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Abstract: Lacunar cerebral infarction is the most common type of cerebral infarction, and atherosclerosis and trigeminal hyperthermia are important causative factors. The earlier the occluded vessels are opened after getting cerebral infarction, the more nerve cells can be preserved and the better the prognosis, and the most aggressive treatment for cerebral infarction at present is ultra-early thrombolytic therapy. This article introduces a case of a patient with sudden dizziness, numbness and weakness of the limbs while carrying heavy objects, who was diagnosed with lacunar cerebral infarction after consultation and improved after ultra-early thrombolysis and drug treatment.
Basic information】Male, 60 years old
Disease Type】Lacunar cerebral infarction
Hospital】Jixi City People’s Hospital
Date of consultation】04/2022
Treatment plan】Medication (alteplase for injection + edaravone injection + aspirin enteric soluble tablets + butylphthalein sodium chloride injection + ginkgo biloba extract injection + insulin injection) + rehabilitation treatment
[Treatment Period] 28 days of hospitalization
Effectiveness】The condition has improved significantly, and the unfavorable movement of the right limb has basically returned to normal.
I. Initial consultation
The patient, Mr. Zhao, came to the clinic because he had obvious lower limb dyskinesia when walking. The patient was carrying goods at 10:00 a.m. when he suddenly felt dizzy, his right limb was numb and he felt weak, and he seemed to be unsteady in walking, which was thought to be caused by unstable blood glucose. The patient’s medical history showed that the patient had diabetes in the past, but never ate drugs regularly, and occasionally took metformin hydrochloride tablets, and usually had the habit of smoking and drinking alcohol, and basically went out drinking with friends every night for a few days before the onset of the disease, and recently worked early in the morning, and did not rest well. Subsequently, the patient was examined accordingly, and it was found that the patient’s right limb muscle strength was grade IV, hyperalgesia, and positive pathological signs on the right side, which could be characterized as acute cerebrovascular disease based on the patient’s physical examination and medical history and symptoms. At this time, the family and the patient were particularly nervous, but fortunately, the onset of the disease came to the hospital in a timely manner, and if they cooperated with the treatment and actively used medication, they could have a good prognosis.
Second, the treatment process
First of all, we immediately opened a green channel for the patient and performed a head CT which showed no hemorrhage, so it could be diagnosed as lacunar cerebral infarction. The patient’s blood pressure was 135/90 mmHg, blood glucose was 9.5 mmol/L before thrombolysis, no bleeding disease, no history of surgery, no abnormal coagulation, no abnormal liver and kidney function, etc. The NIHSS (stroke scale) score was 6, which was consistent with the indication of thrombolysis. The patient and family agreed to thrombolysis and signed the consent form after they understood the condition and treatment measures. The thrombolytic drug, alteplase for injection, was administered to the patient at 90 minutes after the onset of the disease. After the administration of the drug, the patient’s symptoms improved significantly, dizziness was relieved, right limb strength was restored, and the NIHSS score was reduced to 4. Next, the patient was given edaravone injection intravenously to stop the progression of cerebral edema and cerebral infarction and to relieve the accompanying neurological symptoms, as well as to scavenge free radicals, thereby inhibiting oxidative damage to brain cells and nerve cells.
After thrombolysis, the patient was given a repeat cranial CT, which showed a possible left basal ganglia cerebral infarction and excluded hemorrhage. Twenty-four hours after thrombolysis, the patient was reexamined with no hemorrhage on cranial CT, and antiplatelet therapy was immediately initiated with aspirin enteric tablets and butylphthalein sodium chloride injection to reduce the ischemic semidark zone in the infarct area and increase the establishment of collateral circulation, and the patient was given treatment to improve cerebral circulation with Ginkgo biloba extract injection in static doses. Three days after the patient’s onset, a cranial MRI showed a right temporo-occipital brain infarction (acute or subacute stage).
When the patient was examined for relevant risk factors, glycated hemoglobin was 7.5%, fasting glucose was 9.0 mmol/L, and two-hour postprandial glucose was 13 mmol/L. Because vascular disease had developed, insulin injection was given to lower glucose after giving health education about diabetes. The TCD showed cerebral atherosclerosis spectrum, and the head and neck vascular ultrasound showed that the right middle cerebral artery and both posterior cerebral arteries were sclerotic, and the right middle cerebral artery was locally stenosed, so the patient was instructed to improve her living habits and take regular anti-atherosclerosis treatment.
III. Treatment effect
After 14 days of systematic treatment, the patient’s symptoms improved and he was transferred to the rehabilitation ward for rehabilitation treatment. After 28 days of hospitalization, the patient’s symptoms improved significantly and his condition was stable, so he was discharged from the hospital.
IV. Notes
We are glad that the patient received timely treatment, and the indicators and symptoms are gradually improving.
1. In the acute stage of the disease, due to the instability of atherosclerotic plaque, there is a risk of cerebral infarction recurrence or aggravation at any time, therefore, during the acute stage, the patient is advised to avoid exertion, emotional excitement, constipation, etc., reduce activities, rest in bed, and drink moderately more water to ensure cerebral blood perfusion.
2. In addition, patients need to improve their living habits, as they have a long history of smoking, which is one of the important risk factors for the development of atherosclerosis, so patients are instructed to quit smoking, and to limit alcohol and low-salt and low-fat diet.
3. Patients diagnosed with diabetes should follow the healthy diet and lifestyle of diabetes, and should do sports appropriately every day after the acute stage, and patients should be instructed to carry sugar cubes with them to avoid hypoglycemia that may lead to heart and brain damage.
4. Patients should be instructed to take antiplatelet drugs regularly after discharge, and pay attention to whether there is bleeding in the gums and change in the color of stool, etc., and to review liver and kidney functions regularly.
V. Personal insight
Lacunar cerebral infarction is a small penetrating artery in the cerebral hemisphere or deep brainstem based on long-term hypertension and diabetes mellitus, and lesions occur in the vessel wall, resulting in occlusion of the lumen to form a small infarct. Especially, having a bad lifestyle such as smoking, drinking alcohol, and loving greasy food, salt and sugar addiction are also high-risk life factors leading to the development. In this case, the patient had a lot of bad lifestyles on top of having diabetes, and he basically went to restaurants to eat and drink every day before the onset of the disease, and he did not drink water all morning on the day of the onset of the disease, etc. These factors eventually led to the occurrence of cerebral infarction.
After the occurrence of cerebral infarction, it is a battle for time. Rapid assessment of the condition and the patient’s physical status, and giving ultra-early or interventional treatment after meeting the indications to reopen the occluded blood vessels in time can save the dying brain cells, which is the most important means to improve the prognosis. If persistent dizziness, hemiparesis, hemianesthesia, hemianopsia, difficulty in swallowing, choking and coughing, and other physical discomforts occur suddenly in life, it is important to go to a hospital with thrombolytic capability for timely treatment in the first place to maximize brain cell salvage and thus improve the prognosis.