Mirosh Agaraj-Spinocerebellar ataxia-(Albanian)

Patient Name: Mirosh Agaraj
Gender: Male
Age: 34 years
Nationality: Albanian
Diagnosis: Spinocerebellar ataxia

Admission Condition:
The patient was admitted with the main complaint of "abnormal gait, instability while walking, and slurred speech for over 7 years," diagnosed with "spinocerebellar ataxia." He had previously undergone kidney and appendectomy surgeries due to kidney stones and appendicitis, with a good recovery. He denied any other history of genetic or infectious diseases.

Admission Examination:
The patient's blood pressure was 121/71 mmHg, heart rate was 66 beats per minute, height was 178 cm, weight was 76 kg, and he was well-nourished. Cardiac and abdominal examinations were unremarkable.

Neurological Examination:
The patient was alert and in good spirits. His speech was unclear, with mild explosive speech. His memory and calculation abilities were normal. Both pupils measured 3 mm in diameter and reacted sensitively to light. During lateral gaze, horizontal nystagmus was observed; his vision and visual fields were normal. His forehead lines were symmetrical, chewing was strong, and both nasolabial folds were deep, with no facial asymmetry. His soft palate elevation was strong, and the uvula was midline. He demonstrated strong cheek puffing and a midline protruding tongue. Hearing was normal. Neck rotation and shoulder elevation were symmetrical and strong. Muscle strength in all four limbs was approximately 4+. Muscle tone in all four limbs was mostly normal. Tendon reflexes were diminished, and pathological reflexes were negative. Deep and superficial sensations were normal. The bilateral finger-nose test was unsteady, the rapid alternating movement test was clumsy, and the heel-to-shin test was unsteady. The Romberg test (with eyes closed) was positive for instability, while both eyes open and closed were positive. He had an unstable stance with a wide base, could not stand on one foot, and struggled with standing on tiptoes, indicating poor balance. Meningeal signs were negative.

Treatment Process:
The patient was clearly diagnosed with "Spinocerebellar ataxia (SCA)" upon admission. He received CAST treatment, along with a combination of neural stem cells and mesenchymal stem cells to repair cerebellar and spinal cord nerve lesions, nourish nerves, improve the internal environment, and provide immune regulation. This was complemented by comprehensive rehabilitation therapy.

Post-Treatment:
The patient's mental state and energy levels improved significantly. His balance and coordination functions were notably enhanced. The speed and agility of his bilateral rapid alternating movement test improved significantly, and he performed the finger-nose test with much better stability. His heel-to-shin test was stable, and the Romberg test (eyes closed) was nearly negative; he could stand on one foot for about 10 seconds. His pronunciation was noticeably clearer compared to admission. Muscle strength in his all four limbs increased to grade 5.