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Abstract: The patient had a sudden onset of weakness in the left limb, but did not seek treatment because it did not affect the patient’s daily life or work. Recently, he came to our hospital because his symptoms had worsened. The patient was initially diagnosed with cerebral infarction through relevant examinations performed in the outpatient clinic. After special examination and communication with the patient and his family, he agreed to undergo surgery after admission. After symptomatic drug treatment and six months of outpatient follow-up, the patient’s condition has improved.
Basic information】Male, 45 years old
Disease Type】Cerebral infarction
Hospital】Beijing Tiantan Hospital
Date of consultation】August 2021
Treatment plan】Surgical treatment (percutaneous superselective cerebral arteriography, balloon dilation of the right middle cerebral artery) + oral medication (aspirin tablets, clopidogrel hydrogen sulfate tablets, pantoprazole sodium enteric tablets, pitavastatin calcium tablets)
Treatment period】Inpatient treatment for 2 weeks, outpatient follow-up for 6 months
Effectiveness of treatment】The symptoms that existed before the patient’s visit were cured
I. Initial consultation
The patient reported sudden onset of mild left limb weakness, inability to carry heavy things on the upper limbs, and weakness in walking without a cause. He came to our hospital for consultation.
After careful questioning of the patient, he was told that although he had no history of hypertension or other diseases, he had a history of smoking for nearly 20 years, and after a CT examination of his head, he was initially diagnosed with cerebral infarction, which required great attention. After informing the patient of the specific situation, and also to clarify the cause of the disease, the patient agreed to be admitted to the hospital for relevant special examinations.
II. Treatment process
Immediately after admission, the patient was given a series of relevant examinations such as liver and kidney function electrolytes, homocysteine, lipid cholesterol, clotting time, cardiac ultrasound, and ambulatory electrocardiogram, which showed plaque formation in the left carotid artery. In addition, considering the serious lesion of the right middle cerebral artery, we finally agreed to perform cerebrovascular intervention after discussing with the patient and his family.
After routine preoperative examination, the patient had no contraindications and underwent percutaneous superselective cerebral arteriography and balloon dilation of the right middle cerebral artery under general anesthesia, and the procedure went smoothly. After the operation, the patient was given aspirin tablets combined with clopidogrel sulfate tablets for antiplatelet therapy, and pantoprazole sodium enteric tablets and pitavastatin calcium tablets for symptomatic treatment. After the operation, the patient’s limb weakness and other symptoms showed significant improvement, which proved that the treatment was effective. The patient was instructed to continue to consolidate the treatment and to review the treatment after six months.
III. Treatment effect
The patient’s symptoms improved on the postoperative day before the visit, and the patient’s symptoms gradually improved afterwards, and the recovery rate was satisfactory. After 2 weeks of hospitalization, the patient had a strong grip on the left side of the hand and a smooth walking gait, and his basal signs were blood pressure of 125/77 mmHg, body temperature of 36.7℃, heart rate of 70 beats/min, and cardiac rhythm, which met the discharge criteria. Before discharge, the patient was given blood tests, liver and kidney functions, etc. The results did not show any significant abnormalities. Six months later, the patient was re-examined at the outpatient clinic, and the results indicated that the patient’s condition had been cured and there was no sign of recurrence.
IV. Notes
I was relieved to see that the patient’s symptoms were gradually reduced, but for the sake of the patient’s health, I still need to remind the patient to pay attention to the following points in daily life.
1. The patient’s diet should be low in salt and fat, avoiding spicy and irritating foods, and quitting smoking and limiting alcohol. The intake of vitamin foods, such as fresh vegetables and fruits, can be appropriate.
2. Patients are advised to develop good living habits, including avoiding staying up late, ensuring sufficient sleep, and avoiding overeating. Daily physical exercise can be appropriately performed to strengthen physical fitness and resistance.
V. Personal insight
Cerebral infarction can also be clinically called ischemic stroke, which usually refers to patients’ ischemic and hypoxic necrosis of their own brain tissues as a result of impaired blood supply to their own brains. The treatment of cerebral infarction usually requires symptomatic treatment according to the patient’s etiology and symptoms, i.e., an individualized plan, and for the patient in this case, although the effect is ideal after surgery, it does not mean that recurrence will not occur in the future. The recovery of the disease can be facilitated.