Stroke is a major challenge to our healthcare systems because it demands fast decisions involving several specialists. Emergency imaging and interventional neurology transformed the prognosis of stroke.

1. A 82-year-old man with
a hemispheric stroke:
decisions in a complex
case
Hans Jørgen MOE² and Guy-André PELOUZE°
²Medical student at University of Szeged, Hungary
°Chirurgien Thoracique et Cardiovasculaire, Centre
Hospitalier de Perpignan
torsdag 27. oktober 2011

2. Description of case
A 82-year-old man was emitted to the ER after a
domestic accident presenting a left hemiparesis,
suggesting a right embolic stroke. The patient
presented with a moderate facial paralysis and
dysarthria. No previous cerebrovascular symptoms
such as amaurosis fugax (temporary vision loss
due to lack of blood flow to the retina), TIA nor
cardiovascular risk factors were known. He was
successfully thrombolyzed (Actilyse) 3,5 hours
after the vascular accident.
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3. CT scan - at admission 22/07.
Showed a right hemispheric
infarction
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4. Past medical history
His past medical history included no cardiovascular or other related
diseases.
He was on Aspirin, Enoxeparin (LMWH) and Fresubin nutrition drink
prior to the attack.
On examination, the patient had a Glascow coma scale of 15 points, his NIH
score was 17 before the thrombolysis, his pulse was regular, and blood
pressure 147/76.
After the neurological ischemic accident the patient was sent to a
rehabilitation center. Six weeks later he was referred back to the hospital for
imaging and reevaluation of his status.
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5. What type of investigations are indicated
in the EARLY stage?
At admission brain imaging is necessary for two reasons.
At first a brain hemorrhage need to be excluded (responsible for 10 % of all
strokes). Brain tumor is the next pathology to be excluded.
The computed tomography brain scanning was positive at admission.
Showing a right hemispheric infarction.
The CT scan can only recognize a ischemic infarction 48 hours after the
vascular accident.
Routine blood tests (full blood count, urea, electrolytes, and clotting),
electrogardiogram, and chest X-ray were performed before the CT-scan of
the brain. He had regular sinus rhythm, and ECG examination didn´t show
any new or old MI.
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6. Causes of stroke
10 %
Ischemic stroke
Hemorrhagic stroke
90 %
Resource: Stroke interventions, why time is of the essence www.intervention-iq.org
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7. What was the management plan at this
stage?
The following drugs were used Atorvastatine (Tahor®) 80mg, a
prior to the operation: statin to stabilize the plaque, and
to reduce the recurrency of
cardiovascular events elsewhere.
Aspirin (Kardégic®)160mg,
Additional former treatment:
Enoxaparin (Lovenox®) 4000 Fluoxetine (Prozac®) 20mg,
IU/0.4ml, (anti depressive SSRI), Folic acid
3x/d, Tardiferon (Fe supplement,
in Fe def. anemia) 1x2/d,
Lercanidipine (Lercan®) 10 mg, Duphalac 2/d (lactulose- aganist
a calcium channel blocker against constipation)
hypertension,
Heparine IV 45000 IU/d,
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8. Discussion - causes of ischemic
stroke
The causes of ischemic stroke is grossly classified into 3 groups: large artery
atherosclerosis, small artery occlusion and cardiac embolism.
Large artery atherosclerosis leads to cerebral ischemia due to perfusion
failure and artery-to-artery embolism.
In small artery occlusion the thrombosis is caused by atherothrombotic
states.
Cardiac embolism which leads to cerebral ischemia may be due to
myocardial infarction, atrial fibrillation or other cardiac diseases.
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10. How did we identify the source of the
stroke?
A continuous doppler ultrasound showed a severe
stenosis of the right internal carotid artery. The left
side was also stenosed, but does not reach
hemodynamically significance.
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11. Investigation of carotid artery stenosis
The first choice imaging technique in concern of carotid artery stenosis is
continuous doppler ultrasound. This is a non-invasive method of low cost
and can easily be repeated. The severity of the stenosis should be
measured (cross-sectional area or in diameter).
However, the gold standard at present is Angio - MRI, or for someone
Angio-CT. An angio-MRI was done just after the therapeutic thrombolysis
procedure.
Right internal carotid(IC) measured a stenosis of 95 %, and 55% stenosis in
the left IC was discovered.
Earlier, selective arteriogram was the most used technique to investigate
CAS. However, this procedure can provoke a stoke and is hence less used
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12. Angio CT showing - 95 % right
internal carotid artery stenosis
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13. The role of carotid endarterectomy to
prevent recurrent events
In a historical perspective the first carotid reconstructive surgery was
performed by Eascott, at St.Marys hospital in London in 1954. In the mid
90´s carotid artery surgery showed by evidence better outcome than medical
therapy in patient with symptoms of decreased internal carotid artery blood
flow.
The symptomatic patients may show symptoms of amaurosis fugax (short
loss of vision), hemiparesis, transient ischemic attacks or stroke.
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14. After a hemispheric stroke, how soon
should carotid endarterectomy be
The patient underwent elective endarterectomy under general anesthesia 8
weeks after the neurovascular accident. Normally surgeons do the operation
4-6 weeks after the accident to allow the auto regulative mechanism of the
brain to recover.
The patient was discharged at the 7 postoperative day. He recovered very
well after the surgical therapy. However, he went into epileptic crises «état
de mal» at the second postoperative day. The theory of delayed epileptic
attack is based on hyper excitability of the cells after the revascularization of
the ischemic brain area.
In our case the surgery was done 8 weeks after the cerebrovascular accident.
(21/7 - 22/9)
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15. Preventive surgery
In the view of carotid surgery there are some delicate cases where pros and
cons need to be considered.
Some factors could increase the risk of the operation. Such risk could be
prior coronary bypass surgery.
Asymptomatic patients with CAS the rate of stroke is 1-5% per year with the
best medical management.
For symptomatic patients with a CAS of more than 80% the risk of stroke is
15-20% the first year. After 1 year a the risk of stroke tends to be the same
as for asymptomatic patients. The operation risk is at 3%. However, these
results are improved in the recent series of the NASCET.
The surgeon propose these numbers and risks for the patient. Although, its
up to the patient and his/her family to make the final decision.
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16. NASCET trial
The NASCET trials have helped define indications for carotid endarterectomy. It is the
current guideline in the decision to operate or not.
Through the following formula for symptomatic and asymptomatic patients the benefit of
the surgery is calculated.
The percent of stenosis = ( 1 − ( minimal diameter ) / ( poststenotic diameter ) ) × 100%.
Symptomatic patient: [50, 69% [: moderate benefit of surgery (significant for men) [70, 99 [:
marked and significant benefit in both sexes.
For symptomatic patients [50, 69% [: over 5 years the NNT is 22 to avoid a stroke.
Above [70, 99 [ the NNT is 6.3 to avoid a stroke.
In asymptomatic patients best medical treatment give a NNT of 83 in two years.
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17. Best present medical
treatment
To avoid a new episode of stroke the patient should take a low dose of 75 mg
Aspirin daily. If the patient is «Aspirin intolerant» Clopidogrel could be a
good substitution.
The recurrent rate can be lowered even more by adding Dipyridamole.
Among lipid lowering agents only statins demonstrated an efficiency in the
prevention of a recurrent stroke. In our case the patient took Atorvastatin 80
mg daily. The patient would need statins if the LDL level exceeds 1 gram.
The LDL cholesterol was 1,06 g/L.
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18. Carotid endarterectomy or carotid
angioplasty?
A vast amount of todays surgery is done mini-invasively. The field of
vascular surgery is no exception of this trend.
Local anesthesia has still not shown any superiority over general anesthesia
in carotid endarterectomy.
In this specific case the patient was under general anesthesia. The technical
difficulty lies in a relatively high bifurcation and a severe rigidity of the neck.
An alternative today is carotid angioplasty and stenting, which in some cases
have given less cardiovascular events.
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19. The CREST trials, endarterectomy
still the gold standard
The CREST trial has compared CAS with CEA for patients with
symptomatic and asymptomatic carotid disease. There has been however
debate on the interpretation of the results. The CAS was associated with the
worse outcome of death or stroke. An 50 % occurred in the stenting group.
There are also other trials where there has been a tendency of more
complications in CAS. Hence the CEA is still the gold standard in the
treatment.
CREST (the carotid revascularization endarterectomy vs stenting trial) CAS (carotid angioplasty and stenting), CEA (carotid
endarterectomy)
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20. pathological examination
The pathological evaluation showed a 4 cm long plaque lesion, where the
internal carotid measured 3 cm.
The external appearance of the vessel was highly irregular.
No complete occlusion, ulceration or hemorrhage were observed.
Conclusion: a calcified atheromatous ruptured plaque of the right internal
carotid artery.
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21. Pathological specimen of
atherosclerotic plaque
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22. Split endarterectomy - internal
carotid - bulb - thrombus
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23. Follow up
The recommendations in the follow up of the patients suggests a doppler
duplex scan at 1, 3, 6 and 9 months after the operation according to
Rohtwell.
Patient investigations shows that 40-50% of patients don´t follow these.
The quality of life is greatly depressed when the patient don´t follow the
rehabilitation program given by the doctor. In our case the patient has made
a great recovery. His mental status is adequate and his motor strength is 4/5
at presence.
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24. Peripheral hospital
Nallamothu and colleagues have examined the relationship between the
experience of the surgeon and 30-day mortality rate of the patient.
The trials found out that the patients operated on by the lowest-volume
operators (less than 6/year) had increased risk of death compared to patients
operated on by high-volume surgeons (more than 24/year).
The paper also pointed out that some physicians seem to practice too much.
If a procedure is performed where the expected benefit is very low, the skill
of the surgeon is of less importance.
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25. References
1) A 75-Year-Old Woman with a Hemispheric Stroke, Stavros K. Kakkos,
George Geroulakos*
2) Stroke interventions - interventional quarter issue 2, 2010
3) Carotid Stenting at the Crossroads Practice Makes Perfect, But Some
May Be Practicing Too Much (and Not Enough), Ethan A. Halm, MD,
MPH
4) NASCET trials
torsdag 27. oktober 2011