A 53-year-old man fell down the stairs by accident and was hospitalized with TBI in the general ward of the neurology department at the Yaan Second People's Hospital. The swelling of his head and face was obvious, especially on the right side, and he had a typical left raccoon eye (Supplementary Figure 1). The brain computed tomography (CT) on admission showed two parts of abnormal increased signal in the bilateral temporal lobe and frontal lobe, and they might be confused with hemorrhage (Figures 1A,B). In addition, there was discontinuity, respectively, in the left orbital bone, the right cranial parietal bone, and the cranial temporal bone (Figures 1C-E). He was diagnosed with multiple injuries (the face, chest, and lower limbs), traumatic subarachnoid hemorrhage, bilateral frontotemporal lobe brain contusion, right temporoparietal and left orbital bone fractures, and right temporoparietal occipital scalp hematoma, right rib fracture, pulmonary contusion and multiple contusions of lower limbs. The patient was treated well-symptomatically and discharged more than 1 month later. The signal of the previous abnormal parts in the CT changed to low density, they might be manifestations of bleeding absorption (Figures 1F,G). However, pains persisted in the left forehead, especially a few days before the second hospitalization. During the previous month, the right limb occurred weakness twice, which continued for 5 min, but he did not go to hospital. Later, he complained that right limb weakness for more than 4 h and was admitted to our neurology ward at the Yaan People's Hospital. The patient's symptoms continued to worsen. Moreover, he responded slowly, and showed slurred speech, headache, and dizziness. There were no obvious symptoms of fever, dyspnea, gaze, or movement disturbance of other parts. He denied any history of hypertension, diabetes, hyperlipidemia, coronary heart disease, etc. His family had no other history of related diseases.
The physical examination revealed his blood pressure of 150/85 mmHg, and a respiratory rate of 20 breaths per minute. The general condition of the patient was fair, and he had normal auscultatory findings of his heart and lungs. The other general physical examination was normal. The neurological examination showed that his eyes had sensitive to direct and indirect light reflex. However, the right nasolabial fold became shallow, and the tongue stuck out to the right. The neck was soft, the meningeal irritation sign was negative. In the physical movement examination, he could not hold objects with the right upper limb and could not stand and walk. The muscle strength of the right limb was grade 1, and the muscle strength of the left limb was grade 5. The pathological signs of the right side were positive. He had no limbs convulsions. No other focal neurological deficits were elicited. His ability of memory, calculation, time and space orientation all descended. He refused to do the other coordination movement examinations due to inconvenience.
In the imaging examination, the brain CT displayed multiple pieces of decreased signal in the left cerebral hemisphere, this indicated the possibility of AIS (Figure 2A). The artery and angiography exhibited that the M1 segment of the left middle cerebral artery (LMCA) was partially interrupted, and distal blood flow reduced significantly (Figure 2B). The Alberta Stroke Program Early CT Score (ASPECTS) was 8. Moreover, the value of blood glucose was 8.26 mmol/L. The other tests showed normal generally, including the blood test, the biochemical test, the urine test, the stool test, the myocardial enzyme test, and the coagulation test.
After completing various examinations, his National Institute of Health Stroke Scale (NIHSS) score was 13 and Modified Rankin Scale (MRS) score was grade 4. He had clear indications for emergency endovascular treatment and agreed with the interventional operation. The angiography showed there was dissection in the M1 segment of the LMCA (Figure 2C). The result showed that IAD was formed in the patient. He was operated on with balloon dilation and the self-expanding stent of the LMCA under general anesthesia. During the operation, the 3.5*20 mm intracranial self-expanding stent was released, and the LMCA was completely reanalyzed (Figure 2D). The patient was finally diagnosed with AIS and IAD (the M1 segment of the LMCA). The patient recovered well after surgery. Post-operative imaging showed no obvious abnormality, and the lesion gradually recovered (Supplementary Figures 2A,B). After 3 days, he was transferred to our general ward for rehabilitation. During treatment, he was given the aspirin tablet (100 mg once a day) and the clopidogrel tablet (75 mg once a day) to reduce the risk for progressive thrombosis, the atorvastatin tablet (20 mg once a day) to regulate lipid and stabilize plaque, the mannitol injection (125 ml once every 8 h) by intravenous and the furosemide injection (10 mg once every 12 h) to dehydrate and lower intracranial pressure. Subsequently, he requested to be discharged after the clinical symptoms were relieved (Supplementary Video 1), and his NIHSS score was 2 and MRS score was grade 0. Hereafter, we maintained telephone communication with him, and we asked him to take medication and rehabilitation on time. The patient is recovering well.