Case presentationCase presentationDate: 2005/10/7Speaker: Intern Supervisor: Dr.

The patientThe patient

General data

Number:Q120243470 Name:x Sex: male Age: 38 year-old Date of admission: 2005/09/18

Chief complaint

Progressive intermittent speech disturbance for 2 weeks with recent worsening in 2~3 day

Brief historyUnderlie disease

Denied hypertension, DM Smoking(+)

Admitted on 2005/7/23 due to right hand weakness Left intracranial ICA stenosis

Regular follow-up at neurologists outpatient department

Admitted on 2005/9/8

Admission in July

Chief complaint and symptoms/ signs Stepwise downhill of right hand weakness in this

mid-July. Stuttered speech was once noticed but no more after

admission PE

Right hand muscle power: MRC grade 2 Heart: RHB, no murmurs No carotid bruits No conjunctival petechiae, no petechiae at finger, toe

tips

Laboratory survey Hct: 46.8%, WBC: 9.58x10^3 Hypertriglyceredemia (TCH: 336 mg/dL, HDL: 31

mg/dL) INR: 0.98, aPTT: 28.6/28.9 Indicator of autoimmune disease and

hyperchoaglatory status within normal range ESR, CRP, ANCA, ds-DNA, SSA, SSB, RA, protein C,

protein S, antihrombin III, C3, C4, PR3, MPO, cold HA, cryoglobin, homocystein, except for ACA-CT

Brain CT Multiple cortical infarctions over left high frontoparietal

lobe.

Carotid duplex and transcranial duplex study Grossly normal

MRA+ angiography Left supraclinoid ICA stenosis of 52% Relative small caliber of left ACA with sluggish flow. Other normal vessels

20050729 brain CT without contrast

20050729 supratentorial DWI

Impression Ischemic infarction due to left intracranial ICA

stenosis Embolic infarction impressed due to

Stepwise downhill of neurologic function at the same territory.

Cortical infarction

Treatment Bokey 100 mg qd Warfarin 5mg qd

Discharge on 8/8 Improved right hand weakness INR: 1.82 Warfarin 5mg qd

Regular follow up at OPD

8/22: INR: 4.37 ->warfarin 2.5mg qd Regular rehabilitation. Maximal right hand motor function after 2~3 weeks

after discharge, then progressive weakness was noticed again

8/31: INR: 2.30

Admission againSymptoms and signs

Speech Slurred speech noticed for 2 weeks with poorer right hand

muscle power Speech became worse with stutter in these 2~3days

Muscle power Facial asymmetry noticed by his wife. Worsening right hand muscle power Chocking while drinking water

Sensation Right face numbness, right hand fullness sensation

Other positive or negative findings No nausea, vomiting, neck stiffness, diplopia, dizziness,

vertigo, hearing loss, fever, newly unsteady gait No palpitation Mild headache

PE Right central facial palsy Tongue deviated to right Rright hand muscle power: grade 2 with poor

coordination function

Lab INR: 1.2

Brain CT A new hypodense lesion at left parietal lobe

20050729 brain CT 20050914 brain CT

Impression Recurrent ischemic stroke at the territory of stenotic

ICA under medical treatment

Treatment Warfarin 4mg qd Clexane Bokey 100mg qd

Endovascular intervention and extracranial-intracranial bypass has been explained to the family

Clinical Problem and Clinical Problem and evidenceevidence

Is advanced intervention beneficial to our patient in terms of prevention of recurrent CVA?

Advanced intervention: angioplasty with/ without stentPatient: young age, with >50% intracranial carotid stenosis, smoking (+), hypertrilyceredemia, recurrent stroke under aspirin 100mg qdand warfarin INR 1.2

Searching

PubmedSearch intracranial, carotid, atherosclerosis

Field: TitleSearch intracranial, carotid, endovascular Field:

TitleSearch intracranial, carotid, endovascular Field:

TitleSearch intracranial, carotid, stent Field: Title

There is no evidence comparing endovascular intervention and medical treatment

What is the prognosis (recurrence of CVA, mortality) of this patient? Recurrent rate under no medical treatment Recurrent rate under medical treatment Predictors of recurrence, disease prgression

SearchingPubmed

Search intracranial, carotid, atherosclerosisField: Title

Search intracranial, carotid, stenosis Field: TitleSearch intracranial, stenosis Field: TitleSearch intracranial, atherosclerosis Field: Title

The Prognosis of Carotid Siphon Stenosis

15 patients Siphon stenosis > 50% Follow-up 51 months 20% suffered from recurrent stroke (ICA territory) Annual ipsilateral stroke and mortality rates: 3.1%, 4.7%

LAWRENCE R. WECHSLER, M.D, et alStroke Vol 17, No 4, 1986

Case report

Method 21 patients, 45 lesions (ICA, MCA, ACA, PCA, VB) Blind interpretation of angiogram by two radiologist Average interval of repeated angiogram: 26.7 months

Result All intracranial arteries: 43.9 %-> 51.8%(p= 0.32) Clinical prognosis

Death: 1, TIA: 4, ICH: 1

Case report (retrospecitve review of medical records)

Natural history of stenosis from intracranial atherosclerosis by serial angiography

Paul T. Akins, MD, PhD; et alStroke. 1998;29:433-438.

Progression of mean stenosis

Overall: P=0.32

ACA, MCA, PCA: p=0.37

Change< 10%: stable

Regression: 14% ICA, 28% ACA-MCA-PCA group

Risk factors of progressionAge, sex,race,interval between angiograms, DM, HTN, smoking, hypercholesterolemia, ethanol use (-)Abscence of stenosis at bifurcation

Long-term mortality and recurrent stroke risk among Chinese stroke patients with predominant intracranial atherosclerosis

Prospective controlled study

Patient selection 705 patients with acute ischemic stroke population-based

Vascular lesion: TCD Follow-up: 42 months (28+- 5 months)

Ka Sing Wong, MD; Huan Li, MDStroke October 2003

14% 19%

Without V.S. with vascular lesion (CVA): 65 v.s. 88 (p< 0.02)

P

A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke

Multicenter, double-blind, randomized trial

Warfarin (INR: 1.4~2.8) v.s. aspirin 325mg Patient selection

2206 patients, 30~85 year-old

Intracranial internal carotid artery stenosis: longterm prognosis

The natural history of intracranial carotid artery atheroscleosisRichard J, et al.

Neurology foucs:18, Jan, 2005

66 patients Angiogram: stenosis> 50% 3.9 years Annual ipsilateral stroke rate: 3.1%

Resource: review article

Marzewski DJ, et alStroke 12:821, 1982

Conclusion and Conclusion and applicationapplication

Conclusion

Rate of recurrent stroke or TIA: 3.1%~25.7%Stroke and death: 16%

Predictors of disease progression: age, DM, Af, more vessels occluded

Intracranial ICA stenosis more stable

Severity of stenosis?

Application

Currently, there was no strong evidence indicating that endovascular intervention is better than medical therapy to this patient.

Young age, DM(-), Af(-), only one vessel occluded. Severity of stenosis?

Advanced intervention is not advised to this patientAdvanced intervention is not advised to this patient.

Question and Question and CommentsComments

endovascular interventionevidenceendovascular interventionmedical treatmentstrong evidence? reviewno strong

evidence endovascular intervention

studyinterventionoutcome studysearch embolic infarction?

stepwise downhill of muscle powercortical infarctionEmbolic infarctionfavor

embolic infarction? territoryclinical sings

thrombus, ex. AMI, arrythmia.

atherosclerosis? radiologiststenosisatherosclerosiscarotid

dissectioncongenital disease

Case presentationThe patientGeneral dataChief complaintBrief historyAdmission in JulyRegular follow up at OPDAdmission againClinical Problem and evidenceSearchingSearchingNatural history of stenosis from intracranial atherosclerosis by serial angiographyIntracranial internal carotid artery stenosis: longterm prognosisConclusionApplication