a 82 years old man with hemispheric stroke: decisions in a complex case

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

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.


CT scan - at admission 22/07. Showed a right hemispheric

infarction


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.


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.


Causes of stroke

90 %

10 %

Ischemic strokeHemorrhagic stroke

Resource: Stroke interventions, why time is of the essence www.intervention-iq.org


http://www.intervention-iq.org

http://www.intervention-iq.org

What was the management plan at this stage?

The following drugs were used prior to the operation:

Aspirin (Kardégic®)160mg,

Enoxaparin (Lovenox®) 4000 IU/0.4ml,

Lercanidipine (Lercan®) 10 mg, a calcium channel blocker against hypertension,

Heparine IV 45000 IU/d,

Atorvastatine (Tahor®) 80mg, a statin to stabilize the plaque, and to reduce the recurrency of cardiovascular events elsewhere.

Additional former treatment: Fluoxetine (Prozac®) 20mg, (anti depressive SSRI), Folic acid 3x/d, Tardiferon (Fe supplement, in Fe def. anemia) 1x2/d, Duphalac 2/d (lactulose- aganist constipation)


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.


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.


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


Angio CT showing - 95 % right internal carotid artery stenosis

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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.


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)


Preventive surgeryIn 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.


NASCET trialThe 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.


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.


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.


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)


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.


Pathological specimen of atherosclerotic plaque


Split endarterectomy - internal carotid - bulb - thrombus


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.


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.


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


a 82 years old man with hemispheric stroke: decisions in a complex case

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