A case of "stroke" with epilepsy-like onset sharing experience in diagnosis and treatment case Shenghui

*For medical professionals to read for reference only, neuroprotection combined with emergency interventional therapy has greatly improved the prognosis of patients with "epilepsy combined with ischemic stroke" who have been onset for more than 24 hours
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Cerebral stroke is an acute cerebrovascular disease and the first cause of death in China
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Acute ischemic stroke (also known as acute cerebral infarction, AIS) is the most common type of stroke, with five characteristics of high morbidity, high disability rate, high fatality rate, high recurrence rate, and high economic burden.
focus of treatment
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 Early vascular recanalization is the recommended treatment strategy for AIS in national guidelines, and the main methods include intravenous thrombolysis and emergency intervention [1-3]
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The time window of intravenous thrombolysis is 3 to 4.
5 hours after the onset of the disease.
For patients with contraindications, the pros and cons should be weighed
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The recommended time window for emergency interventional therapy is 6-24 hours after onset, which can be used as a treatment plan for patients with contraindications to intravenous thrombolysis, and is more effective for intracranial large vessel occlusion [1]
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In addition, the use of neuroprotective agents is also an effective strategy for the treatment of AIS, which can delay the progression of the ischemic penumbra and win a larger treatment time window for patients [1]
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AIS can cause glutamate excitotoxicity, free radical damage, inflammatory damage,
etc.

Neuroprotective agents play a role in the above mechanisms, and play a positive role in improving neurological symptoms, activities of daily living and dysfunction caused by AIS [4]
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 At present, studies have confirmed that the combination of thrombolysis and neuroprotection can help improve the prognosis of stroke patients [5]
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The case we share in this issue is a stroke patient with epilepsy-like seizures in a hyperglycemic state.
His clinical situation is complex, and he cannot undergo intravenous thrombolysis or interventional therapy within the time window
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Three days after the onset of the disease, the disease progressed rapidly, and interventional treatment was performed after screening
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A neuroprotective agent (concentrated solution of edaravone and dexbornol for injection) was used in combination in this process, and a good prognosis was finally obtained
.

In this issue, we specially invite Zheng Chong, chief physician of the Department of Neurology of Longyan First Hospital, to share with you the specific diagnosis and treatment process of this case
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 Classic case review A 71-year-old male patient was admitted to the hospital due to "sudden unconsciousness and limb convulsions for more than 4 hours".
Admission time: 18:12 on February 9, 2022
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 History of present illness: 4 hours ago (14:00) without obvious incentives, unconsciousness, limb convulsions, and skewed corners of the mouth, which lasted for a few minutes, and then repeated 7-8 times.
Side limb weakness, no headache, vomiting
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She was admitted to the emergency department of our hospital and underwent head CT scan and head and neck CTA examination
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Consider TODD paralysis, symptomatic seizures (secondary to hyperglycemia), chronic occlusion of the right internal carotid artery
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Take in endocrinology
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 Past history: diabetes, hypertension
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Denied smoking history
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 Specialist physical examination: clear consciousness, clear speech, correct answers, left limb muscle strength grade 3, bilateral pathological signs were negative
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National Institutes of Health Stroke Scale (NIHSS) score: 4 points
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 Auxiliary examination: peripheral blood sugar HIGH, biochemical blood sugar 34.
49mmol/L
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Head CT scan (February 9): no bleeding
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Figure 1: Results of head CT examination on February 9.
Head and neck CTA (February 9) showed that the right internal carotid artery was occluded
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Figure 2: Head and neck CTA examination results on February 9.
Initial diagnosis: TODD paralysis, symptomatic seizures (secondary to hyperglycemia), chronic occlusion of the right internal carotid artery, hypertension, and diabetes
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Take in endocrinology
.

 Inpatient condition in endocrinology department: left limb muscle weakness, CTA showed right internal carotid artery occlusion, emergency consultation of neurology department was requested
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 Consultation and diagnosis opinion (neurology department): diagnosis opinion 1 (specialist): hyperglycemic state, epilepsy, chronic right internal carotid artery occlusion Diagnostic opinion 2 (senior physician): hyperglycemia state, right internal carotid artery chronic occlusion , Diagnosis of Diabetic Hemiplegia 3 (second-line physicians): hyperglycemia, epilepsy, acute ischemic stroke, limb shaking type, diabetic eccentric dance to be removed Auxiliary examination: cranial cerebral perfusion results, as shown below
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Figure 3: Results of cranial perfusion examination AI intelligent assessment of perfusion (quantitative), as shown below
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Figure 4: AI intelligent assessment of perfusion results treatment plan: family members refused emergency interventional thrombectomy, and could not have intravenous thrombolysis due to contraindications
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In order to prevent further deterioration of the condition, the following treatments were carried out: antithrombotic, regulating blood lipids, and using the neuroprotective agent edaravone dexbornol for injection concentrated solution to scavenge oxygen free radicals and anti-inflammatory
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It is required to pay attention to the observation of limb function, and to improve the examinations such as brain MRI+DWI, carotid artery color Doppler ultrasound, and cardiac color Doppler ultrasound
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 18:20, February 11: Condition changes: Aspiration occurred, transient coma occurred, SPO2 decreased, improved after sputum suction and other treatments, and regained consciousness; treated with nasogastric feeding tube and ECG monitoring
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At this time, the concentrated solution of edaravone and dexbornol for injection was used for 2 days, and the muscle strength of the patient's left limb was maintained well, and the muscle strength was grade 3-4.

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 11:00 on February 12: The condition has progressed: the speech begins to be slurred, the muscle strength of the left limb is grade 0, and the left Pap's sign is positive
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NIHSS score: 12 points
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 Auxiliary examination: head CT results, as shown in the figure below
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Figure 5: Head CT results on February 12.
Emergency intervention: mechanical thrombectomy
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Materials: CAT6 intermediate catheter, thrombectomy stent, Pro18 microcatheter, PT2 microguide wire, Synchro microguide wire)
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 Auxiliary examination: Preoperative DSA: showed the distal occlusion of the right internal carotid artery, the ophthalmic artery compensated, and refluxed to the cavernous sinus segment
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Figure 6: Preoperative DSA on February 12.
Postoperative DSA and thrombus removal: a large amount of thrombus was removed, and the right internal carotid artery was recanalized
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Figure 7: Postoperative DSA on February 12 Figure 8: Thrombus removed on February 12 Diagnosis: There is no severe stenosis locally, and embolization is considered
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 Auxiliary examination (February 17): MRI of the head, as shown in the figure below
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Figure 9: Head MRI results on February 17 Prognosis: NIHSS score when symptoms worsened: 12 points; after treatment with edaravone dexbornol injection concentrated solution and emergency interventional therapy for thrombectomy, NIHSS score at discharge: 4 points, improved Rankin Scale (mRS) score: 3 points
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 Final diagnosis: cerebral infarction (acute phase), right internal carotid artery occlusion and recanalization (high possibility of cardioembolism), seizures in hyperglycemic state, diabetes, and hypertension
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Expert Comments AIS is an ischemic disease caused by occlusion or stenosis of cerebral blood vessels, which can lead to brain damage and neurological deficits
.

The patient had epileptic seizures in a hyperglycemic state.
After admission, head CT and head and neck CTA showed no intracranial hemorrhage and right internal carotid artery occlusion, suggesting AIS
.

However, the blood glucose level is too high and it is not suitable for intravenous thrombolysis, and the interventional treatment cannot be performed within the time window (6-24h)
.

Three days after the onset, the NIHSS score was as high as 12, and emergency intervention was decided
.

The efficacy of this therapy on acute intracranial arterial occlusion has been confirmed, but for the treatment of such patients (belonging to non-acute intracranial arterial occlusion) with onset of more than 24 hours, there is currently no gold standard therapy at home and abroad
.

The successful experience of this case shows that interventional therapy can also be performed in such patients with appropriate screening
.

This is undoubtedly good news for patients with progressive stroke
.

 The success rate of vascular recanalization is closely related to the treatment time
.

It is generally believed that if the time of recanalization is delayed, the ischemic brain tissue cannot be rescued, and it may even lead to reperfusion injury and further aggravate brain injury
.

In this case, in order to delay the progress of brain injury, Edaravone and Dexbornol Injection Concentrated Solution for Injection (compound preparation, Edaravone and Dexbornol in a 4:1 ratio) were given.
The main mechanisms of nerve injury after ischemia play multiple roles [6]
.

Among them, edaravone reduces oxidative stress by scavenging free radicals, and then partially achieves anti-inflammatory effects; edaravone dexbornol injection concentrated solution can significantly inhibit the pro-inflammatory factors (TNF-α) caused by ischemia-reperfusion injury -α, iNOS, IL-1β and COX-2) expression, also has the effect of inhibiting glutamate excitotoxicity and protecting the blood-brain barrier [7]
.

During the whole process of diagnosis and treatment, the drug can effectively protect the neurons in the penumbra in the ischemic area, and also avoid the ischemia-reperfusion injury caused by revascularization, which greatly improves the prognosis of patients.

.

Combined use of the drug and emergency interventional treatment, the patient's NIHSS score was reduced from 12 to 4, and the MRS score was 3, which showed its definite curative effect
.

 In addition, considering that the patient's blood sugar was too high, intravenous thrombolysis was not used, but for other AIS patients with hyperglycemia and epilepsy, it should not be limited to this case.
Issues such as the relevance of secondary stroke and whether it causes bleeding in critical sites determine whether intravenous thrombolysis should be used
.

Expert Profile Zheng Chong Deputy Chief Physician of the Department of Neurology, Longyan First Hospital, Master of Neurology Member of the Neurological Intervention Group of the Neurology Branch of the Fujian Medical Association Executive Director of the Neurology Branch of the Fujian Strait Medical and Health Exchange Association Member of the Neurology Branch of the Longyan Medical Association Zeng Zeng He studied in the Advanced Seminar of Neurology Department of Xuanwu Hospital in Beijing, and studied neurointervention in the General Hospital of Nanjing Military Region.
He is good at interventional diagnosis and treatment of cerebrovascular diseases.
He has published several papers in CSCD and core journals.
References: [1] Peng Bin, Wu Bo.
Acute shortage in China Guidelines for the diagnosis and treatment of hemorrhagic stroke 2018 [J].
Chinese Journal of Neurology, 2018, 51(09): 666-682.
[2]POWERS WJ, RABINSTEIN AA, ACKERSON T, et al.
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [J].
Stroke, 2019, 50(12): e344-e418.
[3] AHMED N, AUDEBERT H, TURC G, et al.
Consensus statements and recommendations from the ESO-Karolinska Stroke Update Conference, Stockholm 11-13 November 2018 [J].
Eur Stroke J, 2019, 4(4): 307 -317.
[4] Xiao Weimin, Cheng Weiyang.
Current status and research prospects of neuroprotective agents for ischemic stroke [J].
Internal Medicine Theory and Practice, 2019, 14(5): 282-288.
[5] Zhang Libin, Feng Zhipeng, Chen Risheng, etc.
Efficacy of alteplase combined with edaravone and dexbornol in the treatment of acute ischemic stroke[J].
Wisdom Health, 2021, 7(20): 133-135.
[6]XU J, WANG A, MENG X , et al.
Edaravone Dexborneol Versus Edaravone Alone for the Treatment of Acute Ischemic Stroke: A Phase III, Randomized, Double-Blind, Comparative Trial [J].
Stroke, 2021, 52(3): 772-780.
[7]WU HY, TANG Y, GAO LY, et al.
The synergetic effect of edaravone and borneol in the rat model of ischemic stroke [J].
Eur J Pharmacol, 2014, 740: 522-531.
Professionals provide scientific information and do not represent the views of the platformThe synergetic effect of edaravone and borneol in the rat model of ischemic stroke [J].
Eur J Pharmacol, 2014, 740: 522-531.
*This article is for the purpose of providing scientific information to healthcare professionals only and does not represent the views of the platformThe synergetic effect of edaravone and borneol in the rat model of ischemic stroke [J].
Eur J Pharmacol, 2014, 740: 522-531.
*This article is for the purpose of providing scientific information to healthcare professionals only and does not represent the views of the platform