Case presentation

1. Case presentation Int. 8831124 顏志維

2. Chief complaint • A 44 year old man complained right side weakness and dysphasia this morning.

3. Patient profile • Right handed • Smoker 1 pack per day > 20 years • Alcohol occasionally take • His mother had hypertension (HTN) • No chronic drug using history

4. Brief history • Right upper limb weakness for 1 week • Right side deviation when driving and walking • In the morning of admission, poor response was noted when talking. • Facial palsy was noted also.

5. Physical examination • Vital signs : BT: 36.9^C PR: 65 /min RR: 18 /min BP: 136 / 79 mmHg • Consciousness : alert • Head: no trauma scar, no ecchymosis • Neck carotid artery bruit : not auditable • Chest : clear BS, no rales • Heart : regular heart beat, no murmur • Abdomen: soft, no tenderness • Peripheral pulse : strong

6. Higher cerebral function • Judgment • Orientation • Memory • Abstract • Calculate • Generally intact

7. Cranial nerve (CN) • CN II : visual accuracy intact • CN III, IV, VI : ocular motor intact • CN V : facial numbness nil, temporalis intact • CN VII : rightlower facial palsy • CN VIII : intact in auditory function • CN IX, X : intact • CN XI : intact

8. Motor function • Muscle power : right 4 / left 5 • Muscle tone : no rigidity, no spasticity • Deep tendon reflex : right ++/ left ++ symmetrically • Plantar response : right down / left down

9. Sensory function • Generally intact

10. Dysphasia • Non-fluent, hesitant speech • Repeated a few utterances • Good comprehension • Handwriting poor

11. Lab data • TG 158 mg/dl ; TCH 231 mg/dl • BUN / Cre 18 / 1.0 mg/dl • GLU 351 mg/dl • Na/ K 133 / 4.3 mmol/L • WBC 5.82 *10^3/ul • HbA1c 11.2 % • Stool exam : OB strong positive

12. Impression • Acute onset right hemiparesis and motor aphasia plus facial palsy with stepwise course • Localized in frontal to pariatal cortex • Suspect stroke

13. Chest X-ray

14. Brain CT

15. Transcranial Doppler, Carotid Duplex • The carotid duplex study showed neither plaques nor tortuosity. • The flow patterns were all normal. • It implies normal study.

16. MRI DWI

17. MRA- L’t ICA stenosis, cavernous portion

18. Diagnosis • Neurological defect + image study proved -> cerebral infarction • Diabetes • Hyperlipidemia

19. Stroke -U.S. Data

20. Management of acute stroke • 1. prevent progress of present event • 2. prevent immediate complications • 3. prevent subsequent events • 4. to rehabilitate the patient

21. As this patient Well known control diabetes and lipid • What current treatment exist? • What is the choice and their evidence?

22. Current treatment • Medication • Antiplatelet and anticoagulant • Invasive procedure • 1. surgical (EC/IC bypass) • 2. intracranial angioplasty

23. The EBM

24. Warfarin (Vit. K 2,7,9,10) Protein C (Protein S) Fragmin Antithrombin III Heparin Plasmin tPA, urokinase Plasminogen

25. aspirin ticlopidin clopidogrel

26. Medication • Anticoagulant agents : • 1. heparin • 2. warfarin • Antiplatelet agents : • 1. aspirin • 2. ticlopidin • 3. clopidogrel • 4. dipyridamole

27. Anticoagulant or antiplatelet ? • Aspirin superior to warfarin in death rate, cardiac event and hemorrhagic rate. (grade A) The WASID Studies 2005 Mar. NEJM • Clopidogrel was more effective than Aspirin in reducing the risk of ischaemic stroke, myocardial infarction, or vascular death. (grade A) The CAPRIE studies Lancet 1996 Nov.

28. Ticlopidine • Ticlopidine is not more effective than aspirin but increasing TTP, neutropenia, skin rash and diarrhea rate. (Grade A) • Stroke 2000

29. Dipyridamole • Dipyridamole and aspirin showed similar effect in reduction stroke risk (16% : 18%) and combination therapy showed more effective (37%) grade A ESPS2. J Neurol Sci 1996

30. Medication conclusion • Dipyridamole + Aspirin > Aspirin or Dipyridamole • treatment effective for prevent stroke • Aspirin > Ticlopidine • Clopidogrel > Aspirin

31. Other specific therapies • 1. Surgical Revascularization : • EC/IC Bypass Trial (Extracranial to Intracranial). (grade A) • 1377 patients 71 centers, 714 with medical control, while 663 receive STA-MCA bypass plus medication • Failed to show definite benefit in this study • NEJM 1985.

32. Other specific therapies • 2. Intracranial angioplasty and Stenting • Use balloon • Use stent • Use balloon + stent • Stroke rate and their risks

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

34. Angioplasty (grade C) • Use balloon without stent : • The peri-procedural death and stroke rate was 8.3% • The annual stroke rate was 3.36% • A residual stenosis of > or =50% it was 4.5%. • American Journal of Neuroradiology, March 2005

35. SSYLVIA Trial (grade B) • Stenting of SYmptomatic atherosclerotic Lesions in the Vertebral or Intracranial Arteries. • Enrolled symptoms attributed to a single target lesion of > 50% stenosis 61Pts • Risk: peri-procedure mortality 0% • Benefit: recurrent stroke 30 days after procedure 7.3% • Stroke 2004

36. WINGSPAN Trial (grade B) • Combination of balloon dilatation and microstent 15 patients • Symptomatic with intracranial stenosis • All patients were either stable or improved 4 weeks after the treatment. • The Wingspan Study. Neuroradiology 2004

37. WINGSPAN Trial (grade B) • 2005 update to this study • 45 medically refractory,>50% stenosis Pts • Peri-procedure risk: stroke and death 4.4% • Benefit : 7.1% six-month stroke and death rate.

38. Intracranial angioplasty • Current opinion: • Apply in > 50% occlusion patients • Keep medication use • Stenting or Stenting after balloon could made acceptable risk / benefit result • Risk: 5% death or stroke • Benefit: 7% six-month stroke and death

39. Back to our patient • Apply Aspirin and Dipyridamole • If angiography proved > 50% intracranial stenosis plus predict stroke recurrence rate was high (poor controlled DM HTN and hyperlipidemia), I would suggest angioplasty for lowering his risk of death and stroke rate.

40. Comments • 李宜恭主任： 1. 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。 2. 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。 • 許明欽醫師：時間控制不佳。

41. Thanks a lot !