Xu Jinghan, Zhuang Meiting, Bao Guanshui, Zhai Yu, Yang Guo-Yuan, Xue Gang, Li Qiang
Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine.
Neuroscience and Neuroengineering Research Center, Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University.
Medicine (Baltimore). 2020 Feb;99(9):e19247. doi: 10.1097/MD.0000000000019247.
The capsular warning syndrome (CWS) is a rare and special type of transient ischemic attacks (TIAs) syndrome. The pathophysiology of CWS is very complicate, and intracranial atherosclerotic stenosis (ICAS) is rare cause. Moreover, the effective and standard therapy has not yet been established.
A 47-year-old man experienced repeated and exacerbated TIAs of right hemiparesis and dysarthria. Fourteen hours after the first episode of TIAs, he developed more severe right hemiparesis and dysarthria, the National Institute of Health Stroke Scale (NIHSS) score was 12 points, and did not recover in a long time.
The computed tomography (CT) angiography displayed high stenosis in the M1 segment of the left middle cerebral artery. The patient was diagnosed as CWS with ICAS.
Loading dose of clopidogrel and aspirin were started but were ineffective, then we used recombinant tissue plasminogen (r-tPA) for thrombolysis therapy after repeat CT scan that showed small acute infarcts in the right putamen and no bleeding.
The patient was successfully treated by r-tPA intravenous thrombolysis after loading dose of dual-anti-platelet. He recovered rapidly, and the NIHSS score was 0 point, modified Rankin Scale score was 0 point, and Barthel Index score was 100 points at 3-month follow-up.
r-tPA combined with loading dose of dual antiplatelet appears safe and effective in carefully selected CWS patients with ICAS. The collection of similar cases and further randomized controlled trial research would be desirable.
包膜警告综合征（CWS）是一种罕见且特殊类型的短暂性脑缺血发作（TIA）综合征。CWS的病理生理学非常复杂，颅内动脉粥样硬化狭窄（ICAS）是罕见的病因。此外，尚未确立有效的标准治疗方法。
一名47岁男性反复出现右半身轻瘫和构音障碍且症状加重的TIA。首次TIA发作14小时后，他出现更严重的右半身轻瘫和构音障碍，美国国立卫生研究院卒中量表（NIHSS）评分为12分，且长时间未恢复。
计算机断层扫描（CT）血管造影显示左侧大脑中动脉M1段高度狭窄。该患者被诊断为伴有ICAS的CWS。
开始给予氯吡格雷和阿司匹林负荷剂量，但无效，在重复CT扫描显示右侧壳核有小的急性梗死且无出血后，我们使用重组组织型纤溶酶原（r - tPA）进行溶栓治疗。
患者在给予双重抗血小板负荷剂量后通过r - tPA静脉溶栓成功治疗。他恢复迅速，3个月随访时NIHSS评分为0分，改良Rankin量表评分为0分，Barthel指数评分为100分。
r - tPA联合双重抗血小板负荷剂量在精心挑选的伴有ICAS的CWS患者中似乎安全有效。收集类似病例并进行进一步的随机对照试验研究是可取的。
