cardioembolic stroke : how is it different? 강동화서울아산병원울산의대신경과
talk outline 뇌 는 심장 과다르다 Cardioembolic stroke 은다른 stroke subtypes 과어떻게다른가? Ischemic stroke mechanism 추정의어려움
뇌졸중은? 腦卒中 Lumper 中風 Splitter
Ischemic vs. Hemorrhagic strokes cerebral vessel occlusion infarct, ischemic stroke cerebral vessel rupture hemorrhage
CT 이전시대 임상적으로뇌졸중의심 뇌출혈과뇌경색을감별하기위해 뇌척수액검사 혈관조영술 부검
뇌출혈진단 CT (computed tomography) intracerebral hemorrhage subarachnoid hemorrhage cerebral infarction
뇌경색의분류는왜중요한가? stroke subtype influences outcome, recurrence, and choices for management
Combined endpoint occurrence (%) CURE CREDO 15 1-year results (Stroke, MI or death) 10 Placebo (n=1,063) Clopidogrel 11.5 % 8.5% 27% RRR p=0.02 (n=1,053) 5 0 0 3 6 9 12 Months from randomization NEJM 2001 JAMA 2002
MATCH ASA+CPG vs. CPG Management of Atherothrombosis with Clopidogrel in High-risk patients with recent ischemic stroke or TIA Lancet 2004
Dual antiplatelets increases bleeding in stroke!
CHARISMA ASA+CPG vs. ASA NEJM 2006
Stroke mechanism is heterogeneous! Cardioembolism (CE) Large-artery atherosclerosis (LAA) Intracranial LAA Extracranial LAA Small-vessel occlusion (SVO) Other determined etiology Undetermined etiology two or more causes cryptogenic Thrombotic Embolic Cardioembolic Artery-to-artery Hemodynamic Lacunar (small-vessel) Mixed
Stroke outcome is location dependent! 뇌신경경로에따라예후도개인마다다르다
cortical homunculus
sometimes unpredictable! 혈전용해술 소수의기준만으로는예후예측어렵다 Case I Case II Poor outcome Favorable outcome
Characteristics of Cardioembolic Stroke
% bedridden patients Clinical features Maximal deficits at onset 50 40 41.2% More severe clinical presentation 30 20 23.7% 10 Poorer outcome 0 With AF p<0.0005 Without AF Neuroepidemiology 2003
뇌경색의구성요소 4P DWI FLAIR MRA PWI pipe parenchyma perfusion
급성뇌경색, 어디있을까? T2-weighted image diffusion-weighted image (DWI) 확산강조 MR 영상
급성뇌경색, 어느것일까? T2-weighted image DWI
뇌경색패턴을 DWI 보면원인을가늠할 MRA수있다 DWI DWI MRA MRA 가까운혈관탓 middle cerebral a 먼혈관탓 internal carotid a Acute MRA 2.5 days later Acute MRA 2.5 days later 심장탓 cardioembolism Lee DK, Kang DW. Stroke 2005
CE stroke Large or Multiple
Right-brain propensity of cardioembolism Kim HJ, Kang DW. Stroke 2011
Pipe Evaluation of early recanalization is useful MCA disease Cardioembolism Cho AH, Kang DW. J Neurol Sci 2012
막힌혈관은 CT, MRI 에서도보일수있다 CT FLAIR Gradient echo T2*
무엇이막았을까? 혈전성분 red clot ( 적혈전 ) vessel sign white clot ( 백혈전 ) Cho KH, Kang DW. Stroke 2005
혈전성분이중요한이유 혈관재개통여부 심장탓 뇌혈관탓 DWI MRA GRE follow-up MRA
Perfusion MRI Diffusion MRI Perfusion defect Infarct core game over! Mismatch (penumbra) salvageable!
penumbra (pen + umbra) 반음영
Stroke is dynamic! infarct growth acute A B 5-day
Infarct volume NIHSS Infarct volume NIHSS Baseline infarct volume Baseline NIHSS infarct growth p=0.035 p=0.001 CE MCAD CE MCAD 5 day infarct volume 5 day NIHSS CE MCAD p=0.004 CE MCAD p=0.009 CE MCAD p=0.116 Kim HJ, Kang DW. J Neurol Sci 2008
Stroke is dynamic! new infarcts lesion recurrence 34% clinical recurrence 2% 1.2h 26h 5d Kang DW et al. Ann Neurol 2003, Neurology 2004, Arch Neurol 2006
MCA 탓 5-day 심장탓 5-day Kang DW et al. Arch Neurol 2007
Summary features of CE stroke Prevalence is increasing Maximal deficits at onset More severe, poorer outcome Larger or multiple infarcts at baseline More infarct growth Recanalize shortly Red (fibrin-rich) clot, responsive to fibrinolytic Rx
Stroke mechanism 추정의어려움 - puzzle 인가? mystery 인가? -
F/71yr, pafib, SSS, HT, HL TIA (dysarthria, left mild weakness)
M/75 CC: aphasia HT, DM, HL, smoker Afib newly found Right carotid Left carotid
Occam s razor William of Ockham (Occam) 14th-century English logician, theologian The simplest explanation or strategy tends to be the best one Among competing hypotheses, favor the simplest one
Occam s razor vs. Hickam s dictum Occam s razor Hickam s dictum age fever, anemia, retinal embolus, cardiac murmur Infective endocarditis in young patients Aspirin-induced blood loss, cholesterol embolus, insignificant aortic sclerosis, viral illness in older pts
Small-vessel occlusion (lacunar infarct)
variable branch patterns, variable size
Variations in perforating arteries 7T MRI Kang CK, Cho ZH. Magn Reson Med 2009
Vessel Wall MRI
Small-Vessel Disease lacune microbleed leukoaraiosis hypertensive ICH
DWI 급성뇌출혈과급성뇌경색의공존 GRE Kang DW et al. Neurology 2012
Puzzle? Mystery?