A 72-year-old female was admitted to our emergency department, with acute onset blurred of vision, headache and unresponsive for 3 days. She denied the history of hypertension, diabetes, heart disease, hyperlipidemia, other vascular risk factors, the history of recent respiratory infections and history of anemia. On neurological examination, the understanding and executive is slightly reduced, no other deficits were apparent except for blurred vision. She was therefore unable to receive treatment for thrombolytic therapy and thrombectomy because of the onset time of 3 days.
Her initial National Institutes of Health Stroke Scale (NIHSS) score was 2 (complete hemianopia). Brain magnetic resonance imaging (MRI) revealed the acute cerebral infarction in the right occipital temporal lobe and corpus callosum (Fig. 1). Brain computed tomography angiography (CTA) indicated a right posterior cerebral artery P2 segmental occlusion, bilateral intracranial artery intracranial segment\bilateral anterior middle cerebral artery proximal stenosis, bilateral cerebral artery M1 segment\bilateral anterior cerebral artery A1 segment running area with multiple small blood vessels (Fig. 2). Her laboratory test revealed pancytopenia (hemoglobin concentration, 10.0 g/dL; white blood cell count, 1.24×109/L; platelet count:77×109/L) and progressive decline, which was diagnosed as MDS- excess blasts 2 according to the WHO classification. The reticulocyte ratio was 0.018 and low fluorescence reticulocyte ratio was 0.911. Bone marrow chromosome detection reported 46, XX, N (20). Morphological analysis of bone marrow revealed dysplasia in erythroid cells and neutrophil granulocytic, manifested as abnormal nuclear shape and megaloblastoid changes. The patient had high fasting blood sugar, whose glycated hemoglobin was 6.9%; Abnormal serum lipid profile (total cholesterol, 4.67mmol/L; high-density lipoprotein, 0.80mmol/L; low-density lipoprotein 3.56mmol/L).
On the third day,the patient's temperature and CRP were increased compared to her time of admission, and a chest CT scan showed inflammation progression. We gave her cefoperazone-sulbactam anti-infective. On the 7th day, the patient recurring visual hallucinations and choking whiles drinking water. Valproic acid-Depakine and lamotrigine were used to control seizures, which improved her symptoms. Due to the use of Depakine, the patient developed a rash hence we discontinued the use of lamotrigine, relieving her off this side effect (Fig. 3). On the 12th day of admission, the patient presented sudden numbness in the right arm and leg her NIHSS was 10 (complete hemianopia 2;no movement at all in arm 4 and no movement at all in leg 4). We gave 100mg aspirin and rehydration to improve cerebral perfusion stabilizing her symptoms. On the 23rd day of admission, she underwent a rehabilitation consult. Manual muscle strength test (MMT) of which the right arm was grade 3 proximally and grade 4 at the wrist and the right leg was grade 4 at the whole lower limb. Conservative treatments were administered including transfusion. Additional chemotherapy was not possible because of poor general conditions and economic state. On the 31th day of admission, the patient was transferred to a secondary local hospital. On the day of discharge at secondary local hospital, her NIHSS score was 4 (visual field 2༌right arm motor 1, right leg motor1) and had ecchymosis. After half a year of telephone follow-up, the patient was reported to have not undergone further chemotherapy due to her economic status, and died with unknown reason.