377.4 📋 章末速蚘 Summary

377.4.1 🔑 䞀句話瞜結

Stroke = 2nd leading cause of death worldwide + leading cause of long-term disability; ischemic ~ 85% vs hemorrhagic 15% (ICH 10% + SAH 5%); TOAST etiology classification — (1) large-artery atherosclerosis (20-25%) carotid/vertebrobasilar/intracranial, (2) cardioembolic (20-30%) AF most common + MI/LV thrombus + valves + cardiomyopathy + endocarditis + PFO paradoxical + cardiac tumors, (3) small-vessel lacunar (20-25%) lipohyalinosis chronic HTN/DM — pure motor (posterior limb IC) + pure sensory (thalamus) + sensorimotor + ataxic hemiparesis + dysarthria-clumsy hand, (4) other (5%) — dissection (young!) + vasculitis (PACNS, GCA) + hypercoagulable + hereditary (CADASIL NOTCH3, Fabry α-Gal A) + drug use (cocaine, amphetamine) + RCVS (postpartum, vasoactive drugs), (5) cryptogenic 25-30% (ESUS); vascular territory syndromes — MCA (contralateral face + arm > leg + aphasia dominant or neglect non-dominant + gaze toward lesion) + ACA (leg > arm + cognitive) + PCA (homonymous hemianopia macular sparing + memory + thalamic) + vertebrobasilar (crossed signs, cranial nerves, ataxia, vertigo, top of basilar LOC, locked-in ventral pons) + cerebellar (5 Ds, obstructive hydrocephalus risk) + lacunar; acute workup — time is brain (1.9 million neurons/min die), door-to-needle < 60 min, door-to-groin < 90-120 min; NIHSS + CT head non-contrast + ASPECTS + CTA head/neck + CT perfusion + MRI DWI (definitive); labs + ECG + echo + carotid imaging + Holter/ILR (occult AF); acute treatment 2015-2024 paradigm: IV thrombolysis alteplase 0.9 mg/kg (10% bolus + 90% over 60 min) ≀ 4.5 hr → tenecteplase TNK 0.25 mg/kg single bolus (ATTEST-2/AcT/TWIST 2022-2023 equivalent/non-inferior, easier admin, increasing adoption) + mechanical thrombectomy LVO ≀ 6 hr standard → DAWN (2018) + DEFUSE-3 (2018) extended window 6-24 hr with clinical/perfusion mismatch + MR-CLEAN-LATE (2023) less strict criteria 6-24 hr + SELECT-2/ANGEL-ASPECT/RESCUE-Japan-LIMIT (2022-2023) expanded large core eligibility ASPECTS 3-5 + basilar BAOCHE/ATTENTION (2022) thrombectomy beneficial extended window; alteplase contraindications — hemorrhage, recent stroke/surgery/major bleed, INR > 1.7, BP > 185/110 (treat first), glucose < 50 or > 400; acute BP pre-tPA < 185/110, post-tPA < 180/105 × 24 hr, no reperfusion permissive unless > 220/120; hemicraniectomy malignant MCA within 48 hr age < 60 best benefit (saves lives, disability burden); secondary prevention — antiplatelet (non-cardioembolic) aspirin 50-325 mg/d first-line + clopidogrel + aspirin/dipyridamole (Aggrenox); DAPT short-term — CHANCE/POINT ASA + clopidogrel × 21 days for high-risk minor stroke/TIA + THALES ASA + ticagrelor × 30 days; anticoagulation cardioembolic AF — DOACs preferred (apixaban/dabigatran/rivaroxaban/edoxaban) + warfarin for mechanical valves only + APLS warfarin (TRAPS suggests caution with DOACs); high-intensity statin atorvastatin 80 mg or rosuvastatin 20-40 mg + LDL target < 70 (SPARCL); BP target < 130/80; DM A1c < 7% individualized; lifestyle smoking + Mediterranean diet + exercise + weight; carotid intervention — symptomatic 50-99% CEA preferred (NASCET) within 2 weeks ideal + asymptomatic 70-99% CEA if life expectancy > 5 years + CAS alternative younger/high-risk; PFO closure cryptogenic in young (< 60) with high-risk features (RoPE score) — RESPECT/REDUCE/CLOSE; AF detection extended monitoring + ILR (CRYSTAL-AF, STROKE-AF); post-stroke care stroke unit (reduces mortality) + dysphagia screen + DVT prevention + early rehab + depression SSRIs。

377.4.2 💊 治療粟芁

  • IV alteplase0.9 mg/kg IV (10% bolus, 90% over 60 min) within 4.5 hours symptom onset — inclusion age ≥ 18 + disabling deficit; exclusions ICH/recent stroke/major surgery/INR > 1.7/BP > 185/110/glucose < 50 or > 400
  • IV tenecteplase0.25 mg/kg single IV bolus within 4.5 hr (emerging standard, easier admin, equivalent — AcT/ATTEST-2/TWIST 2022-2023)
  • mechanical thrombectomyLVO (ICA, M1, M2, basilar) within 6 hr standard + 6-24 hr extended window with clinical-imaging mismatch (DAWN) or perfusion-imaging mismatch (DEFUSE-3) + MR-CLEAN-LATE less strict criteria + SELECT-2/ANGEL-ASPECT/RESCUE-Japan-LIMIT for large core ASPECTS 3-5
  • acute BPpre-tPA < 185/110 (treat with labetalol 10-20 mg IV q10 min or nicardipine 5 mg/h titrate); post-tPA < 180/105 × 24 hr; no reperfusion permissive unless > 220/120
  • acute glucosetarget 140-180 mg/dL
  • antiplatelet (non-cardioembolic)aspirin 50-325 mg/d or clopidogrel 75 mg/d or aspirin + ER dipyridamole (Aggrenox); DAPT short-term ASA + clopidogrel × 21 days (CHANCE/POINT) for high-risk minor stroke (NIHSS ≀ 3) / TIA (ABCD2 ≥ 4) then aspirin alone
  • anticoagulation cardioembolicDOACs first-line for AF — apixaban 5 mg BID (2.5 if 2 of: age ≥ 80, weight ≀ 60 kg, Cr ≥ 1.5) + dabigatran 150 mg BID + rivaroxaban 20 mg daily + edoxaban 60 mg daily; warfarin INR 2-3 for mechanical valve only
  • high-intensity statinatorvastatin 80 mg or rosuvastatin 20-40 mg + LDL target < 70 (SPARCL)
  • BP secondary preventiontarget < 130/80 (most), ACEI/ARB + thiazide + CCB combinations
  • carotid interventionCEA for symptomatic 50-99% within 2 weeks ideal (NASCET); CAS alternative younger/high-risk for surgery; asymptomatic 70-99% CEA if life expectancy > 5 years + surgical risk < 3%
  • PFO closurecryptogenic stroke in young (< 60) with high-risk PFO features (large shunt, atrial septal aneurysm, RoPE score)

377.4.3 🎯 盧醫垫的考前提醒

  1. TOAST classification (memorize 5 categories): (1) large-artery atherosclerosis + (2) cardioembolic (AF most common) + (3) small-vessel lacunar + (4) other (dissection, vasculitis, hypercoagulable, hereditary, drug, RCVS) + (5) cryptogenic (ESUS)
  2. Vascular territory syndromes: MCA (face + arm > leg + aphasia/neglect) + ACA (leg > arm + cognitive) + PCA (hemianopia + memory + thalamic) + vertebrobasilar (crossed signs + cranial nerves + ataxia + vertigo) + lacunar (pure motor IC, pure sensory thalamus, ataxic hemiparesis, dysarthria-clumsy hand)
  3. Time windows (memorize): IV alteplase ≀ 4.5 hr + IV tenecteplase ≀ 4.5 hr (emerging equivalent, easier — single bolus 0.25 mg/kg) + mechanical thrombectomy ≀ 6 hr standard + 6-24 hr extended (DAWN, DEFUSE-3 2018, MR-CLEAN-LATE 2023)
  4. LVO thrombectomy criteria: ICA + M1 + M2 + basilar + NIHSS ≥ 6 + ASPECTS ≥ 6 (expanded by SELECT-2/ANGEL-ASPECT 2023 for ASPECTS 3-5 large core) + premorbid mRS 0-1
  5. Basilar artery occlusion: devastating untreated — BAOCHE + ATTENTION (2022) thrombectomy beneficial extended window; IV thrombolysis if eligible; earlier intervention better
  6. Acute BP management: pre-tPA < 185/110 (treat with labetalol or nicardipine first), post-tPA < 180/105 × 24 hr, no reperfusion permissive unless > 220/120 (lower carefully if so)
  7. Secondary prevention multifactorial: antiplatelet (aspirin 50-325 mg/d) + DAPT short-term (CHANCE/POINT ASA + clopidogrel × 21 days for high-risk minor stroke/TIA) + anticoagulation (AF — DOACs preferred) + high-intensity statin (atorvastatin 80 or rosuvastatin 20-40, LDL < 70 SPARCL) + BP < 130/80 + DM control + lifestyle + carotid intervention + PFO closure cryptogenic young
  8. Symptomatic carotid stenosis 50-99%: CEA within 2 weeks ideal (NASCET); CAS alternative for younger or high-risk for surgery; asymptomatic 70-99% CEA if life expectancy > 5 yr + surgical risk < 3%
  9. PFO closure: cryptogenic stroke in young (< 60) + high-risk features (large shunt, atrial septal aneurysm, RoPE score) — RESPECT/REDUCE/CLOSE positive
  10. Stroke in young: think dissection (carotid headache + Horner + neck pain; vertebral occipital headache + vertigo) + hypercoagulable + paradoxical (PFO) + drug use + vasculitis + CADASIL (AD NOTCH3, anterior temporal white matter) + Fabry + MELAS + Moyamoya + RCVS; stroke mimics — migraine + seizure Todd + hypoglycemia + conversion + hemiplegic migraine + MS exacerbation + ICH + tumor (need imaging!)