Sandra Pinto de Souza-Ataxia-(Unite States)

Patient Name: Sandra Pinto de Souza
Gender: Female
Age: 61 years old
Nationality: Unite States
Diagnosis: Ataxia

Pre-treatment:
This patient was admitted due to "progressive balance disorders with hoarseness for 7 years" and was diagnosed with ataxia. Her main symptoms include the onset of balance disorders with hoarseness, progressive development, inability to stand and walk independently, poor fine motor skills, decreased vision, and no headaches, nausea, vomiting, etc. She has a history of diabetes and hypertension for 7 years, underwent gallbladder removal surgery 5 years ago, and had a tibia fracture surgery 3 years ago. Her mother had similar symptoms in the family.

Physical examination at admission:
The patient's blood pressure was 150/95 mmHg, and the pulse rate was 90 beats per minute. She had a diabetic appearance. There was a scar on her right lower leg after tibia fracture surgery. Mild cyanosis was observed on her lips. Mild congestion was seen in her pharynx, and no enlarged tonsils were noted. Clear breath sounds were heard in both lungs without any dry or wet rales. Strong heart sounds were heard, and no significant murmurs were detected in the auscultation areas of the valves. Her abdomen was soft, with no tenderness or rebound tenderness, and the liver and spleen were not palpable. There were no deformities in her limbs and spine, and no edema in the lower extremities.

Neurological examination:
The patient was alert, with hoarseness and slow speech. Her memory, calculation, and orientation were normal. The pupils were equal and reactive, with a diameter of 3.0 mm. Limited upward gaze was observed in her left eye. Horizontal and vertical nystagmus were present in both eyes, and convergence was basically normal. Her forehead was symmetrical, and she had strong eyelid closure. She had deep nasolabial grooves, no deviation of the mouth angle, strong chewing, no air leakage when puffing cheeks, sluggish gag reflex, occasional choking during eating and drinking. She had strong neck flexion and shoulder shrug. The muscle strength of her upper limbs was grade 5, with no resting tremor but slight difficulty in writing. The muscle strength of her lower limbs was grade 5, with difficulty in turning over independently and unable to sit up or stand independently. The muscle tone in all limbs was normal, and the tendon reflexes were significantly reduced. Positive Babinski sign was observed on both sides. Decreased pain sensation in both feet, while other deep and superficial sensations were mostly normal. The finger-to-nose test and finger-to-finger test showed poor stability on both sides, and the rapid alternating movement test was slow and clumsy. The heel-knee-shin test was unstable on both sides. She couldn't walk independently or stand on one leg, and even with assistance, she had difficulty walking, wide-based gait, abnormal gait, instability, and a tendency to fall. Positive Romberg's sign with her eyes closed. Negative meningeal irritation sign.

Treatment process:
The patient received CAST therapy and combined treatment with neural stem cells and mesenchymal stem cells to repair cranial nerves, improve nerve nutrition, enhance the internal environment, regulate immunity, and undergo rehabilitation training.

Post-treatment:
The patient's articulation became clear, and hoarseness significantly reduced. Her balance and motor function improved significantly. She could independently turn over and sit up, stand independently, walk short distances independently, and walk longer distances with slight assistance. She could perform turning movements while walking. The tendon reflexes in her limbs basically returned to normal. The finger-to-nose test and finger-to-finger test mostly returned to normal. The speed and accuracy of the rapid alternating movement test and heel-knee-shin test significantly improved compared to before treatment. The Romberg's sign with her eyes closed turned negative. Her eye movements were no longer restricted. Horizontal and vertical nystagmus significantly decreased. Her energy, physical fitness, and endurance improved significantly.