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Abstract: Mr. Wang, a patient with previous diabetes mellitus and hypertension and poorly controlled blood pressure and glucose, came to our hospital with “sudden unsteadiness in walking”. The outpatient examination showed bilateral lacunar cerebral infarction on head CT and ataxia on physical examination. After admission, the patient was given symptomatic treatment with relevant drugs. The patient was hospitalized for 7 days, and the symptoms of unsteadiness in walking were relieved, and the treatment effect was remarkable.
Basic information】Male, 49 years old
Disease Type】Ataxia, lacunar cerebral infarction
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】January 2022
Treatment plan】Medication (alteplase for injection, lanosterine injection, edaravone injection, clopidogrel sulfate tablets, pravastatin sodium tablets, folic acid tablets, vitamin B12 tablets, metformin hydrochloride tablets, valsartan tablets)
[Treatment period] Hospitalization for 7 days
【Treatment effect】The symptoms of unstable walking improved and the treatment effect was good
I. Initial interview
The patient came to our hospital in January 2022, and reported: 2 hours ago, he had a sudden onset of unstable walking, unable to walk in a straight line, with a sense of swaying and swaying that could not be controlled by himself, accompanied by dizziness, nausea and vomiting, including vomiting twice, and the vomit was the contents of the stomach. The patient was told that cerebral infarction was not excluded, and the unstable walking symptoms might be caused by ataxia due to cerebral infarction. The patient’s medical history was followed up and he was informed that he had hypertension and diabetes mellitus in the past, while his blood pressure and blood sugar were poorly controlled. The patient and his family agreed to the inpatient treatment.
II. Treatment history
After admission, physical examination: body temperature 36.4℃, blood pressure 170/95mmHg, heart rate 75 beats/min, respiration 18 breaths/min, clear consciousness, fluent speech, free bilateral eye movements with horizontal and rotational nystagmus, normal muscle strength of the limbs, ataxia of the upper limbs and ataxia of the trunk. Head MRI showed lacunar cerebral infarction, DWI showed restricted cerebellar diffusion and cerebral arteriosclerotic stenosis.
The patient and his family were informed of his condition: according to the examination results, the patient did not exclude acute cerebral infarction, but he was admitted to the hospital 2 hours after he got the disease, and if he was active, he could be treated with intravenous thrombolysis, and the family agreed. Electrocardiography, blood pressure and oxygen saturation monitoring were given, followed by thrombolytic therapy with injectable alteplase, improvement of microcirculation with lanchin injection, scavenging of free radicals with edaravone injection, antiplatelet with clopidogrel sulfate tablets, lowering of blood lipids with pravastatin sodium tablets, lowering of homocysteine with folic acid tablets and vitamin B12 tablets, controlling of blood sugar with metformin hydrochloride tablets and controlling of blood pressure with valsartan tablets.
(Head MRI)
III. Treatment effect
The patient recovered well after thrombolysis. 6 hours after thrombolysis, no hemorrhagic foci were seen on the repeat head CT. After 24 hours of thrombolysis, antiplatelet drug therapy was initiated, and blood pressure was well controlled during hospitalization. After 7 days of hospitalization, the patient’s symptoms of unstable walking improved, dizziness, nausea and vomiting were relieved, blood sugar control was stable, and the treatment effect was good. Before discharge, the patient was informed to have a review in 1 month, and was instructed on the post-rehabilitation treatment.
IV. Notes
We are glad that the patient was successfully thrombolized after timely treatment, and the adverse symptoms disappeared, while the blood sugar and blood pressure were smoothly controlled. After discharge, the patient needs to pay attention to regular oral antihypertensive and glucose-lowering drugs due to many previous underlying diseases and poor control. it is recommended to take oral antihypertensive drugs and glucose-lowering drugs regularly, measure blood pressure several times a day (at least 3 times), self-check the effect of drugs to control blood pressure, and combine antihypertensive drugs if necessary; measure blood glucose 7 times a day every week, and adjust the glucose-lowering drug regimen by the endocrinology department. 1 month recheck blood routine, liver and kidney function, etc., so that the strength of antiplatelet drugs can be adjusted. In daily life, quit smoking and alcohol, and eat less high-oil, high-salt and spicy stimulating food. At the same time, if patients still have dizziness symptoms, they should avoid straining and driving and other occupations after discharge from the hospital to avoid accidents.
V. Personal insight
In this case, the patient started to walk unsteadily and came to the hospital in 2 hours, and no bleeding was seen on the perfect head CT. Cerebral infarction is a disease with high disability, high recurrence and high mortality, which must be treated actively and seriously, so you should go to the hospital immediately after the appearance of the above symptoms.