Sato Naoki, Ishikawa Toshihito, Ebihara Kenichi, Endo Katsuhiro, Endo Yuji, Ota Mamoru
Department of Neurosurgery, Masu Memorial Hospital.
No Shinkei Geka. 2019 Oct;47(10):1093-1100. doi: 10.11477/mf.1436204079.
We report a case of embolic stroke with an atypical course after endovascular therapy performed during the subacute stage of progressive stroke, where symptom relapse could not be controlled despite medical treatment.
An 81-year-old woman developed slight weakness in her left leg and was hospitalized three days after the onset of symptoms. On admission, her consciousness was almost clear and she exhibited left hemiparesis. The computed tomography(CT)and magnetic resonance imaging(MRI)revealed a cerebral infarction in the right caudate head and corona radiata, and CT perfusion showed no difference in the cerebral blood flow. However, three-dimensional computed tomography angiography showed right M1 occlusion. Considering the clinical course of the leg weakness without atrial fibrillation, antiplatelet therapy for atherosclerotic cerebral infarction was administered. Five days after the symptom onset, the left hemiparesis deteriorated. CT and diffusion-weighted MRI showed increasing edema associated with the cerebral infarction, and CTP showed decreased cerebral blood flow in the right middle cerebral artery region. Because angiography revealed an obstruction involving a long lesion with loss of contrast, we suspected an embolic stroke. Endovascular surgery was performed successfully using the Penumbra system. Postoperatively, the hemiparesis resolved and the patient was transferred to the rehabilitation hospital.
In rare cases, patients with an embolic stroke develop gradual progression of symptoms. To differentiate between cardioembolic stroke and atherosclerotic cerebral infarction in such patients, a follow-up examination of the brain blood flow must be performed, especially when there is a change in symptoms. This may provide useful information for intravascular treatment even in the subacute period.
我们报告一例在进展性卒中亚急性期进行血管内治疗后出现非典型病程的栓塞性卒中病例，尽管进行了药物治疗，但症状复发仍无法得到控制。
一名81岁女性出现左腿轻度无力，症状发作三天后住院。入院时，她意识基本清醒，表现为左侧偏瘫。计算机断层扫描（CT）和磁共振成像（MRI）显示右侧尾状核头部和放射冠有脑梗死，CT灌注显示脑血流量无差异。然而，三维计算机断层血管造影显示右侧M1闭塞。考虑到腿部无力的临床病程且无房颤，给予抗血小板治疗以治疗动脉粥样硬化性脑梗死。症状发作五天后，左侧偏瘫加重。CT和扩散加权MRI显示与脑梗死相关的水肿增加，CTP显示右侧大脑中动脉区域脑血流量减少。由于血管造影显示病变较长且造影剂流失，我们怀疑是栓塞性卒中。使用Penumbra系统成功进行了血管内手术。术后，偏瘫症状消失，患者被转至康复医院。
在罕见情况下，栓塞性卒中患者会出现症状逐渐进展。为了区分此类患者的心源性栓塞性卒中和动脉粥样硬化性脑梗死，必须对脑血流量进行随访检查，尤其是在症状发生变化时。这即使在亚急性期也可能为血管内治疗提供有用信息。
