don’t remember what I felt depressed about.” Her memory for the years leading up to her diagnosis is spotty.
She enrolled in a community college but withdrew after forgetting to turn in assignments, a sharp contrast to high school when she was focused and organized. And she was fired from jobs at a movie theater and a local market because she couldn’t remember instructions.
“It was very upsetting,” Chloe said.
Her mother, who practices yoga, thought it might boost her daughter’s mood. But she noticed that Chloe seemed wobbly, even in basic positions with her hands and knees flat on the floor. Her unsteadiness was the latest of physical changes that had begun in early adolescence. She tended to veer to one side when she walked, bumping into whoever was beside her. Sometimes she tripped climbing stairs. Although Chloe had been a good skier, around age 13 she fell more frequently and ultimately gave up the sport.
“Throughout high school I did have issues of not being able to walk in a straight line,” Chloe recalled. “It became sort of a joke.”
She also fainted periodically. In early 2018 she was taken by ambulance to an ER after fainting; no cause was found. When Alison followed up with the pediatrician, she said the doctor’s response was “Some people faint a lot.”
In late 2018, a therapist friend of Alison’s suggested that Chloe might have attention-deficit/hyperactivity disorder (ADHD). Testing revealed a mild case along with severe anxiety.
Despite therapy and various combinations of drugs, Chloe seemed worse. In 2019 she experienced what appeared to be bipolar episodes. She was not sleeping, talked rapidly and was uncharacteristically aggressive. Once she disappeared for two days.
At other times she clung to her mother and followed her around the house for hours like a toddler. Her psychiatrist, who had prescribed drugs to treat bipolar depression, told Alison her daughter was also showing signs of derealization, a disorder sometimes associated with trauma, in which people think their surroundings are not real. Chloe expressed doubts that her father, a composer, and her mother were her parents.
“Nothing seemed to help,” Alison said.
Beginning in the summer of 2020, Alison noticed that Chloe sometimes dragged her right foot when the pair took walks.
“There were so many things going on,” Alison noted, “and I kept thinking if I got to a doctor and she doesn’t” drag her foot, then what was the point? She assumed it was another sign of worsening mental illness.
By fall, Chloe was spending her days on the living room sofa, inert. She forgot to bathe or brush her teeth. Once she urinated on herself while riding in her mother’s car. Her parents consulted a second psychiatrist who told them she needed to be hospitalized. In September she 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,” Alison recalled of the lengthy intake interview. “They told me they noticed her odd gait.” When Chloe wet her pants during an hour-long visit with her mother a few weeks after her admission, Alison informed the staff.
“They said ‘Oh, maybe she has a UTI,’ ” Alison says she was told. But after Chloe tested negative for a urinary tract infection, that seemed to be the end of the matter.
Her six-month stay cost her parents $180,000. “It was our savings plus some of her college fund,” Alison 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.”
Mitchell’s first call to Alison from the ER was brief. Her daughter was being evaluated, the doctor said, before her transfer to a psychiatric hospital an hour away.
Less than two hours later she phoned again with bombshell news. Chloe had a life-threatening condition that Mitchell characterized as “the most severe case of hydrocephalus I’ve ever seen.” She needed brain surgery as soon as it could be scheduled and was being sent to the neuro-ICU at Cedars-Sinai.
Hydrocephalus, popularly known as “water on the brain,” is caused by the accumulation of cerebrospinal fluid in cavities known as ventricles. Spinal fluid, which cushions the brain, is critically important to a wide variety of brain functions. Excess fluid was compressing the brain’s frontal lobes — responsible for memory, decision-making and emotion — against the inside of Chloe’s skull because it could not be reabsorbed. Without treatment, hydrocephalus, which can be present at birth or occur later in life, can cause brain damage, coma or death.
Alison had never heard of hydrocephalus. And Chloe, she told Mitchell, had never undergone brain imaging.
Mitchell mentioned the diagnostic mnemonic she had learned in medical school; “wet, wobbly and wacky.” She was incredulous as Alison ticked off telltale symptoms of hydrocephalus, many of which dated back years: 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.”
“There were things we noticed and certainly I didn’t put them together and the medical people didn’t put them together,” Alison said.
An MRI scan determined that Chloe’s hydrocephalus was caused by aqueductal stenosis, a narrowing between the ventricles that caused an obstruction. The obstruction, which was present at birth, was partial and her brain compensated until it no longer could, said neurosurgeon Ray M. Chu, who treated her at Cedars-Sinai.
Had Chloe developed headaches, double vision or nausea, which can also be symptoms of hydrocephalus, or had her symptoms occurred over a few months, Chu believes she might have been diagnosed sooner.
“If there’s anything funny going on it doesn’t hurt to get brain imaging,” Chu said, which would have revealed the hydrocephalus. He characterized the years-long delay as “pretty unusual.”
“It’s a cautionary tale,” Chu observed. “People get pigeonholed” if they have a psychiatric diagnosis.
Chu performed an endoscopic third ventriculostomy, a minimally invasive procedure that creates a permanent pathway to relieve the pressure and allow fluid to drain properly.
The day after her operation, Alison received a call from Chloe, who had been incoherent just 24 hours earlier. “She said ‘Oh, hi Mom, can you bring some magazines or something? It’s really boring here.’ It was like a miracle.” Some patients aren’t so lucky; hydrocephalus can cause irreversible brain damage.
Chloe went home after a five-day stay. Chu, who saw her in June, described her as a “a totally different person.” She had resumed driving, was working at Nordstrom and was headed to college in San Francisco.
Chloe continues to take mental health medication. Doctors have said they cannot determine whether all of her psychiatric symptoms were related to the hydrocephalus. “I’m not mad, like ‘Why did this happen to me?’ I’m past that now,” she said. She recently completed a semester of college and is taking a break at home.
Alison, who says she is particularly grateful to Mitchell, feels traumatized by the ordeal. She has repeatedly wondered what she should have done differently. And she regrets not taking Chloe to a doctor after she began dragging her foot, which might “have been a game changer.”
“I felt utterly overwhelmed,” Alison said. “I saw her life disappearing and felt utterly powerless to know what to do to help her. I have a lot of sadness around that and the things she’s had to go through. And then of course how much it has cost us financially.”
Mitchell has pondered what Chloe’s future might have looked like without that CT scan. “I think she 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.”