For a case of DWI-negative ischemic stroke patients who have been onset for more than 24 hours, have you chosen the right treatment plan?

*It is only for medical professionals to read and reference.
This medication regimen enables patients with DWI-negative ischemic stroke who have been onset for more than 24 hours to be effectively treated
.

Stroke is a common neurological disease with the characteristics of high morbidity, high recurrence rate, high disability rate, and high mortality rate [1]
.

With the acceleration of social aging and urbanization and the prevalence of unhealthy life>
.

Acute ischemic stroke is the most common type of stroke, accounting for 69.
6%-70.
8% of strokes in China [3]
.

Clinical symptoms are an important basis for the diagnosis of ischemic stroke.
Head MRI, especially diffusion-weighted imaging (DWI), is also an important diagnostic method for ischemic stroke.
The sensitivity of DWI can reach 80%-100%, and the specificity can reach 95%-100%.
[4,5], but there is still a possibility of missed diagnosis.
Studies have shown that 6.
8% of patients with acute ischemic stroke are DWI negative [6]
.

For DWI-negative patients with acute ischemic stroke, early consideration of vascular recanalization and neuron protection therapy may improve the prognosis of patients
.

In this issue, we invited Dr.
Wang Tan from Qilu Hospital of Shandong University to share a classic case.
This ischemic stroke patient showed negative DWI and did not undergo thrombolytic therapy.
His condition suddenly worsened more than 24 hours after the onset.
How should this patient be treated? What about treatment? Let's take a look together
.

The basic situation of classic case review: male, 58 years old, admitted to the hospital on September 22, 2020
.

Main complaint: paroxysmal numbness and weakness of the right limb, accompanied by dizziness for 8 hours
.

History of present illness: 8 hours ago, the patient had numbness of the right fingertips without obvious inducement, and gradually progressed to the right upper and lower limbs, accompanied by weakness of the right limbs, accompanied by dizziness, non-rotational, head drowsiness, no headache, no speech disadvantage, No nausea, vomiting, ignorance of rotation and diplopia, unconscious disturbances and other discomforts, which can be completely relieved for 20-30 minutes
.

Without regular treatment, her condition recurred and had more than 10 episodes before admission
.

Past medical history: A history of hypertension for more than 20 years, the highest blood pressure is 170/110mmHg, and the blood pressure is maintained at 130-140/90-100mmHg by taking medicine
.

Denies the history of coronary heart disease and diabetes
.

Specialist physical examination: Consciousness
.

Bilateral frontal lines are symmetrical, bilateral nasolabial folds are basically symmetrical, uvula is centered, pharyngeal reflex is normal, and tongue sticking out is centered
.

Muscle strength: Extremities muscle strength is level 5, limb muscle tension is normal, bilateral collateral movement is roughly normal, and the whole body feels normal without loss
.

Bilateral tendon reflexes are symmetrical (++), bilateral Babinski sign (-)
.

Soft neck, Kernig sign (-)
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After admission, the patient still had paroxysmal right limb weakness, which lasted for more than 10 minutes to relieve
.

Physical examination during the attack: cranial nerves (-), muscle strength of the right limbs 4+, and pathological signs on the right side (-)
.

National Institutes of Health Stroke Scale (NIHSS) score: 2 points
.

Auxiliary examination: cranial MRI+MRA, cervical vascular MRA: a few ischemic lesions of white matter in both cerebral hemispheres; cerebral artery MRA and carotid CE-MRA have no obvious abnormalities
.

Figure 1: Craniocerebral MRI+MRA and cervical vascular MRA.
Carotid ultrasound: bilateral internal carotid artery intima-media thickened, and the initial segment of the left internal carotid artery was 1.
5×7.
1mm with moderate echo plaque
.

24-hour ambulatory blood pressure: the mean blood pressure is 132/90mmHg, the highest blood pressure is 155/111mmHg, the systolic load is 46.
9, and the diastolic load is 87.
5
.

Liver function: bilirubin 29.
8μmol/L (direct bilirubin 8.
2μmol/L, indirect bilirubin 21.
6μmol/L)
.

Blood lipid: TG 1.
63mmol/L; LDL-C 2.
91mmol/L
.

Diagnosis: Transient ischemic attack (ischemic stroke)
.

Treatment plan: dual antiplatelet drugs: aspirin 100mg + clopidogrel 75mg qd; statins: atorvastatin 20mg qd; antihypertensive drugs: temporarily continue to use the original antihypertensive drugs to monitor blood pressure changes; anticoagulant drugs: Atorvastatin Add varices 2.
5mg/h continuous micro-pump pumping; improve circulation: Ginkgo biloba extract, butylphthalide
.

Condition changes: After admission, the patient used the above treatment plan and did not recur on the right limb weakness, but felt irritable at around 23:00 on the second day after admission.
The blood pressure rose to about 170/90mmHg, and paroxysmal right limb weakness occurred again.
The duration was gradually extended and did not relieve after 2:30 in the morning
.

No hemorrhage was found on CT brain CT
.

Physical examination revealed: Slightly less fluent in spoken language
.

The bilateral nasolabial grooves are symmetrical, showing that the teeth are symmetrical, and the tongue is slightly offset to the right
.

The proximal muscle strength of the right limb is grade 4, the distal muscle strength is grade 3, the muscle tension is basically normal, and the tendon reflexes of the limbs (++)
.

Pain in the right side of the body is reduced
.

Bilateral pathological signs (-)
.

Freemasonry movement (-)
.

NIHSS: 5 points
.

Considering that the patient has used a variety of antiplatelet and anticoagulant drugs, there is no evidence of significant arterial stenosis, and the time of onset has been more than 24 hours, the risk of thrombolysis is higher, and edaravone dexcamphanol is added 4 hours after the symptoms worsen Concentrated solution for injection 30mg bid treatment
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Re-examination of the cranial MR 12 hours after symptoms aggravated: T1 long T2 signal was seen on the left side of the pons, T2 Flair showed slightly high signal, DWI display was unclear, consider the possibility of ischemic focus or infarct focus
.

Figure 2: Reexamination of craniocerebral MR discharge 12 hours after symptoms worsened: Consciousness, normal speech, reasonable question and answer, rough measurement of direction, memory, and calculation ability are basically normal
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The frontal lines and nasolabial folds are symmetrical on both sides, the uvula is in the center, and the tongue is in the center
.

Examination of the remaining cranial nerves was normal
.

Muscle strength: the proximal muscle strength of the right upper limb is 4+, the distal muscle strength is 4, the proximal muscle strength of the right lower limb is 4, the distal muscle strength is 4, the right toe dorsiflexion strength is weak, the limb muscles The tension is normal, the bilateral collateral movement is roughly normal, and the whole body feels normal without loss
.

Right tendon reflex (+++), bilateral Babinski sign (-), soft neck, Kernig sign (-)
.

NIHSS: 2 points
.

Dr.
Wang Tan commented that this patient was diagnosed with a transient ischemic attack, which was mainly treated with antiplatelet and anticoagulant drugs, but the next day the condition worsened and the muscle strength of the limbs decreased.
The NIHSS score increased from 2 points to 5 points, imaging The study considers the possibility of ischemia or infarction, but at this time it has been more than 24 hours from the onset, and the risk of thrombolysis is higher
.

Therefore, early negative DWI cannot completely rule out the possibility of acute ischemic stroke.
The clinical symptoms should be combined with a variety of auxiliary examinations (including perfusion imaging, EEG, etc.
) or review to improve the diagnosis rate
.

Patients with obvious symptoms of ischemic stroke but negative DWI should still intervene as soon as possible [1]
.

This patient was treated with concentrated solution of edaravone and dexcamphanol injection 4 hours after his condition worsened.
DWI was negative after 12 hours, and the patient's symptoms gradually improved.
On the 6th day of admission, his right limb muscle strength returned to level 4 Around, on the 10th day of admission, the superficial sensation of the limbs basically returned to normal, and on the 13th day of admission, the tongue was in the middle, and the cranial nerve examination showed no obvious abnormality.
By the time of discharge from the hospital on October 7 (application of edaravone dexcamphanol injection concentrated solution Treatment for 14 days) The NIHSS score was reduced to 2, and the physical condition was significantly improved
.

More importantly, this patient used edaravone and dexcamphanol injection concentrated solution after the onset of more than 24 hours to achieve a better effect
.

The concentrated solution of edaravone and dexcamphane for injection contains two active ingredients, edaravone and dexcamphane, which can synergistically inhibit nerve damage and positively improve the prognosis of patients
.

Phase III clinical research results also proved [7] that the concentrated solution of edaravone dexcamphanol injection can extend the treatment time window to 48 hours, and the effect is still significant after 24 hours.
The earlier the use, the better the effect, and There are curative advantages in all stroke subtypes
.

For patients with acute ischemic stroke, extending the time window to 48 hours can increase the proportion of patients with clinical benefit and bring more feasible treatment options for patients with acute ischemic stroke
.

Case provider Wang Tan graduated from Shandong University School of Medicine in 2014 and received a doctorate in medicine.
Attending physician in the Department of Geriatric Neurology, Qilu Hospital of Shandong University, is mainly engaged in research on the molecular pathology of Alzheimer's disease and related clinical diagnosis and treatment.
Wisdom of Chinese Society of Geriatrics Member of the Medical Technology and Management Branch Member of the Dementia and Cognitive Impairment Professional Committee of Shandong Geriatrics Society Member of the Geriatrics Professional Committee of Shandong Pain Research Association Presided over one project of the National Natural Science Foundation of China, and three projects of national and provincial scientific research funds in China More than ten references published in foreign academic journals: [1] Li Yue, Wei Yilan, Ouyang Quping.
Analysis of related factors of negative MRI diffusion weighted imaging in acute cerebral infarction[J].
Beijing Medical Journal, 2020, 42 (08) :703-707.
[2] "China Stroke Prevention and Treatment Report" Writing Group.
Summary of "China Stroke Prevention and Treatment Report 2019"[J].
Chinese Journal of Cerebrovascular Disease, 2020, 017(005):272-281.
[3 ]Chinese Medical Association Neurology Branch.
Guidelines for Diagnosis and Treatment of Acute Ischemic Stroke 2018[J].
Health Guidelines (Middle-aged and Elderly), 2018(12):8-10.
[4]Jauch EC, Saver JL, Adams Jr HP, et al.
Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J].
Stroke, 2013, 44(3): 870-947.
[5]Simonsen CZ , Madsen MH, Schmitz ML, et al.
Sensitivity of diffusion-and perfusion-weighted imaging for diagnosing acute ischemic stroke is 97.
5%[J].
Stroke, 2015, 46(1): 98-101.
[6]Edlow BL, Hurwitz S,Edlow JA.
Diagnosis of DWI-negative acute ischemic stroke: A meta-analysis[J].
Neurology.
2017 Jul 18;89（3):256-262.
[7]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.
*This article is only for medical treatment The scientific information provided by health professionals does not represent the views of the platform