Fully Functional Recovery after Brainstem Infarction in a Young Patient- A Case Report

Pengyu Huang^1#, Dandan Lu^1,2#, Haixia Lu^1*

¹Department of Neurobiology, School of Biomedical Sciences, Xi’an Jiaotong University Health Science Center, Xi’an, 710061, China

²Rehabilitation Department of Traditional Chinese Medicine, East District of the 1st Affiliated Hospital, Xi’an Jiaotong University Health Science Center, Xi’an, 710061, China

^#Those two authors contributed equally to this work.

*Corresponding Author: Haixia Lu, Professor, Department of Neurobiology, School of Biomedical Sciences, Xi’an Jiaotong University Health Science Center, Xi’an, 710061, China.

Received: 14 October 2022; Accepted: 02 November 2022; Published: 25 November 2022

1. Introduction

Ischemic stroke accounts for 85% of all strokes. It is one of the most common cerebrovascular diseases and characterized by high incidence, morbidity, and mortality [1-2]. Stroke has become the major cause of disability and the second leading cause of death in the world [3]. Stroke in people younger than 45 years is less frequent than in older people but has major impact on the individual and society. Due to various factors, the proportion of stroke in adolescents and young adults (aged from 18-50) has increased to approximately 15%-18% in recent years [4,5]. Patients in this age are almost in a critical period of life when important decisions should be made on starting a family or a career. It also remain at high risk for recurrence [6]. Therefore, close attention should be made for the therapy of young patients and the functional recovery is urgently required. Ischemic brainstem strokes constitute about 10% of all ischemic brain strokes. Patients with brainstem strokes may experience minimal functional or cognitive deficits, or devastating injury. A patient under 30 years old and with severe motor deficits after brainstem infarction could fully functional recovered is extremely infrequent. We outline the patient’s hospital course and eventual improvement here is for calling more attention to brainstem stroke in young.

2. Case Presentation

A 26-year old man with sudden right-sided hemiplegia and dizziness was admitted to hospital. On admission, he was diagnosed with brainstem infarction based on the image of CT scan and extremely high level of homocysteine (71 μmol/L). He denied for the history of hypertension, diabetes, coronary heart disease or other chronic disorders and felt perfectly well before the symptoms occurred. He has been smoking for over 8 years with 10-15 cigarettes per day and drinking 4 to 6 bottles of beer daily for over 7 years. Physical examination showed the lower myodynamia on right arm and leg. Muscle tension of right limb was normal. He lost balance when made a move and the ability of daily life decreased dramatically (was in moderately dependent). No cognitive deficit was noticed and all the reflex were normal. After admission, he received 12 days treatment with anticoagulants, vasodilator and neuroprotective agents to improve the circulation and enhance collateral circulation establishment. As soon as finishing the acute treatment, function rehabilitation training was admitted (Table 1). The initial treatment effect was noticed by Brunnstrom stage 20 days later and the decrease of homocysteine level (59 μmol/L) was observed 3 months later. Five months later, the myodynamia of right limb, the balance (showed by Brunnstrom stage and Berg Balance Scale, Table 2 and supplement) basically recovered to normal levels. The ability of daily living (showed by Barthel Index, Table 2 and supplement) recovered to almost independent. The homocysteine level reversed to 27 μmol/L.

Table 1: Personalized Rehabilitation Training Strategy

Table 2: Brunnstrom stage, Berg Balance Scale and Barthel Index

3. Discussion

Stroke patients younger than 50 may have etiology varies [7]. According to the traditional TOAST classification of stroke, the patient we reported here could be classified as stroke of undetermined etiology [8]. Based on the risk factor classification given by International Pediatric Stroke Center [9-11], the long history of excessive alcohol consumption and cigarettes smoking might be the main etiology for this 26-year old ischemic brainstem stroke patient. In addition, existed data showed that hyperhomocysteinemia may be risky for ischemic stroke [12-13]. Accordingly, we noticed the homocysteine level of this patient is far beyond the normal value (0-20 μmol/L) and the treatment with folic acid tablets and methylcobalamin capsules was quite successful. The treatment of brainstem infarction mostly relies on drugs and works poorly in most cases. For stroke in young, function recovery is critically required. Therefore, a personalized rehabilitation training was given to this patient immediately after acute treatment and last for 4.5 months [14-17]. An optimistic result, including the regain of postural balance and ability of daily life as well as the reverse of homocysteine level was achieved. In summary, stroke in young patient requires different approach to investigate and management. The recovery from stroke in young patient is quicker and better than that for older adults. To our knowledge, this is the first report of ischemic brainstem stroke in patient younger than 30 years. Our experience leads us to call for more cases and new strategies for diagnosing and treatment of stroke in lower age.

Funding

This research was partially supported by the National Nature Science Foundation of China (Grant No. 81870981 and 82171389).

Disclosure

All authors declared no conflict of interest.

References

1. Hatano S. Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ 54 (1976): 541-553.
2. Bamford J, Sandercock P, Dennis M, et al. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry 51 (1988): 1373-1380.
3. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation 127 (2013): e6-e245.
4. Singhal AB, Biller J, Elkind MS, et al. Recognition and management of stroke in young adults and adolescents. Neurology 81 (2013): 1089-1097.
5. Kissela BM, Khoury JC, Alwell K, et al. Age at stroke: temporal trends in stroke incidence in a large, biracial population. Neurology 79 (2012): 1781-1787.
6. Arntz RM, van Alebeek ME, Synhaeve NE, et al. The very long-term risk and predictors of recurrent ischaemic events after a stroke at a young age: The FUTURE study. Eur Stroke J 1 (2016): 337-345.
7. Babtain, Fawzi A, et al. Stroke Etiology Varies with Age in Patients Younger than 50 Years: Assessment of Stroke Etiology and Classifications in Young Saudi Patients. American Journal of Medicine and Medical Sciences 4 (2014): 14-18.
8. Adams HP, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24 (1993): 35-41.
9. van Alebeek ME, Arntz RM, Ekker MS, et al. Risk factors and mechanisms of stroke in young adults: The FUTURE study. J Cereb Blood Flow Metab 38 (2018): 1631-1641.
10. Mackay MT, Wiznitzer M, Benedict SL, et al. Arterial ischemic stroke risk factors: the International Pediatric Stroke Study. Ann Neurol 69 (2011): 130-140.
11. Smajlovic D. Strokes in young adults: epidemiology and prevention. Vasc Health Risk Manag 11 (2015): 157-164.
12. Yang G, Wang Y, Zeng Y, et al. Rapid health transition in China, 1990-2010: findings from the global burden of disease study 2010. Lancet 381 (2013): 1987-2015.
13. Zhang T, Jiang Y, Zhang S, et al. The association between homocysteine and ischemic stroke subtypes in Chinese: A meta-analysis. Medicine (Baltimore) 99 (2020): e19467.
14. Schmid AA, Van Puymbroeck M, Altenburger PA, et al. Balance is associated with quality of life in chronic stroke. Top Stroke Rehabil 20 (2013): 340-346.
15. Krakauer JW, Carmichael ST, Corbett D, et al. Getting neurorehabilitation right: what can be learned from animal models? Neurorehabil Neural Repair 26 (2012): 923-931.
16. Stinear C, Ackerley S, Byblow W. Rehabilitation is initiated early after stroke, but most motor rehabilitation trials are not: a systematic review. Stroke 44 (2013): 2039-2045.
17. Yang ZX, Bian JL, Xu JF, et al. Multi-central controlled study on acupuncture for treatment of cerebral infarction in restoration stage. Zhongguo Zhen Jiu 28 (2008): 239-243.