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*Only for medical professionals to read and refer to the layered analysis, Liu Yinhua is another village
.
Case review Patient Wang, female, 76 years old
.
▌ Chief Complaint: Sudden chest tightness, chest pain, numbness and weakness of the left lower limb for 3 hours
.
▌ History of present illness: 3 hours ago, the patient developed chest tightness and chest pain without obvious inducement when resting at home 3 hours ago, and then found that the left lower extremity was unfavorable and numb, accompanied by nausea, vomiting, and stomach contents 4 times, without urination disorder
.
After self-administering "Suxiao Jiuxin Pill", the chest pain eased slightly
.
Seek a doctor in the emergency department of this hospital
.
A complete electrocardiogram in the internal medicine department showed left ventricular hypertrophy and ST-T changes, so she was referred to the department of neurology
.
▌ Past history: more than 10 years of history of hypertension and diabetes, more than 10 years of coronary heart disease, coronary stent placement (4 stents) 2 years ago, long-term oral aspirin and clopidogrel after surgery
.
▌ Physical examination: blood pressure on the left side is 166/104mmHg, blood pressure on the right side is 164/98mmHg, there is no abnormality in the cardiopulmonary examination
.
Nervous system examination: left lower extremity muscle strength level 2, left lower extremity decreased pain and touch, left Babinski sign is positive, the rest of the physical examination is generally normal, the National Institutes of Health Stroke Scale (NIHSS) score 4 points
.
▌ Auxiliary examination: There are no obvious abnormalities in blood routine, blood sugar, and cTnI
.
Positioning, qualitative diagnosis? ■ Location diagnosis: The patient is elderly female with acute onset.
According to the medical history, the patient has chest pain accompanied by numbness and weakness of the left lower extremity, physical examination of left lower extremity muscle strength, decreased left lower extremity pain and tactile sensation, and positive left Babinski sign.
Consider localization in the brain Motor neurons and sensory neurons in the cortex, the pyramidal tract and the spinothalamic tract are not excluded
.
■ Qualitative diagnosis: Considering the clinical manifestations of the patient comprehensively, it is considered as a stroke (infarction) disease-cerebral infarction or spinal cord infarction
.
The cause of the patient's chest pain is considered to be acute coronary syndrome or acute aortic syndrome
.
During the diagnosis and treatment, patients with cerebral infarction are more likely to have cerebral infarction.
In order not to delay the treatment of the patients, intravenous thrombolysis (4 hours and 10 minutes from the onset) immediately, using alteplase 0.
6 mg/kg (total 30 mg)
.
Aortic full-length CTA examination was performed during thrombolysis: multiple localized dissections and intermural hematomas of the aorta, multiple mural thrombosis and penetrating ulcers occurred
.
CTA of the patient's aorta suggested limited dissection, and thrombolysis was stopped immediately
.
Eight hours after the patient's onset, the patient had urinary retention again
.
Physical examination again: the left lower limb muscle strength is level 2, the pain and touch sensation below the T7-8 plane on the left side is decreased, and the deep feeling is normal
.
Babinski sign on the left is positive
.
Modified diagnosis: the possibility of spinal cord infarction is high
.
At this time, MRI of the brain was not abnormal in the imaging examination, and MRA suggested cerebral arteriosclerosis
.
MRI of the spinal cord showed lesions on the left side of the thoracic spinal cord at the level of the T4-5 vertebral body
.
Figure 1: MRI location of the patient's thoracic spinal cord: left thoracic spinal cord (T4-5 level); qualitative: vascular infarction; definite cause: embolism caused by aortic plaque; definite blood vessel: left spinal sulcus artery
.
Final diagnosis: sulci spinal artery syndrome
.
Treatment and follow-up: Prednisone, dehydration, vitamin B12 and other drugs are given supplemented by rehabilitation training.
When the patient is discharged from the hospital (14 days after onset), the left lower limb weakness (muscle strength level 3), fecal incontinence and mild urinary incontinence are still left
.
Follow-up 2 months after discharge, the muscle strength of the left lower limb recovered to grade 5, and the urination was basically controllable
.
Discussion ■ Discussion 1: What are the neurological syndromes related to spinal cord ischemia? There are many common types of spinal cord ischemia.
Different types of responsible blood vessels and clinical manifestations are different.
It is of diagnostic and differential diagnosis significance to clarify the neurological syndrome related to spinal cord ischemia
.
Central medulla syndrome (anterior spinal artery/ASA syndrome): flaccid paralysis at the infarct level, paraplegia or quadriplegia below the infarct level (spasticity), positive Babinski sign, dissociative sensory disturbance (loss of pain and temperature perception), bladder and Intestinal dysfunction, autonomic dysfunction and Horner sign
.
SSA syndrome (spinal sulcal artery): flaccid paralysis at the level of the infarction, spastic paralysis (half) below the level of the infarction, dissociative sensory disturbance on the contralateral side
.
Barrel man syndrome: bilateral proximal flaccid paralysis of the upper limbs, no movement disorder of the lower limbs, no sensory disturbance
.
PSA syndrome (posterior spinal artery syndrome): proprioception (touch and vibration) disorders, ataxia gait
.
Adamkiewicz Arterial Syndrome (Lumbar Dilatation Artery): Complete (incomplete) Transverse Spinal Cord Syndrome: Flaccid paralysis at the infarct level, Paraplegia below the infarct level (spasticity), positive Babinski sign, complete (incomplete) sensory disturbance, bladder and bowel Dysfunction
.
Figure 2: Diagram of common spinal cord ischemic syndromes ■ Discussion 2: Can intravenous thrombolysis be performed for spinal cord infarction? Early diagnosis of spinal cord infarction is difficult: first, most hospitals cannot perform emergency spinal cord MRI, especially spinal cord DWI; second, spinal cord DWI has a low detection rate of spinal cord infarction within 12 hours of onset
.
Intravenous thrombolytic therapy of spinal cord infarction still lacks evidence-based medicine
.
If spinal cord infarction is clinically diagnosed and there is no contraindication to thrombolysis (MRI of the spinal cord excludes intraspinal hemorrhage/vascular malformation, etc.
, CTA of the aorta excludes arterial dissection), intravenous thrombolysis within 4.
5 hours of onset may be reasonable, at least safe
.
Case retrospective analysis suggests: the earlier the thrombolysis, the better the recovery
.
Summary: For patients with single limb paralysis and numbness as the first symptom, it is best to perfect head MRI+DWI before intravenous thrombolysis to diagnose cerebral infarction
.
When intravenous thrombolysis, beware of aortic dissection
.
Enhance the ability to recognize atypical spinal cord infarction (sulcus artery syndrome)
.
The content of this article is compiled from the "Medical Circle" and Xiangya Hospital jointly produced the case show of young teachers, Chinese teacher Yanbin brought us a lecture entitled "Dissection Thrombolysis" Suspected No Way, "Spinal Infarction" Another Village"
.
.
Case review Patient Wang, female, 76 years old
.
▌ Chief Complaint: Sudden chest tightness, chest pain, numbness and weakness of the left lower limb for 3 hours
.
▌ History of present illness: 3 hours ago, the patient developed chest tightness and chest pain without obvious inducement when resting at home 3 hours ago, and then found that the left lower extremity was unfavorable and numb, accompanied by nausea, vomiting, and stomach contents 4 times, without urination disorder
.
After self-administering "Suxiao Jiuxin Pill", the chest pain eased slightly
.
Seek a doctor in the emergency department of this hospital
.
A complete electrocardiogram in the internal medicine department showed left ventricular hypertrophy and ST-T changes, so she was referred to the department of neurology
.
▌ Past history: more than 10 years of history of hypertension and diabetes, more than 10 years of coronary heart disease, coronary stent placement (4 stents) 2 years ago, long-term oral aspirin and clopidogrel after surgery
.
▌ Physical examination: blood pressure on the left side is 166/104mmHg, blood pressure on the right side is 164/98mmHg, there is no abnormality in the cardiopulmonary examination
.
Nervous system examination: left lower extremity muscle strength level 2, left lower extremity decreased pain and touch, left Babinski sign is positive, the rest of the physical examination is generally normal, the National Institutes of Health Stroke Scale (NIHSS) score 4 points
.
▌ Auxiliary examination: There are no obvious abnormalities in blood routine, blood sugar, and cTnI
.
Positioning, qualitative diagnosis? ■ Location diagnosis: The patient is elderly female with acute onset.
According to the medical history, the patient has chest pain accompanied by numbness and weakness of the left lower extremity, physical examination of left lower extremity muscle strength, decreased left lower extremity pain and tactile sensation, and positive left Babinski sign.
Consider localization in the brain Motor neurons and sensory neurons in the cortex, the pyramidal tract and the spinothalamic tract are not excluded
.
■ Qualitative diagnosis: Considering the clinical manifestations of the patient comprehensively, it is considered as a stroke (infarction) disease-cerebral infarction or spinal cord infarction
.
The cause of the patient's chest pain is considered to be acute coronary syndrome or acute aortic syndrome
.
During the diagnosis and treatment, patients with cerebral infarction are more likely to have cerebral infarction.
In order not to delay the treatment of the patients, intravenous thrombolysis (4 hours and 10 minutes from the onset) immediately, using alteplase 0.
6 mg/kg (total 30 mg)
.
Aortic full-length CTA examination was performed during thrombolysis: multiple localized dissections and intermural hematomas of the aorta, multiple mural thrombosis and penetrating ulcers occurred
.
CTA of the patient's aorta suggested limited dissection, and thrombolysis was stopped immediately
.
Eight hours after the patient's onset, the patient had urinary retention again
.
Physical examination again: the left lower limb muscle strength is level 2, the pain and touch sensation below the T7-8 plane on the left side is decreased, and the deep feeling is normal
.
Babinski sign on the left is positive
.
Modified diagnosis: the possibility of spinal cord infarction is high
.
At this time, MRI of the brain was not abnormal in the imaging examination, and MRA suggested cerebral arteriosclerosis
.
MRI of the spinal cord showed lesions on the left side of the thoracic spinal cord at the level of the T4-5 vertebral body
.
Figure 1: MRI location of the patient's thoracic spinal cord: left thoracic spinal cord (T4-5 level); qualitative: vascular infarction; definite cause: embolism caused by aortic plaque; definite blood vessel: left spinal sulcus artery
.
Final diagnosis: sulci spinal artery syndrome
.
Treatment and follow-up: Prednisone, dehydration, vitamin B12 and other drugs are given supplemented by rehabilitation training.
When the patient is discharged from the hospital (14 days after onset), the left lower limb weakness (muscle strength level 3), fecal incontinence and mild urinary incontinence are still left
.
Follow-up 2 months after discharge, the muscle strength of the left lower limb recovered to grade 5, and the urination was basically controllable
.
Discussion ■ Discussion 1: What are the neurological syndromes related to spinal cord ischemia? There are many common types of spinal cord ischemia.
Different types of responsible blood vessels and clinical manifestations are different.
It is of diagnostic and differential diagnosis significance to clarify the neurological syndrome related to spinal cord ischemia
.
Central medulla syndrome (anterior spinal artery/ASA syndrome): flaccid paralysis at the infarct level, paraplegia or quadriplegia below the infarct level (spasticity), positive Babinski sign, dissociative sensory disturbance (loss of pain and temperature perception), bladder and Intestinal dysfunction, autonomic dysfunction and Horner sign
.
SSA syndrome (spinal sulcal artery): flaccid paralysis at the level of the infarction, spastic paralysis (half) below the level of the infarction, dissociative sensory disturbance on the contralateral side
.
Barrel man syndrome: bilateral proximal flaccid paralysis of the upper limbs, no movement disorder of the lower limbs, no sensory disturbance
.
PSA syndrome (posterior spinal artery syndrome): proprioception (touch and vibration) disorders, ataxia gait
.
Adamkiewicz Arterial Syndrome (Lumbar Dilatation Artery): Complete (incomplete) Transverse Spinal Cord Syndrome: Flaccid paralysis at the infarct level, Paraplegia below the infarct level (spasticity), positive Babinski sign, complete (incomplete) sensory disturbance, bladder and bowel Dysfunction
.
Figure 2: Diagram of common spinal cord ischemic syndromes ■ Discussion 2: Can intravenous thrombolysis be performed for spinal cord infarction? Early diagnosis of spinal cord infarction is difficult: first, most hospitals cannot perform emergency spinal cord MRI, especially spinal cord DWI; second, spinal cord DWI has a low detection rate of spinal cord infarction within 12 hours of onset
.
Intravenous thrombolytic therapy of spinal cord infarction still lacks evidence-based medicine
.
If spinal cord infarction is clinically diagnosed and there is no contraindication to thrombolysis (MRI of the spinal cord excludes intraspinal hemorrhage/vascular malformation, etc.
, CTA of the aorta excludes arterial dissection), intravenous thrombolysis within 4.
5 hours of onset may be reasonable, at least safe
.
Case retrospective analysis suggests: the earlier the thrombolysis, the better the recovery
.
Summary: For patients with single limb paralysis and numbness as the first symptom, it is best to perfect head MRI+DWI before intravenous thrombolysis to diagnose cerebral infarction
.
When intravenous thrombolysis, beware of aortic dissection
.
Enhance the ability to recognize atypical spinal cord infarction (sulcus artery syndrome)
.
The content of this article is compiled from the "Medical Circle" and Xiangya Hospital jointly produced the case show of young teachers, Chinese teacher Yanbin brought us a lecture entitled "Dissection Thrombolysis" Suspected No Way, "Spinal Infarction" Another Village"
.
