Case Presentation PK 6 Identifying Data Name Jung

Case Presentation 신경과 PK 6조 김진석, 신동환

Identifying Data Name : Jung O O n Sex : male n Age : 61 n

Chief Complaint n Transient Rt. Sided weakness for 8 hr.

Personal History n n n n Smoking (+) 1 pack 40 yrs Alcohol (+) 3 -4#/weeks 소주 1병 Occupation : 자영업 Rt. Handednss Height, weight : 182 cm, 87 kg EKG : unremarkable Chest X-ray : unremarkable

Past History n n n Hypertension (-) Diabetes mellitus (-) Pulmonary tuberculosis (-) Previous cerebrovascular history (-) Myocardial infarction(+) : 2000년 anteroseptal infaction후 regular medication Previous illness Hx: 2001년 glottis ca. OP후 RTX,

Family History Hypertension (-) n Diabetes mellitus (-) n Pulmonary tuberculosis (-) n Cerebrovascular accident history (-) n

Physical Examination n n Vital Sign BP 140/90 mm. Hg PR 80/min RR 20 /min BT 36. 5 C General appearance Well developed

System review n n n n Eyes Throat Carotid bruit Respiratory Cardiovascular Gastrointestinal Musculoskeletal Not pale conjunctiva Anicteric sclera No throat injection (-/-) Symmetrical expansion on respiration Clear breathing sound s rale Regular heart beat s murmur Soft and flat Normoactive bowel sound No muscular atrophy No pitting edema No cyanosis

Neurologic Examination 1. Mental Status Consciousness level : alert Speech : intact Memory : Remote, recent immediate: intact Orientation : Time, place, person : intact

Neurologic Examination 2. Cranial Nerve I. Olfactory : intact II. V/A : (20/20), (20/20) V/F : intact Fundus : no papilledema & retinal change (-) III. IV. VI EOM : full range Pupil : RRERL c 3 mm Nystagmus : no spontaneous or gaze evoked nystagmus

Neurologic Examination V. Facial sensation Pain, temperature Touch - intact Vibration VII. NLFF (-/-) Forehead wrinkling (+/+) VIII. Hearing difficulty : (-/-) Weber test : no lateralization Rinne test : (AC>BC), (AC>BC)

Neurologic Examination IX. X Gag reflex : (+/+) Uvular deviation : (-) XI. SCM & Trapezius muscle - intact XII. No tongue deviation on protrusion

Neurologic Examination 3. Motor 1) Tone : normal 2) Power : pronator sign(-) Hand grasp (5/5) all MMT symmetical (5/5) 3) Muscle bulk : no muscular atrophy 4. Sensory Pain, temperature Touch - intact Vibration

Neurologic Examination 5. DTR Brachioradialis jerk(+/+) Biceps jerk (++/++) Triceps jerk(+/+) Patellar jerk(++/++) Ankle gerk(+/+) Babibski’s sign(-/-)

Neurologic Examination 6. Cerebellar sign Finger to nose test : intact Heel to shin test : intact Romberg test : (-) Stepping gait : no deviation Tandem gait : no tilting 7. Gait : intact

Formulation * Neurologic Examination상 unremarkable • History상 transient Rt. Sided weakness주소로 내원한 old age, MI등의 CVA risk factor가진 환 자로 sudden onset neurologic deficit으로 보 아 vascular origin이 의심되며 8시간만에 증상 완전 호전된 것으로 보아 TIA가능성 큼.

Impression n R/O Cerebral infarction

Diagnostic Plan Diagnostic CT brain angio Brain MRI & MRA& carotid TTE n Therapeutic TFCA n

CT brain angio

Brain MRI DWI

TFCA

Diagnosis n Acute infaction of left watershed zone due to left proximal ICA occlusion.

Therapeutic Plan Antithrombotics. (a. PPT 34 -50 sec) n Bed rest and conservative manage n

ICA infarction (TIA)썄 PK 6조 김진석, 신동환 www. ptline. com

Anatomy of the ICA Pathophysiology of ischemia 1) Thrombosis (atherosclerosis) 2) Embolism (heart, aortic arch) 3) Hemodynamic Perfusion failure Ischemia www. ptline. com

Collateral Pathway 1) Contrallateral ICA via the circle of Willis 2) Anastomosis with the ECA and OA 3) Vertebrobasilar system through ipsilat. Pcom 4) Border zone anastomosis www. ptline. com

Transient Ischemic Attacks • Incidence : 2. 2 ~ 8/1000/year • Definition temporary, focal neurologic deficit presumably related to ischemia and lasting less than 24 hours • Duration of typical carotid territory TIAs lasting only 7~10 min www. ptline. com

Transient Ischemic Attacks • Premonitory Sx. paresthesia, paralysis, monocular blindness, aphasia • Perspective of carotid stroke prior TIA incidence : 50~75% • Patient whose stenosis exceeded 70% endarterectomy > medical therapy www. ptline. com

Transient Monocular Blindness • Important manifestation of carotid artery disease (Amaurosis fugax) • retinal a. cholesterol crystal, platelet complex, vasoconstriction • Brief monocular visual obscuration pt. ’s complaint : fog, blur, cloud, mist duration : 1 ~ 5 min (<30 min) usually fully restored after an attack (⇔ permanent visual loss because of retinal infarction) • TMB tends to precede the first THA • Rarely occurs simultaneously with other neurologic deficits www. ptline. com

Transient Hemispheral Attacks • Intracranial branch occlusion : short lived cerebral embolus • M/C Sx. ① followed by pure motor & sensory dysfunction of the contralateral limbs (arm & hand) ② lastly, isolated dysphasia • Duration 1~10 min(<15 min) www. ptline. com

Transient Hemispheral Attacks • Risk of ipsilateral stroke at 2 yr : TMB vs. THA 11~22. 2% vs. 36. 8~50. 2% (P=0. 002) Kaplan-Meier estimates • Uncommon form of THA : limb shaking typically associated with severe carotid stenosis or occlusion : recurrent, involuntary, irregular, wavering movements of the contralateral arm or leg www. ptline. com

Reference • Stroke, pathophysiology, diagnosis and management - 4 th edition J. P. Mohr (Churchill Livingstone) www. ptline. com