個案討論：ST段上升心肌梗塞後缺血性腦梗塞之成因與治療

A case of ST elevation myocardial infarction with concurrent ischemic stroke: etiology and therapy

急性心肌梗塞後之缺血性腦梗塞發生率低，但同時合併急性心肌梗塞和缺血性腦梗塞，患者的死亡率會明顯上升。常見的原因包括心肌梗塞後新發生的心房顫動、左心室前壁梗塞引起的心室內血栓或病患本身有凝血異常的疾病。一位64 歲男性患有ST上升型心肌梗塞合併心因性休克而住院，心導管檢查顯示左主冠狀動脈至左前降支和左迴旋支阻塞，接受緊急心導管介入治療，由於生命徵象不穩定，使用強心劑、主動脈氣球幫浦和呼吸器以維持血流動力學，按照現行治療指引使用雙重抗血小板藥物和抗凝劑治療，而後病況逐漸穩定。然而，移除主動脈氣球幫浦後，發生缺血性腦梗塞併有左側偏癱和失語症。病人接受顱內動脈取栓術後恢復良好，美國國家衛生院腦中風評估表(NIHSS)從 14 分下降到2分。我們詳細回顧了心肌梗塞後缺血性腦梗塞的病生理機轉，包含左心室功能下降造成血液鬱積、心內膜缺血壞死造成發炎反應、新發生的心房顫動或本身凝血功能異常容易產生血栓。若是和心房顫動相關，按照現行治療指引使用抗血小板藥物和非維他命K拮抗劑類口服抗凝血劑治療為主，若為左心室內血栓可以抗凝血劑治療三到六個月後再追蹤，但目前無隨機對照試驗顯示哪一種抗凝血劑效果較好。

 

Post-myocardial infarction (MI) ischemic stroke is rare but increases mortality than those not complicated with stroke. Here, we present a 64-year-old man suffered from ST segment elevation myocardial infarction and complicated with cardiogenic shock. Primary percutaneous coronary intervention was done for left main to left anterior descending. Inotropic agent, intra-arterial balloon pump (IABP) and me-chanical ventilator support were used for unstable hemodynamics. Dual anti-platelet and anticoagulation were used as guideline recommendation. However, ischemic stroke happened with left side hemiplegia and aphasia after removing IABP. In-tra-arterial thrombectomy was done for right middle cerebral infarct. National Insti-tutes of Health Stroke Scale improved from 14 to 2 after thrombectomy. The patho-genesis of post-MI stroke includes extensive anterior wall akinesia leading to blood stasis, inflammatory changes by subendocardial injury, new onset atrial fibrillation (AF), and hypercoagulable status. Preexisting AF with acute coronary syndrome has clear recommendation with antithrombotic therapy with anti-platelet and non-vitamin K antagonist oral anticoagulant (NOAC) use. However, stroke preven-tion after acute MI is limited for those without AF. Guidelines suggest considering anticoagulation for 3 to 6 months once LV thrombus observed, but there was no ran-domized controlled trial to confirm which anticoagulant is better.