作者： 蔡昇達
過年前的一天晚上 11:55，外院轉診的急性腦中風患者抵達，正在評估中風嚴重度時，床尾突然有個熟悉的聲音叫我，「蔡醫師」。原來眼前的這位正是我之前門診照顧多年的患者，每次皆是兒子帶著她，開車近兩個小時前來，往事也漸漸浮現。
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照片一，第一次中風的腦部影像，白色楕圓的區域即為中風的地方 (箭頭所指)
六年前患者第一次腦中風，在左腦皮質處，檢查發現有三高(糖尿病、高血壓、高血脂)，開始藥物治療，但影像的特徵和病人的症狀(時常心悸)，提醒著我可能是心房顫動(一種心律不整)造成的中風，但做了三張一次性的心電圖，及 24 小時心電圖，皆未發現心律不整，故以三高造成的中風治療，給予抗血小板藥物(Aspirin or Clopidogrel)。兩年前又發生一次中風，一樣未發現心律不整，這次又中風，嚴重度很高，不過兒子及女兒有了兩次的經驗，非常警覺，兒子送媽媽上床睡覺時覺得媽媽怎麼突然不動、不講話了，立刻知道又中風了，馬上送到急診室，醫師也立即施打了血栓溶解劑，轉到我們醫院，症狀已大幅改善，外院急診的心電圖見心房顫動、本院剛做完的 24 小時心電圖(執行原因：時常心悸)也證實為心房顫動。
這六年來我向兒子解釋時，時常會提到心律不整，並不定時安排心臟的檢查，這次跟他說明，「中風的兇手終於現形了，是心房顫動，一種心律不整」，兒子聽完後非常狐疑的問我，「心律不整會中風？」讓我頗為驚訝，這六年來兒子親力親為照顧媽媽，各種檢查、治療皆問得非常詳細，對中風的知識已接近醫療人員水準，但這項我跟他講了數年的概念，卻仍然無法了解，讓我知道這件事的複雜性，也決定寫下這篇文章。
簡單的說，當心臟發生心房顫動時，心臟上面的「心房」不再正常收縮，而是像在抖動，沒有真正把血擠出去，結果造成血流變慢、變亂，因而容易形成血栓 (古文說，戶樞不蠹，流水不腐)，而血栓跑出心臟，到達腦部血管，即造成栓塞性腦中風(embolic stroke)。而這種中風，所要吃的藥是不同的，抗血小板藥物(Aspirin, Clopidogrel, Cilostazol……等)是不足夠的，必須要升級至抗凝血藥物(Dabigatran, Rivaroxaban, Apixaban, Edoxaban, Warfarin……等)，而前任美國總統拜登，即是長期服用抗凝血藥，避免心房顫動造成栓塞性腦中風。
病歷整理完、向兒子說明完整，差不多時間要入住加護病房了，陪著患者搭電梯的時候，問了她一句，「記得我是誰嗎？」這時阿姨突然很清楚的跟我說，「你出國進修兩年，回來了，歡迎回來過年！」聽完很感動，感謝阿姨把我記住，也再次體會到血栓溶解劑的威力，可以讓嚴重的症狀很快改善、恢復正常。實在是相當棒的見面禮。
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照片二，此次中風的腦部影像，白色的區域即為中風的地方 (箭頭所指)
Title: Cardiac Arrhythmia Cause a Stroke?
Author: Sheng-Ta Tsai
One evening just before the Lunar New Year, at 11:55 p.m., a patient with acute ischemic stroke arrived after being transferred from another hospital. While I was assessing the severity of the stroke (The National Institutes of Health Stroke Scale, NIHSS), a familiar voice suddenly called out from the foot of the bed: “Dr. Tsai.” I immediately recognized him—she was a patient whom I had followed in the outpatient clinic for many years. Each time she visited, her son drove nearly two hours to bring her to the hospital. As I saw her again that night, many memories came back to me.
Figure 1. Brain imaging from the patient’s first stroke. The white oval region indicates the infarcted area (arrowhead).
Six years earlier, the patient had her first stroke, involving the left cerebral cortex. Examination revealed three major vascular risk factors—diabetes mellitus, hypertension, and hyperlipidemia—and medical treatment was initiated accordingly. However, both the imaging characteristics and the patient’s symptoms (frequent palpitations) suggested the possibility of atrial fibrillation, a type of cardiac arrhythmia that can lead to stroke. We performed three standard electrocardiograms as well as a 24-hour Holter monitor, but none detected any arrhythmia. Therefore, the stroke was treated as one related to vascular risk factors, and antiplatelet therapy (such as aspirin or clopidogrel) was prescribed.
Two years ago, she suffered another stroke. Again, no arrhythmia was detected. This time, however, the stroke was more severe. Fortunately, her son and daughter had gained experience from the previous events and were extremely vigilant. When her son helped his mother into bed that evening, he noticed that she suddenly stopped moving and speaking. Realizing that she might be having another stroke, he immediately took her to the emergency department. The emergency physician promptly administered thrombolytic therapy, and she was transferred to our hospital. By the time she arrived, her symptoms had already improved substantially. An electrocardiogram performed in the referring hospital’s emergency department revealed atrial fibrillation, and the 24-hour Holter monitoring we had just completed at our hospital (ordered because of her frequent palpitations) also confirmed atrial fibrillation.
Over the past six years, whenever I explained her condition to her son, I frequently mentioned the possibility of arrhythmia and arranged cardiac evaluations periodically. This time I told him, “The culprit behind the stroke has finally appeared—it is atrial fibrillation, a type of arrhythmia.” The son looked puzzled and asked, “Arrhythmia can cause stroke?” I was quite surprised. For six years he had devoted himself to caring for his mother, asking detailed questions about every examination and treatment. His understanding of stroke was almost at the level of a healthcare professional. Yet this concept—one that I had explained to him repeatedly over the years—remained difficult to grasp. At that moment I realized how complex this issue can be, which prompted me to write this article.
In simple terms, when atrial fibrillation occurs, the upper chambers of the heart—the atria—no longer contract normally. Instead, they quiver ineffectively and fail to pump blood efficiently. As a result, blood flow becomes sluggish and disorganized, which promotes the formation of blood clots (as an old saying suggests, “a moving hinge does not rust, and flowing water does not stagnate”). If such a clot travels out of the heart and reaches the blood vessels of the brain, it can block the vessel and cause an embolic stroke. The medications required to prevent this type of stroke are different. Antiplatelet agents (such as aspirin, clopidogrel, or cilostazol) are not sufficient; treatment must be escalated to anticoagulant therapy (such as dabigatran, rivaroxaban, apixaban, edoxaban, or warfarin). For example, former U.S. President Joe Biden has reportedly taken long-term anticoagulant therapy to prevent embolic stroke associated with asymptomatic atrial fibrillation.
After completing the medical documentation and explaining the situation thoroughly to her son, it was time for the patient to be admitted to the intensive care unit. While accompanying her in the elevator, I asked gently, “Do you remember who I am?” The patient suddenly replied clearly, “You went abroad for two years of training, and now you’re back—welcome home for the New Year!” I was deeply touched. I felt grateful that she still remembered me, and it reminded me once again of the remarkable effectiveness of thrombolytic therapy, which can rapidly improve even severe neurological symptoms and restore normal function. It was truly a wonderful reunion gift.
Figure 2. Brain imaging from the most recent stroke. The white area indicates the infarcted region (arrowhead).
