Man, 49, Overcomes Walking Instability Caused by Ataxia Through Timely Medical Intervention and Drug Therapy

Understanding a Real-World Case of Ataxia Linked to Lacunar Infarction

In this clinical case study, we explore the journey of Mr. Wang, a 49-year-old male patient who presented with sudden-onset gait instability due to ataxia caused by bilateral lacunar cerebral infarctions. With a history of poorly managed hypertension and type 2 diabetes, Mr. Wang's condition highlights the importance of early diagnosis and prompt treatment in preventing long-term neurological damage. After being admitted to the Second Affiliated Hospital of Harbin Medical University in January 2022, he underwent a comprehensive treatment plan that included intravenous thrombolysis and oral maintenance medications. His symptoms significantly improved within one week, demonstrating the effectiveness of timely medical intervention.

Patient Profile and Clinical Presentation

Age & Gender: 49-year-old maleDiagnosis: Ataxia secondary to bilateral lacunar infarctsHospital: Second Affiliated Hospital of Harbin Medical UniversityTreatment Duration: 7 days inpatient careTherapeutic Approach: Intravenous thrombolytic therapy combined with antiplatelet agents, neuroprotective drugs, lipid-lowering medication, and chronic disease management

Initial Assessment: Recognizing the Signs of Acute Neurological Distress

Mr. Wang arrived at the emergency department just two hours after experiencing sudden difficulty walking. He described an inability to walk in a straight line, accompanied by body swaying, dizziness, nausea, and two episodes of vomiting containing gastric contents. Notably, while limb movement remained intact, he reported occasional misjudgment when reaching for objects—indicative of impaired coordination.

Physical examination revealed stable vital signs: temperature 36.4°C, blood pressure 170/95 mmHg, heart rate 75 bpm, respiratory rate 18 breaths per minute. The patient was alert and spoke fluently. However, clinicians observed horizontal and rotational nystagmus during eye movement testing. Muscle strength in all extremities was normal, but both upper limbs and trunk showed clear signs of ataxia. Given his history of uncontrolled diabetes and hypertension, these findings raised immediate concern for cerebrovascular pathology.

Diagnostic Workup and Confirmation of Stroke

A non-contrast head CT scan was performed immediately upon admission, revealing multiple small areas of ischemic change consistent with bilateral lacunar infarcts—small strokes located deep within the brain tissue, often linked to chronic vascular risk factors like high blood pressure and hyperglycemia.

Given the acute onset and time window eligibility (within 4.5 hours of symptom onset), the medical team discussed intravenous thrombolysis using Alteplase (recombinant tissue plasminogen activator) with the patient and his family. Informed consent was obtained, and treatment commenced promptly under continuous cardiac and oxygen saturation monitoring.

Comprehensive Treatment Strategy for Optimal Recovery

The therapeutic regimen was designed not only to address the acute stroke event but also to stabilize underlying metabolic conditions and prevent recurrence:

Intravenous Medications: Alteplase for clot dissolution; Dengzhan Xixin Injection to enhance microcirculation; Edaravone to neutralize free radicals and protect neural tissue.
Oral Maintenance Therapies: Clopidogrel bisulfate for platelet inhibition; Pravastatin sodium for cholesterol reduction; Folic acid and Vitamin B12 to support nerve health; Metformin hydrochloride for glycemic control; Valsartan tablets to manage blood pressure.

This multimodal approach targeted both immediate neuroprotection and long-term cardiovascular risk mitigation—a critical component in patients with comorbid metabolic disorders.

Positive Treatment Outcomes After One Week of Care

Six hours post-thrombolysis, a follow-up CT scan confirmed no hemorrhagic transformation, ruling out complications from the clot-busting drug. Over the next seven days, Mr. Wang experienced steady improvement:

His gait instability gradually resolved, allowing him to walk steadily without assistance. Dizziness, nausea, and vomiting subsided significantly. Blood glucose levels stabilized under medication, and blood pressure trends showed better control. By day seven, he met discharge criteria based on clinical stability and functional improvement.

Before discharge, the healthcare team emphasized the importance of outpatient follow-up in one month, including repeat blood tests (CBC, liver and kidney function panels) and continued rehabilitation guidance.

Key Recommendations for Post-Discharge Management

Lifestyle Modifications and Ongoing Monitoring

To reduce the risk of recurrent stroke and further neurological decline, Mr. Wang was advised to adopt several lifestyle changes:

Maintain strict adherence to prescribed antihypertensive and antidiabetic medications.
Monitor blood pressure regularly at home and adjust therapy in consultation with a physician.
Perform self-monitoring of blood glucose—measuring seven times on one day weekly—to assess glycemic control and guide endocrinology follow-ups.
Attend scheduled appointments for lab work and specialist evaluations.
Eliminate smoking and alcohol consumption entirely.
Adopt a heart-healthy diet low in saturated fats, sodium, and processed or spicy foods.

Additionally, due to residual dizziness, he was cautioned against engaging in physically demanding tasks or operating vehicles until fully cleared by his neurologist—ensuring personal safety and public well-being.

Clinical Insights: Why Early Action Saves Brain Function

This case underscores a crucial message in modern stroke care: time is brain. While initial imaging ruled out hemorrhage, the presence of ataxia, nystagmus, and vascular risk factors pointed strongly toward ischemic stroke. Even though some cases of gait imbalance may be mistaken for vertigo or inner ear issues, clinicians must maintain a high index of suspicion for cerebrovascular events—especially in middle-aged patients with comorbidities.

Thanks to rapid triage, accurate diagnosis, and evidence-based interventions—including IV thrombolysis—the patient avoided severe disability. This outcome reinforces current guidelines recommending that anyone experiencing sudden neurological symptoms seek emergency care immediately.

Furthermore, managing modifiable risk factors such as hypertension and diabetes remains foundational in stroke prevention. Public education about warning signs—like sudden imbalance, slurred speech, facial drooping, or limb weakness—can empower individuals to act fast and improve survival and recovery rates.