Case presentation

Int. 8831124 Int. 8831124 顏志維顏志維

Chief complaintChief complaint

A 44 year old man complained right A 44 year old man complained right side weakness and dysphasia this side weakness and dysphasia this morning.morning.

Patient profilePatient profile

Right handedRight handed Smoker 1 pack per day > 20 yearsSmoker 1 pack per day > 20 years Alcohol occasionally takeAlcohol occasionally take His mother had hypertension (HTN)His mother had hypertension (HTN) No chronic drug using historyNo chronic drug using history

Brief historyBrief history

Right upper limb weakness for 1 weekRight upper limb weakness for 1 week Right side deviation when driving and Right side deviation when driving and

walkingwalking In the morning of admission, poor In the morning of admission, poor

response was noted when talking.response was noted when talking. Facial palsy was noted also.Facial palsy was noted also.

Physical examinationPhysical examination

Vital signs : BT: 36.9^C PR: 65 /min RR: Vital signs : BT: 36.9^C PR: 65 /min RR: 18 /min BP: 136 / 79 mmHg18 /min BP: 136 / 79 mmHg

Consciousness : alertConsciousness : alert Head: no trauma scar, no ecchymosisHead: no trauma scar, no ecchymosis Neck carotid artery bruit : not auditable Neck carotid artery bruit : not auditable Chest : clear BS, no ralesChest : clear BS, no rales Heart : Heart : regular heart beat, no murmurregular heart beat, no murmur Abdomen: soft, no tendernessAbdomen: soft, no tenderness Peripheral pulse : strongPeripheral pulse : strong

Higher cerebral functionHigher cerebral function

JudgmentJudgment OrientationOrientation MemoryMemory AbstractAbstract CalculateCalculate

– Generally intactGenerally intact

Cranial nerve (CN)Cranial nerve (CN)

CN II : visual accuracy intactCN II : visual accuracy intact CN III, IV, VI : ocular motor intactCN III, IV, VI : ocular motor intact CN V : facial numbness nil, CN V : facial numbness nil,

temporalis intacttemporalis intact CN VII : rightCN VII : right lower facial palsylower facial palsy CN VIII : intact in auditory functionCN VIII : intact in auditory function CN IX, X : intactCN IX, X : intact CN XI : intactCN XI : intact

Motor functionMotor function

Muscle power : right 4 / left 5Muscle power : right 4 / left 5 Muscle tone : no rigidity, no Muscle tone : no rigidity, no

spasticityspasticity Deep tendon reflex : right ++/ left +Deep tendon reflex : right ++/ left +

+ symmetrically+ symmetrically Plantar response : right down / left Plantar response : right down / left

downdown

Sensory functionSensory function

Generally intactGenerally intact

DysphasiaDysphasia

Non-fluent, hesitant speechNon-fluent, hesitant speech Repeated a few utterancesRepeated a few utterances Good comprehensionGood comprehension Handwriting poor Handwriting poor

Lab dataLab data

TG 158 mg/dl ; TCH TG 158 mg/dl ; TCH 231231 mg/dl mg/dl BUN / Cre 18 / 1.0 mg/dlBUN / Cre 18 / 1.0 mg/dl GLU GLU 351351 mg/dl mg/dl Na/ K 133 / 4.3 mmol/LNa/ K 133 / 4.3 mmol/L WBC 5.82 *10^3/ulWBC 5.82 *10^3/ul HbA1c HbA1c 11.211.2 % % Stool exam : Stool exam : OB strong positiveOB strong positive

ImpressionImpression

Acute onsetAcute onset right hemiparesis and right hemiparesis and motor aphasia plus facial palsy with motor aphasia plus facial palsy with stepwise coursestepwise course– Localized in Localized in frontal to pariatal cortexfrontal to pariatal cortex

Suspect Suspect strokestroke

Chest X-rayChest X-ray

Brain CTBrain CT

Transcranial Doppler, Transcranial Doppler, Carotid Duplex Carotid Duplex

The carotid duplex study showed The carotid duplex study showed neither plaques nor tortuosity. neither plaques nor tortuosity.

The flow patterns were all normal. The flow patterns were all normal. It implies normal study. It implies normal study.

MRI DWIMRI DWI

MRA- MRA- L’t ICA stenosis, cavernous L’t ICA stenosis, cavernous portionportion

DiagnosisDiagnosis

Neurological defect + image study Neurological defect + image study proved -> cerebral infarctionproved -> cerebral infarction

DiabetesDiabetes HyperlipidemiaHyperlipidemia

Stroke -U.S. DataStroke -U.S. Data

Management of acute Management of acute strokestroke

1. prevent progress of present event1. prevent progress of present event 2. prevent immediate complications2. prevent immediate complications 3. prevent subsequent events3. prevent subsequent events 4. to rehabilitate the patient4. to rehabilitate the patient

As this patientAs this patient

Well known control diabetes and lipidWell known control diabetes and lipid

What current treatment exist?What current treatment exist? What is the choice and their What is the choice and their

evidence?evidence?

Current treatmentCurrent treatment

Medication Medication – Antiplatelet and anticoagulantAntiplatelet and anticoagulant

Invasive procedureInvasive procedure– 1. surgical (EC/IC bypass)1. surgical (EC/IC bypass)– 2. intracranial angioplasty2. intracranial angioplasty

The EBMThe EBM

Antithrombin III

Plasmin

Plasminogen tPA, urokinase

Heparin

Fragmin

Warfarin(Vit. K 2,7,9,10)

Protein C(Protein S)

aspirinticlopidinclopidogrel

MedicationMedication

Anticoagulant agents : Anticoagulant agents : 1. heparin 1. heparin 2. warfarin2. warfarin Antiplatelet agents :Antiplatelet agents : 1. aspirin1. aspirin 2. ticlopidin2. ticlopidin 3. clopidogrel3. clopidogrel 4. dipyridamole4. dipyridamole

Anticoagulant or antiplatelet Anticoagulant or antiplatelet ??

Aspirin superior to warfarin in death Aspirin superior to warfarin in death rate, cardiac event and hemorrhagic rate, cardiac event and hemorrhagic rate. (grade A) rate. (grade A) The WASID Studies 2005 Mar. The WASID Studies 2005 Mar. NEJMNEJM

Clopidogrel was more effective than Clopidogrel was more effective than Aspirin in reducing the risk of Aspirin in reducing the risk of ischaemic stroke, myocardial ischaemic stroke, myocardial infarction, or vascular death. (grade infarction, or vascular death. (grade A) A) The CAPRIE studies Lancet 1996 Nov.The CAPRIE studies Lancet 1996 Nov.

TiclopidineTiclopidine

Ticlopidine is not more effective than Ticlopidine is not more effective than aspirin but increasing TTP, aspirin but increasing TTP, neutropenia, skin rash and diarrhea neutropenia, skin rash and diarrhea rate. (Grade A)rate. (Grade A)– Stroke Stroke

20002000

DipyridamoleDipyridamole

Dipyridamole and aspirin showed Dipyridamole and aspirin showed similar effect in reduction stroke risk similar effect in reduction stroke risk (16% : 18%) and combination (16% : 18%) and combination therapy showed more effective therapy showed more effective (37%) grade A (37%) grade A

ESPS2. J Neurol Sci ESPS2. J Neurol Sci

19961996

Medication conclusionMedication conclusion

Dipyridamole + Aspirin > Aspirin or Dipyridamole + Aspirin > Aspirin or DipyridamoleDipyridamole– treatment effective for prevent treatment effective for prevent

stroke stroke Aspirin > TiclopidineAspirin > Ticlopidine Clopidogrel > AspirinClopidogrel > Aspirin

Other specific therapiesOther specific therapies 1. Surgical Revascularization : 1. Surgical Revascularization : EC/IC Bypass Trial (Extracranial to EC/IC Bypass Trial (Extracranial to

Intracranial). (grade A)Intracranial). (grade A) 1377 patients 71 centers, 714 with 1377 patients 71 centers, 714 with

medical control, while 663 receive medical control, while 663 receive STA-MCA bypass plus medicationSTA-MCA bypass plus medication

Failed to show definite benefit in this Failed to show definite benefit in this studystudy– NEJM 1985NEJM 1985. .

Other specific therapiesOther specific therapies

2. Intracranial angioplasty and 2. Intracranial angioplasty and Stenting Stenting

Use balloon Use balloon Use stentUse stent Use balloon + stentUse balloon + stent Stroke rate and their risksStroke rate and their risks

Intracranial Angioplasty and Stent Placement for Cerebral Atherosclerosis Grade B J Vasc Interv Radiol, January 2004

Angioplasty (grade C)Angioplasty (grade C)

Use balloon without stent :Use balloon without stent : The peri-procedural death and stroke The peri-procedural death and stroke

rate was 8.3%rate was 8.3% The annual stroke rate was 3.36%The annual stroke rate was 3.36% A residual stenosis of > or =50% it A residual stenosis of > or =50% it

was 4.5%. was 4.5%. – American Journal of Neuroradiology, March American Journal of Neuroradiology, March

20052005

SSYLVIA Trial (grade B)SSYLVIA Trial (grade B)

Stenting of SYmptomatic Stenting of SYmptomatic atherosclerotic Lesions in the atherosclerotic Lesions in the Vertebral or Intracranial Arteries.Vertebral or Intracranial Arteries.

Enrolled symptoms attributed to a Enrolled symptoms attributed to a single target lesion of > 50% stenosis single target lesion of > 50% stenosis 61Pts 61Pts

Risk: peri-procedure mortality 0%Risk: peri-procedure mortality 0% Benefit: recurrent stroke 30 days after Benefit: recurrent stroke 30 days after

procedure 7.3% procedure 7.3% – Stroke 2004Stroke 2004

WINGSPAN Trial (grade B)WINGSPAN Trial (grade B)

Combination of balloon dilatation and Combination of balloon dilatation and microstent 15 microstent 15 patientspatients

Symptomatic with intracranial stenosis Symptomatic with intracranial stenosis All patients were either stable or All patients were either stable or

improved 4 weeks after the treatment.improved 4 weeks after the treatment.– The Wingspan Study. Neuroradiology The Wingspan Study. Neuroradiology

20042004

WINGSPAN Trial (grade B)WINGSPAN Trial (grade B)

2005 update to this study 2005 update to this study 45 medically refractory,>50% 45 medically refractory,>50%

stenosis Ptsstenosis Pts Peri-procedure risk: stroke and death Peri-procedure risk: stroke and death

4.4%4.4% Benefit : 7.1% six-month stroke and Benefit : 7.1% six-month stroke and

death rate. death rate.

Intracranial angioplastyIntracranial angioplasty

Current opinion: Current opinion: Apply in > 50% occlusion patientsApply in > 50% occlusion patients Keep medication use Keep medication use Stenting or Stenting after balloon Stenting or Stenting after balloon

could made acceptable risk / benefit could made acceptable risk / benefit resultresult

Risk: 5% death or strokeRisk: 5% death or stroke Benefit: 7% six-month stroke and Benefit: 7% six-month stroke and

deathdeath

Back to our patientBack to our patient

Apply Apply Aspirin and DipyridamoleAspirin and Dipyridamole If If angiography proved > 50% angiography proved > 50%

intracranial stenosisintracranial stenosis plus plus predict predict stroke recurrence rate was highstroke recurrence rate was high (poor controlled DM HTN and (poor controlled DM HTN and hyperlipidemia), I would suggest hyperlipidemia), I would suggest angioplasty for lowering his risk of angioplasty for lowering his risk of death and stroke rate.death and stroke rate.

CommentsComments

李宜恭主任：李宜恭主任：1. 1. 報告時間過長，雖然資料很豐富，但無法報告時間過長，雖然資料很豐富，但無法 扼要說明主題的重點。扼要說明主題的重點。2. 2. 證據等級的分類及依據，請適時加以說明。證據等級的分類及依據，請適時加以說明。

劉耿彰醫師：資料內容需再消化。劉耿彰醫師：資料內容需再消化。 許明欽醫師：時間控制不佳。許明欽醫師：時間控制不佳。

Thanks a lot !