A case of lateral infarction of extended myelin with suspected spinal cord lesions

When the torso appears sensory disorder plane, especially the sensory disorder plane upward development, first consider spinal cord lesions, but the appearance of sensory disorder plane is not necessarily spinal cord lesions, the author is now reported a case of suspected spinal cord lesions, the lesions site is located at the outside of the lower end of the extension of myelin, the clinical performance is relatively rare, if the diagnosis is not timely, may delay the diseasepatient male, aged 45, was treated in neurology at Hebei Medical University's Second Hospital on September 3, 2016 due to "numbness of the lower right limb 3d"Patients in the hospital before 3d work tired suddenly appeared in the right lower limb numbness, accompanied by mild head weight light feeling, no drinking water cough, swallowing difficulty, limb weakness, stool abnormality, fever and so onPatients have been healthy, smoke-free, alcohol addictionadmitted to hospital for physical examination: body temperature 36.7 degrees C, pulse 76 times/min, 19 breaths/min, blood pressure 127/93mmHgThe medical system is checked normallyNervous system examination: clear consciousness, speech fluency, responsiveness, orientation is normalLeft pupil and eye fissure smaller than the opposite side, the facial symmetry of the double forehead, the residual brain nerve physical examination did not see abnormalThe right T6 level below the pain temperature loss, the two-sided deep feeling check no abnormality, the limbs of the movement of stableLimb muscle strength Vclass, normal dystonia, normal tendon reflex, pathological signs (-)The neck is soft and no resistanceclinical examination: total cholesterol 5.75mmol/L, LDL 3.98mmol/LBlood, urine, and consternation were not abnormalElectrocardiogram, head CT, lung CT did not see abnormalitiesHead MRI, diffusion weighted imaging (DWI) did not show acute infarction MrI of the thoracic spinal cord showed no abnormalities in the thoracic vertebrae and spinal cord Induced potential shows that the two-sided visual induced potential did not see obvious abnormalities, brain stem-hearing induced potential did not see abnormal, double upper limb sensation induced potential anomaly, double lower limb sensation induced potential anomaly Combined with patient symptoms, signs and clinical examination, the preliminary diagnosis: spinal cord lesions, nature to be investigated; hyperlipidemia into the hospital's neurology department after the injection of methylcobalamin, injection with calf serum deprotein extract and other nutritional nerves and support treatment of the disease On the 2nd day of admission, the patient's right limb numbness increased, physical examination saw the right T1 to T8 plane torso shallow feeling decreased, the right T8 plane below the shallow sensation disappeared, suspected spinal cord lesions progress, added semyson sodium phosphate injection and pissemi injection treatment, treatment 3d, the right limb numbness symptoms did not improve, and appeared on the left forehead, face, neck sweat secretion decreased patients with symptoms aggravated, and accompanied by Horner, suspected that the lesions are located in the lower section of the extended myelin, due to the lower position of the head MRI was not scanned, the head and neck junction MRI, showing: (1) DWI see the extension of the left rear small flax diffusion restricted signal (Figure 1a), the apparent diffusion coefficient graph is slightly lower signal (Figure 1b), T1 weighted imaging saw a slightly lower signal in the small flakes behind the left of the myelin (Figure 1c), t2 weighted imaging graphics showed a slightly higher signal (Figure 1d), a suspected subacute ischemic lesions; (2) conformed to intracranial atherosclerosis; and (3) no significant abnormalities were observed at the cranial neck junction Corrective diagnosis: cerebral infarction; hyperlipidemia; intracranial atherosclerosis change the treatment plan for aspirin antiplatelet aggregation, atoflavatin anti-inflammatory lipid-reducing plaque, hydrophobic injection to improve circulation, etc After treatment of 10d, the patient's right lower limb numbness is better than before, the left forehead, face, neck skin sweating better than before, headless weight Physical examination: the light feeling below the right T8 plane is slightly lower than the opposite side, the same as before After discharge from the hospital continue dysentery secondary prevention, 3 months after follow-up, the patient's condition no further aggravation, the right lower limb still has numbness symptoms discuss Lateral myelin external infarction (LMI) has a higher incidence in the clinic, among which the most common epithelial back syndrome, also known as Wallenberg syndrome, is clinically characterized by five main signs, namely vertigo, nausea, vomiting, eye shock, lesions, palaeontost, lesions side of the lesions, Horner syndrome, and cross-sensory disorders, i.e side side of the lesions Due to the large number of eomereal nerve nucleogroups and nerve fiber stoma, the arterial variation of the supply of eomellin is complex, the location of the infarction and the surrounding edema range is different, the clinical manifestations of LMI are diverse, its sensory disorders are also complex and variable, the typical performance of cross-sensory disorders only 26% Ogawa et al classified LMI's sensory disorderinto into four types, of which type I is cross-sensory disorder, lesions damage to the trigeminal spinal nucleus and spinal courchos, type II is lesions to the side of the body (including the face) pain, temperature disorder, lesions Damage to the spinal courchucytic beam and the trigeminal system; type III is the lesions to the side body (excluding the face) pain, temperature disorder, lesions damage spinal courchos, type IV is the same side of the lesions, lesions damage the trigeminal spinal cord nucleus kim and others included 50 specific cases with sensory disorder semenin infarction, including hypotherus sensation of shallow sensation above the T6 plane (including or excluding the face), single limb shallow sensation and single limb distant end shallow sensation Hongo and others reported 1 case of patients with LMI with reduced sensation below the side T6 plane, and Kon and others reported 1 case of LMI patients who simply showed pain and reduced temperature in the side taper T8 plane The first symptom of single limb sensory abnormality, and then the case of extended myelin infarction with abnormal plane upward section development, has not been reported, because of its development characteristics and spinal cord lesions are very similar, clinically very easy to misdiagnosis The previous diffusion pallophotography study showed that the spinal courchos beam was on the outside of the elongated myelin, consistent with the terrier site shown in the dWI of the head in this case in the lower part of the extended myelin, the nerve fibers arranged from the inside out in the spinal cplaceobrain bundle are from the neck, chest, waist, and cesis If the lesions are small, only part of the spinal courchus, patients can be shown as single limbs, a sensory plane above or a sense plane below the conductive beam sensory disorder; in combination with this case for analysis, the patient's initial stage of disease, the terrier lesions on the outside of the lower part of the myelin and the nerve fibers from part of the chest and all lumbar and storks in the spinal coral brain bundle, manifested as a superficial sensory disorder below the opposite T6 level, the second day after admission to the hospital, due to the death of the cerebral infarction thrombosis and inflammatory reaction is not controlled, the side branch circulation is not fully established, etc., the damage area expands to the inside, tired from the whole chest section of the spinal clotic brain beam, the performance of the side-feeling disorder plane rise, T1 level below the limb shallow sensory disorder This case of patients in the 5th day after the onset of progressive cerebral infarction, the main pathological basis is: unstable plaque rupture led to end-of-art almost embolism and new thrombosis, thrombosis caused by new vascular stenosis or clotting, short-term establishment of the side branch circulation has not been perfected, cerebral infarction after the inflammatory reaction caused secondary injury aspirin has good anti-platelet aggregation, can effectively prevent thrombosis and blood vessels from narrowing Atavastatin not only has the effect of lipid reduction, in the early stages of cerebral infarction has a good brain protection effect The application of atoflavine in mice early after cerebral infarction can improve the function of vascular endothelial cells, reduce the activation of small glial cells, and reduce the adhesion and immersion of white blood cells the early use of atovastatin in the early stages of death in rats, protecting the blood-brain barrier by lowering inflammatory markers Clinical results show that the acute stage of cerebral infarction patients using athoratin treatment, compared with patients in the chronic stage, can effectively reduce the inflammatory factors and adhesion factors, and significantly improve the loss of nerve function The high-risk structure of atherosclerosis plaques is associated with the inflammatory reaction of plaques, and atoflavatine improves the stability of plaques by reducing the inflammatory reaction Therefore, atoflavatin applied to the acute stage of cerebral infarction produced by the early brain protection effect may not only be because of its lipid-lowering effects, but also to reduce inflammatory reactions, protect the blood-brain barrier and stabilize the atherosclerosis plaqueand and other effects Hydrophilic injection has the effect of enhancing the fibrous activity of microvascular in the brain and improving the circulation of side branches open circulation of the brain's side branch increases the blood supply in the terrier and surrounding areas The richness of the side branch circulation and the ability of compensation are closely related to the prognosis of cerebral infarction In this case, after giving aspirin, atofvastatin and hydrophobic injections on the 8th day after the onset of the disease, the progressive lesions were relatively short due to the relatively short time of appearance (3d), the nerve fiber function was relatively light, and after the increase in blood circulation and inhibition of inflammatory reactions, the nerve function gradually recovered; LMI is mainly caused by the vertebral artery and/or the lower arteries of the cerebellum, the base artery, the cerebellum pre-arteries is rare, but can also cause LMI, the main cause of atherosclerosis The vertebral artery mezzanine is also a cause that LMI cannot be ignored, resulting in LMI accounting for 29% of the total LMI, and more studies have shown that this proportion can be as high as 50% Other rare causes include myelin haemorrhage, aneurysms, poor vertebral artery development, organophosphate poisoning, scorpion bites, etc most LMI patients prognosis can, after completing inpatient rehabilitation treatment, less neurological impairment, after discharge of nerve function can continue to improve, and restore the previous social activities; The eomereal is the life center, and if the eomelylesions affect the respiratory or cardiovascular adjustment center, it can be life-threatening Terao and others reported that one patient died of a sudden respiratory syndrome half a day after the onset of LMI Recent results show that cardiovascular automodulation is decreasing in some LMI patients therefore, in the acute phase of LMI, it is necessary to closely observe the vital signs of patients and to be vigilant The clinical performance of LMI is complex and variable, but the LMI is rare in the development of sensory plane segment, and is easily confused with spinal cord disease In clinical cases, when patients are found to have a sensory disorder of segmented development, they should ask for medical history in detail, carefully examine physical examination, especially when combining symptoms and signs of other LMI injuries, should consider the possibility of LMI in order to achieve early diagnosis and early treatment