• 72 year-old male 黃OO
• Chief Complaint
Acute onset of right limbs weakness when riding motorcycle in the morning on 101/03/15
• Present Illness
He didn’t have any discomfort yesterday evening except occasionally difficult to urinate.
He rode motorcycle to buy meat in the morning on
101/03/15. Then, he suffered from acute onset of
right limbs weakness when riding motorcycle.
He stopped immediately and got unstable gait
without falling down.
A passerby found something wrong from his facial
expression and patient didn’t say anything. The
someone call 911 for help.
He was sent to our ER by ambulance on 101/03/15.
• Past History/Social History
1.Herniated Intervertebral Disc, L4-5 with frequent backache
2.Left knee osteoarthritis
3.HTN ?
4.Tobacco: 1.5 PPD for 30 years
5.Alcohol: Social drinking
6.Betel nut: +, 20 years
• Physical Examination
TPR: 36/48/18 BP: 158/66 mmHg
Conjunctivae: not anemic
Neck: supple
Hear: RHB, no murmur
Chest: clear BS, no crackle/ wheezing
Abdomen: soft, no tenderness
Extremities: no pitting edema
• Neurological Examination
1.Alertness / Attention: Well
2.Language: (Mixed transcortical aphasia)
Comprehension: impairment
Fluency: impairment
Repetition: fair
3.Orientation/Memory: Unknown
• Neurologic examination
1. VA/VF: intact
2. Pupil:3 mm/ 3mm; Light reflex: +/+
3. Right central type facial palsy
4. Forced eye gazing to left
side
0
-3
0
-3 0
0 0
0
00 0 0
0
0
0
0
0
• 101/03/15 08:55 • 血色素檢查(Hemaglobin) 15.6 g/dL 13.0 - 18.0• 血球比容值測定 44.7 % 40.0 - 54.0• (Hematocrite)• 白血球記數(W.B.C) 6.80 K/ul 4.00 - 10.00• 白血球分類記數 (WBC differential count)• 節狀中性球 64.2 % 55.0 - 75.0• (Segmented neutrophil)• 嗜伊紅性白血球 1.9 % 0.0 - 5.0• (Eosinophil)• Baso 0.4 % 0.0 - 1.0• 單核球(Monocyte) H 10.4 % 0.0 - 10.0• 淋巴球(Lymphocyte) 23.1 % 20.0 - 40.0• 血小板記數 161 K/uL 140 - 450• (Platelet count)
101/03/15 生化
• 飯前葡萄糖(Glucuse AC) H 113 mg/dL 70 - 99• 血清麩胺酸苯醋酸 25 IU/L 15 - 41• S-GOT• 血中尿素氮(BUN) 11 mg/dL 8 - 20• 肌肝(Creatinine) 1.1 mg/dL 0.4 - 1.2• GFR• Age 71 y/o• Estimated GFR(MDRD) 66.0 mL/min• 鉀(K) 4.1 mEq/L 3.5 - 5.1• 鈉(Na) 139 mEq/L 136 - 144• 肌酸磷化同? 80 IU/L 38 - 397• (CK isoenzyme)• CKMB 2.20 ng/mL 0.00 - 5.40• CKMB mass/Total CK HH 2.8 %• Troponin-I 0.05 ng/ml <0.50• Normal 99%: <0.04 ng/mL• AMI Cutoff: < 0.5 ng/mL
• Impression
1.Cerebral Ischemic Infarction, Left
middle cerebral artery
2.HTN
3.Sinus bradycardia
4.HIVD
5.BPH
Admission--101/03/16 生化
• 飯前葡萄糖(Glucuse AC) 84 mg/dL 70 - 99• 白蛋白(Albumin) 3.6 g/dL 3.5 - 5.0• 直接膽紅素(Biliruin direct) 0.3 mg/dL 0.1 - 0.5• 膽紅素總量(Bilirubin total) 1.0 mg/dL 0.3 - 1.2• 鹼性磷酯 (Alkaline phosphatase) 79 IU/L 38 - 126• (S-GPT) 18 IU/L 14 - 40
• 總膽固醇 (Cholesterol,total) H 225 mg/dL 130 - 200• 三酸甘油酯 (Triglyceride) H 169 mg/dL 35 - 150• 尿酸(Uric acid) H 7.7 mg/dL 4.4 - 7.6• P 3.0 MG/DL 2.7 - 4.• 鈣(Ca) L 8.5 MG/DL 8.9 - 10.3• Mg 1.8 MG/DL 1.8 - 2.5• LDL-Cholesterol H 163 MG/DL <130•• HDL-Cholesterol L 31 MG/DL >50 -
Admission
• 101/03/16
Aphasia/Right central type facial palsy
Brain MRI
Heart echo
24 hours holter
Carotid doppler
1
1 55
1 5
51
HOLTER 101/03/17
• Conclusions
[1] Basically sinus rhythm with ventricular
rate, min 39 bpm, max 88 bpm, average 53
bpm;
[2] A few of PVCs, isolated;
[3] Persitent ST-T segment horizontal or
downsloped depression 0.5-2mV at channel
2 and 3;
[4] No SVT, VT, or long pause;
心超 101/03/16Conclusions
• [1] Aortic valve sclerosis, aortic root dilatation, LAE, LVH ;• [2] Preserved global LV systolic performance, but impaired
diastolic compliance ;• [3] Normal pulmonary pressure .
• Prosthetic value:AV MV St.Jude B-Shiley• P't Normal P't Normal• AO (H)41 (20-38) (mm) LVIDd 53 (37-53) (mm)• AV 22 (16-26) (mm) LVIDs 33 (24-36) (mm)• LA (H)49 (19-40) (mm) LVEDV 134 (80-180) (ml)• RV (L) ( 5-21) (mm) LVESV 43 (16-83) (ml)
• EF Slpoe (L)75 (80-150) (mm/sec) EF 68 (50-70) ( %)• IVS (H)14 ( 7-11) (mm) HR (L)52 (60-100)
(/m)• LVPW (H)14 ( 9-11) (mm) CO 4.75 (2.5-7.2) (L/m)• EPSS ( < 8) (mm) DT (160-220)(msec)• IVRT (70-90) (msec) E (cm/s)• A (cm/s)
Right :• TerminalCarotid• M C A ACA P 1 P 2 VA VA BA BA• ICA Siphon
Depth(mm)43 46 56 58 61 64 56 64 69 78 84• MV 31.6 32.1 36.9 44.4 65.4 33.6 33 62 61 44 40• PI 1.59 1.53 1.60 1.70 1.13 0.96 1.26 1.44 1.48 1.711.71
Left :• TerminalCarotid• M C A ACA P 1 P 2 VA VA BA BA• ICA Siphon• Depth(mm)40 48 54 56 62 66 64 62 68 51 71 75 80 88• MV 41.5 44.3 47.6 53.4 34.7 35 31.1 26 29.2 24.4 31.1 27.4 41 33• PI 1.27 1.10 1.12 1.21 1.28 1.31 1.08 1.57 1.50 1.78 1.76 1.99 1.751.55
Diagnosis
• Hyperlipidemia
• Left symptomatic carotid stenosis
Carotid endarterectomy
Carotid artery stenting
Admission• 101/03/17-101/04/01 Pneumonia (Sputum culture: Klebsiella pneumoniae) x 2
• 101/03/26 11:03 胡智銘 廖秋珠(東) • [檢驗項目]: Sputum (痰液) - Routine culture(需氧)• ---------------------------------------------------------------• 1. Klebsiella pneumoniae ssp pneumoniae (moderate)• ------------------------- 1.MIC• Ampicillin R(>=32)• Amikin S(<=2)• Ceftazidime S(<=1)• Ciprofloxacin S(<=0.25)• Cefpirome S(<=1)• Cefotaxime S(<=1)• Cefuroxime S(<=1)• Cefazolin S(<=4)• Ertapenem S(<=0.5)• Flomoxef S(<=2)• Cefoxitin S(<=4)• Gentamicin S(<=1)• Imipenem S(<=1)• Meropenem S(<=0.25)
• Moxifloxacin S(<=0.25)• Trimethoprim/Sulfamethoxa S(<=20)• Tigecycline S(<=0.5)
Medication
• Bokey 1# qd Combine Plavix 1# qd
• Dipyridamole 25mg 2# tidac
• Lipitor 40mg 1# qd
• Norvasc 1# qd
• Diovan 0.5# qd
• Hytrin 0.5# qhs
Admission
• 101/04/17---Carotid angiography and stenting
Heart rate down to 30 /min during Balloon dilatation atropine 1mg 1V IV st BP elevation (180/100 mmHg)
Nicardipine 10mg/10ml 1cc BP down to 120/70 mmHg Transfer to MICU
Challenge Poly starch 500ml
Atropine 1mg IV
MICU 607A
Atrpine0.25mg IV
Meptin 1# bid
Atropin 1mg IV
Theophylline 250mg 1# bid
EKG Transfer to CCU
On TPM (60 BPM)
DC meptin and theophylline
Dopamine premix 3mg/ml 200ml
run 8-10 ml/hr
Skin rash drug related ?
Recheck cardiac enzyme nomal
Admission• 101/04/17-101/04/25
(During Hemodynamic Depression)
No Muscle power decrement, except conscious change
• Discharge on 101/05/03
Medication: (Allergy to Plavix)
Bokey 1# qd
Cilostazol 1# bid
Tamsulosin 1# qhs
Captopril 25mg 0.5# bid
Berotec 2.5mg 1# qd
• 檢查日期 :101/08/14• 開單日期 : 61043• Case No : 11007 BW : BL : • Brachial BP : R't L't : Pulse • Right :• TerminalCarotid• M C A ACA P 1 P 2 VA VA BA BA• ICA Siphon• Depth(mm)49 51 54 59 62 58 62 63 55 60 53 65 78 87• MV 44 47 43 43 26 43 44 33 30 28 38 77 29 20• PI 1.46 1.57 1.86 1.02 1.23 1.48 0.92 1.87 1.12 1.25 1.15 1.10 1.610.98• Left :• TerminalCarotid• M C A ACA P 1 P 2 VA VA BA BA• ICA Siphon• Depth(mm)48 50 52 57 62 58 62 58 58 51 58 66 82 90• MV 29 26 28 29 29 28 37 48 36 29 27 58 34 15• PI 2.03 1.63 1.43 1.69 0.96 1.72 1.37 1.17 0.97 0.98 1.42 1.17 1.421.04
Discussion
• 為何會有 Hypotension and bradycardia after carotid artery stenting (CAS)?
Extension manipulation in the vicinity of the carotid sinus
Increased parasympathetic discharge (Bradycardia) and a reduction of systemic arterial smooth muscles tone (Hypotension)
Discussion--Definition
• Post-CAS Hypotension
Systolic BP <100 mmHg or
Blood pressure fall > 30mmHg
• Post-CAS Bradycardia
Heart rate < 60 beats or
A decreased of > 20 beats/min
Am J Cardiol 1998;82:1077-1081
Discussion—Hemodynamic change
• Predilatation/Stent delivery/Postdilatation
Predilatation: Initial balloon dilatation
until stent deployment
Stent delivery: Stent deployment until the
postdilatation balloon
inflation
Postdilatation: Remainder of the procedure
Am J Cardiol 1998;82:1077-1081
Discussion—Hemodynamic change
• Predilatation/Stent delivery/Postdilatation
Incidence of bradycardia:
No differing significantly from one period of the next Predilatation(32%) / Stent delivery(21%) / Postdilatation(32%)
Incidence of hypotension:
After stent delivery(23%) and after postdilatation(26%)
Am J Cardiol 1998;82:1077-1081
Discussion--發生率
Post-CAS Hypotension: 14%
Post-CAS Bradycardia: 27%
Combine Post-CAS hypotension and bradycardia: 5%
J Vas Surge 2007;46:846-54
Duration: Median 12 hours (range 1 to 96 hours)
J Am Coll Cardiol 2006;47:1538-43
Discussion
• Factors associated with hypotension and bradycardia after carotid artery stenting (CAS)?
1.Age
2.History of coronary artery disease
3.Larger balloon diameters
4.Elevated SBP > 180mmHg before the procedure
5.Lesions involving carotid bulb or heavy calcification and ulceration
VASCULAR DISEASE MANAGEMENT 2012;9(2):E17–E19
Discussion—Age/CAD
Elderly patients / coronary artery disease / low ejection fraction
depressed cardiac output state and diastolic ventricular dysfunction
Carotid baroreceptor stimulation by balloon angioplasty or stent placement
Not have a full cerebral autoregulatory response or impairment of myocardial function to bradycardia or hypotension
J Vas Surg 2007;46:846-54
Discussion—Prior ipsilateral CEA
• Carotid bulb was been divided or interrupted surgically
• Unable to send impulse to the medulla when triggered by balloon dilatation
J Vas Surg 2007;46:846-54
Discussion—Larger Balloon Diameter
Radiology 2000; 215:677-683
Balloon-expandable stent placement
VSSelf-expanding
stent placement
Discussion—Larger Balloon Diameter
• Hemodynamic change:
Statistically significant association between the insertion of large stents
(≧10 mm in diameter or ≧ 40 mm in length)
Am J Cardiol 1998;82:1077-1081
Discussion-Lesions involving carotid bulb or heavy calcification and ulceration
Patients with calcified
plaque
in the carotid bulbe
Discussion-Lesions involving carotid bulb or heavy calcification and ulceration
J Am Coll Cardiol 2006;47:1538-43
Discussion-Lesions involving carotid bulb or heavy calcification and ulceration
J Am Coll Cardiol 2006;47:1538-43
Discussion-Lesions involving carotid bulb or heavy calcification and ulceration
J Am Coll Cardiol 2006;47:1538-43
Therapy
• Isotonic Fluid
• Atropine
• Intravenous vasopressor therapy
(Dopamine average 7.8±2.9μg/kg/min
0.6-0.3mg/kg/hr) Am J Cardiol 1998;82:1077-1081
• Pacemaker (暫時性 or 永久性 ?)
Conclusion
• Large stent
• Balloon-expandable stent placement
• Sinus bradycardia
• Carotid sinus
• Smoking
心超 101/03/16
• Conclusions• [1] Aortic valve sclerosis, aortic root dilatation, LAE, LVH ;• [2] Preserved global LV systolic performance, but impaired diastolic compliance ;• [3] Normal pulmonary pressure .
• Prosthetic value:AV MV St.Jude B-Shiley• P't Normal P't Normal• AO (H)41 (20-38) (mm) LVIDd 53 (37-53) (mm)• AV 22 (16-26) (mm) LVIDs 33 (24-36) (mm)• LA (H)49 (19-40) (mm) LVEDV 134 (80-180) (ml)• RV (L) ( 5-21) (mm) LVESV 43 (16-83) (ml)• EF Slpoe (L)75 (80-150) (mm/sec) EF 68 (50-70) ( %)• IVS (H)14 ( 7-11) (mm) HR (L)52 (60-100) (/m)• LVPW (H)14 ( 9-11) (mm) CO 4.75 (2.5-7.2) (L/m)• EPSS ( < 8) (mm) DT (160-220)(msec)• IVRT (70-90) (msec) E (cm/s)• A (cm/s)
• FINDINGS : • (V) LAE ( ) LVE (V) LVH ( ) RAE ( ) RVE ( ) ASH• AR : ( ) Trivial ( ) Mild ( ) Moderate ( ) Severe AS:PG9.5 mmHg• MR : ( ) Trivial ( ) Mild ( ) Moderate ( ) Severe MS:PG mmHg• PR : ( ) Trivial ( ) Mild ( ) Moderate ( ) Severe PS:PG mmHg• TR : ( ) Trivial ( ) Mild ( ) Moderate ( ) Severe TS:PG17.2 mmHg• PAP : mmHg ; AVA : c㎡ ; MVA : c㎡ ; • [1] No regional wall motion abnormality ;• [2] Reversed E/A ratio ;• [3] ECG -- sinus bradycardia ;