Case 4: Stenting or Medication?

Cuong Tran Chi MD.PhD;  Dang Nguyen MMed (Rad); Chinh Nguyen Duc MD

University Medical Center HCM City, Vietnam 


A 69-year-old Vietnamese gentleman presented to HCM City Medical University Hospital with right hand weakness after an episode of convulsion on his right arm in about half a minute. During the event, he was still alert and felt a tingling - numbness sensation on the right face. He also complained of deviation of his face to the right side in the contracture.

On examination, he was alert with normal vital signs. He had mild palsy of the left VII nerve and there was slight reduction of his movement on the right arm and right leg (4/5 or above), however, he still can ambulate well with no assistance.

His history is significant with high blood pressure which has been on antihypertensive drugs. He also had similar symptoms 4 months ago with the diagnosis of severe left M1 stenosis and chronic occlusion of right M1 which was treated with clopidogrel 75mg PO daily and aspirin 81mg PO daily. He is a chronic smoker with 1 pack-year. 

MRI was done and showed a focus of old lacuna infarct at the right basal ganglia and small focal infarct at left corona radiata. MRA TOF showed no signal of the right middle cerebral artery (MCA) with cut-off appearance at M1 portion suggestive of right MCA occlusion. There was also significant stenosis at M1 portion of the left MCA.

His biological studies showed normal renal and liver functions. There were increase in serum cholesterol (223mg/dl) and triglyceride (387mg/dl).

A discussion between neurointervention team, neurologists and neurosurgeons was organized. There were different opinions about the treatment strategies and finally the patient was keep treated conservatively. He was administered aspirin 162mg PO bid, plavix 75mg PO daily and rosuvastatin 10mg PO daily. Currently (three days after admission), he still has mild right upper and lower limb weakness with mild left VII nerve palsy, however, his daily life is not much affected with almost no dependency. His Glasgow comma scale and blood pressure are normal.

Figure: MRA TOF of the patient upon admission.


What is your opinion about the management for this patient?

a. Medication only.

b. Angioplasty/ stenting of the left MCA stenosis.

c. Angioplasty/ stenting of the left MCA stenosis after being failed with another stretch of medication.

d. Others.

* We will follow up this patient and update you on the AAFITN 2014 in Danang during cases discussion.