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Abstract: This patient came to our hospital urgently due to dizziness with no obvious cause and symptoms worsened when turning his head or getting up, accompanied by nausea and vomiting, etc. After examination, the patient was found to have neurological dysfunction caused by acute phase cerebellar infarction. After emergency admission, the patient’s dizziness and nausea were relieved and his condition gradually recovered after cerebral protection therapy and treatment to improve circulation.
Basic information】Male, 40 years old
Disease Type】Neurological Dysfunction
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】February 2022
Treatment plan】Intravenous injection (edaravone injection) + intramuscular injection (wake-up call injection) + oral medication (haematocrit capsule, aspirin enteric dissolved tablets, atorvastatin calcium dispersible tablets)
Treatment period】7 days of hospitalization, 1 month of outpatient follow-up
Treatment effect】The patient’s dizziness and nausea were relieved and her condition gradually recovered.
I. Initial consultation
The patient was 40 years old, and had dizziness with no obvious cause one day before admission, with persistent symptoms and a feeling of spinning, accompanied by nausea and vomiting, the vomit was stomach contents. The head MRI showed acute cerebral infarction, which confirmed the diagnosis of neurological dysfunction caused by acute cerebellar infarction.
II. Treatment history
After the patient was diagnosed with neurological dysfunction caused by acute cerebellar infarction, he was promptly admitted to the hospital. After excluding contraindications to medication, the patient was given intramuscular injection of wake-up call, intravenous injection of edaravone, and oral capsule of hemosiderin to protect brain tissue and improve circulation and scavenge free radicals. The patient was also given aspirin enteric solution tablets for antiplatelet and atorvastatin calcium dispersible tablets for plaque stabilization.
(The above is the result of head MRI)
III. Treatment effect
The patient’s condition did not fluctuate during the 7 days of hospitalization, the symptoms of dizziness, nausea and vomiting were relieved, the patient’s consciousness was clear, his speech was fluent, nystagmus disappeared, and his mental outlook was better than before. 7 days later, the patient was granted discharge, and after discharge, regular nutritional neurological treatment and rehabilitation therapy were carried out, and the patient was told to eat less salty and less oily food and actively control blood pressure. The patient was instructed to follow up on an outpatient basis for 1 month after discharge without significant aggravation.
IV. Precautions
We are glad that the patient recovered, but we still need to advise the patient to pay attention to low-salt and low-fat diet in daily life, develop the habit of drinking more water, and drink a glass of water before bedtime to reduce blood viscosity and prevent the recurrence of neurological dysfunction symptoms. Also pay attention to proper exercise, quit smoking and alcohol, pay attention to rest and sleep, relax, divert attention and review regularly. If subsequent patients experience dizziness, nausea, vomiting and other symptoms in their lives, they need to seek medical attention promptly.
V. Personal insight
In this case, the patient started with symptoms such as dizziness, nausea and vomiting, and had nystagmus on examination. Damage to the cerebellar brainstem connecting fibers was considered, and the diagnosis of neurological dysfunction due to acute phase cerebellar infarction was made after consultation. Therefore, if similar symptoms occur, they need to be taken seriously enough. Usually, pay attention to physical examination, avoid staying up late, pay attention to the combination of work and rest, and you can do exercises such as swimming and running. If you have chronic diseases such as hypertension and diabetes, you must pay attention to controlling blood pressure and blood sugar in a stable state.