377.3 🏥 內科專科考前版

377.3.1 Mechanistic Deep Dive

377.3.1.1 Ischemic Penumbra

  • Core infarct: irreversible
  • Penumbra: at risk, salvageable
  • DWI = core
  • Perfusion = at-risk tissue
  • Mismatch = penumbra

377.3.1.2 Collateral Circulation

  • Critical for outcomes
  • Better collaterals = better prognosis
  • Imaging on CTA/MRA

377.3.2 Recent Trials & Updates

377.3.2.1 Tenecteplase Trials

  • ATTEST-2 (2023): non-inferior to alteplase
  • AcT (2022): comparable
  • TWIST (2022): better recanalization
  • Increasing adoption

377.3.2.2 MR-CLEAN-LATE (2023)

  • 6-24 hr thrombectomy
  • Without strict imaging criteria
  • Positive results
  • Extends eligibility

377.3.2.3 MR-CLEAN-NO IV (2021)

  • Bridging IV thrombolysis before thrombectomy
  • Non-inferior to direct thrombectomy
  • But other trials (DIRECT-MT, etc.) mixed

377.3.2.4 SELECT-2 (2023)

  • Thrombectomy in large core (ASPECTS 3-5 or core 50-70 mL)
  • Positive results
  • Expanded eligibility

377.3.2.5 ANGEL-ASPECT (2023)

  • Thrombectomy in large core (ASPECTS 3-5)
  • Positive

377.3.2.6 RESCUE-Japan LIMIT (2022)

  • Thrombectomy in large core
  • Positive

377.3.2.7 Basilar Trials

  • BAOCHE (2022)
  • ATTENTION (2022)
  • Endovascular extends benefit

377.3.2.8 CRYSTAL-AF, STROKE-AF

  • ILR detects more AF than conventional
  • Important for cryptogenic stroke management

377.3.2.9 EMBRACE, STROKE AF

  • Extended monitoring for AF

377.3.2.10 LAA Closure

  • Watchman device
  • For AF with contraindication to anticoagulation
  • PROTECT-AF, PREVAIL

377.3.3 High-Yield Specialist Points

377.3.3.1 NIHSS Scale

  • 0-42
  • 0 normal
  • 1-4 minor
  • 5-15 moderate
  • 16-20 moderate-severe

  • 20 severe

377.3.3.2 ASPECTS Score

  • Alberta Stroke Program Early CT Score
  • 10 regions of MCA territory
  • Subtract 1 for each affected
  • Higher = better
  • Threshold ≥ 6 for thrombectomy traditional (expanded by SELECT-2 etc.)

377.3.3.3 Pre-Stroke Mortality

  • 1-month mortality 8-15%
  • Higher with severity, age, comorbidities

377.3.3.4 Hemorrhagic Transformation

  • Risk after thrombolysis ~ 6%
  • Symptomatic ICH ~ 2-3%
  • Risk factors: severity, age, glucose, BP, time

377.3.3.5 Stroke Mimics

  • Migraine
  • Seizure (Todd paralysis)
  • Hypoglycemia
  • Conversion disorder
  • Bell palsy
  • Hemiplegic migraine
  • MS exacerbation
  • ICH (need imaging!)
  • Tumor

377.3.3.6 Embolic Stroke of Undetermined Source (ESUS)

  • Non-lacunar with no identified source
  • Currently aspirin (NAVIGATE-ESUS rivaroxaban negative; RE-SPECT-ESUS dabigatran negative)
  • Look for occult AF + PFO + cancer

377.3.3.7 Stroke in Young

  • Different etiology
  • Dissection, hypercoagulable, paradoxical (PFO), drug use, vasculitis, CADASIL, MELAS, Fabry
  • Workup more extensive

377.3.3.8 Stroke in Pregnancy/Postpartum

  • Increased risk
  • Causes: PRES, RCVS, eclampsia, CVST, peripartum cardiomyopathy
  • Management challenging
  • Multidisciplinary

377.3.3.9 Vascular Cognitive Impairment

  • Stepwise decline
  • Mixed AD-vascular common

377.3.3.10 Telestroke

  • Tele-medicine for acute stroke
  • Rural access to thrombolysis decisions

377.3.3.11 Mobile Stroke Units

  • CT in ambulance
  • B_PROUD (2021) positive
  • Spreading

377.3.3.12 Neuroprotection

  • Many trials negative
  • NA-1 (nerinetide) — ESCAPE-NA1 was negative
  • Edaravone (Japan)

377.3.3.13 Anti-Inflammatory

  • Several agents tested

377.3.4 Pearls

  • 85% ischemic, 15% hemorrhagic
  • TOAST classification
  • MCA, ACA, PCA, vertebrobasilar, lacunar syndromes
  • Alteplase ≀ 4.5 hr; tenecteplase emerging
  • Thrombectomy ≀ 6 hr standard, ≀ 24 hr extended (DAWN, DEFUSE-3)
  • MR-CLEAN-LATE, SELECT-2, ANGEL-ASPECT (2023): expanded eligibility
  • Basilar trials (BAOCHE, ATTENTION 2022): thrombectomy
  • Secondary prevention multifactorial
  • DAPT short-term (CHANCE/POINT) for high-risk minor stroke/TIA
  • AF: DOACs preferred
  • Carotid stenosis symptomatic 50-99%: CEA
  • PFO closure for cryptogenic in young
  • Stroke unit + rehab