作者： 蔡昇達
馬斯垂克是荷蘭古老的城市，名稱源自拉丁語「Trajectum ad Mosam」，意為「馬斯河（Meuse）上的交叉點」，羅馬人在此建造了橋樑與定居點，作為連接科隆與北海的重要貿易站。17 世紀時，因為能跨過馬斯河的橋樑僅有兩座，故此城市為兵家必爭之地，1673 年，法國國王路易十四利用聖彼得山（Sint-Pietersberg）的高地優勢砲擊城市，輕易攻下馬斯垂克，後為了防止悲劇重演，荷蘭決定在該高地上興建聖彼得堡壘(Fort Sint Pieter)。
聖彼得堡壘 (Fort Sint Pieter)
不過大家較熟悉的，應是歷史學過的《馬斯垂克條約》（Maastricht Treaty），1992年，條約在此簽署，歐洲聯盟（EU）於是成立、共同貨幣為歐元，故馬斯垂克可以說是歐盟的誕生地。
參加會議收穫最大的，是看到台灣和世界的差距，兩年前剛到 Mayo Clinic，與同團隊的神經內科醫師，Dr. Hawkes 討論腦中風，他跟我說 Mayo Clinic 已經沒有在使用 alteplase 了，皆是使用 tenecteplase (TNK)，我覺得有些驚訝，再問了他一些問題，後來他為我分析世界三大腦中風會議，ESOC、ISC、WSC，他表示 ESOC 的水準是最高的，相當推荐參加，感謝 Dr. Hawkes 的介紹，讓我毫無懸念報名此次會議。
Dr. Hawkes 是中間那位 (Dr. Hawkes is the one in the middle.)
第一天中午的場次，有位阿根廷的醫師，Matías Alet，分享他們各醫院使用血栓溶解劑的狀況，從約一年半前，2024 年的 11 月，各醫院即開始可使用 TNK，目前全國的轉換率約為 30%。演講很精彩，但也讓我深刻看到台灣和世界的差距，依據 2024 年的數據，台灣的 GDP per capita (人均國內生產毛額)為 $34,238 USD，阿根廷是 $13,970 USD，台灣是阿根廷的 2.45 倍，但我們目前只有研究計劃可使用 TNK，可知對藥廠而言，藥物進阿根廷，可得的利潤比進台灣還要高，台灣雖有傲視世界的全民健保，卻影響了新藥、新醫材的引進，更不用說有資源或是經費自己開發新藥和新醫材。
兩天半密集的課程，更新了許多腦中風的診斷和治療知識，第二天中午時一同用餐的荷蘭中年醫師問我，「這次會議是否有什麼東西是你帶回去，即可用在病人身上的？」實在是一個相當好的問題，的確參加各個會議、課程，最後要有一個帶的走的東西，「Call for action」。仔細想想，最大的收穫有三：
1. 動脈取栓後 24 小時的收縮壓，建議控制於 130-180 mmHg，壓到 130 mmHg 以下有害(會讓腦部的灌流不足)，低於 130 mmHg 時不建議使用升壓劑升壓，優先考慮增加點滴的量以增加血管內容積。
2. 中風取栓打通血管後，可以在患側施打 alteplase (0.225 mg/kg) or TNK (0.125 mg/kg)，不會增加腦出血風險，但可以改善病人的預後 (主要在 excellent outcome, mRS= 0 or 1)，建議可選取 mTICI 2b 的病人。此建議是來自九篇大型的隨機對照試驗： CHOICE (2022), PEARL (2025), POST-TNK (2025), ANGEL-TNK (2025), DATE (2025), POST-UK (2025), ATTENTION-IA (2025), IAT-TOP (2026), CHOICE2 (2026 ISC)。
3. 取栓時及取栓後使用針劑 Tirofiban 是安全的，已有許多大型的隨機對照試驗背書(如 ATILA...)，在嚴重狹窄的血管，亦可考慮在手術前即開始滴注。
除急性治療外，也聽了到院前處置、Mobile stroke unit、復健、護理的場次，得到許多啟發，如將超音波帶上直昇機，診斷中大腦動脈阻塞，診斷率可達 90% (Cerebrovasc Dis. 2012;33(3):262-71)。此次問問題時發現場地預設的麥克風高度皆頗高，我站著還要稍微抬頭才搆得到，可見歐洲人的平均身高的確是很高(感覺上應該是預設 180 公分)。
Mobile stroke unit，搭載電腦斷層機器 (Mobile stroke unit equipped with a CT scanner)
Echo on the helicopter (TCD at left MCA)
此次也有貼 poster 分享院內的幹細胞研究，有幸得到美國佛州前輩的鼓勵： 要繼續做下去，覺得很棒。
開完會後參觀前述的聖彼得堡壘和地下洞窟，很尊敬導覽員們的專業和深入的說明，尤其是歷史文化的介紹，相當棒，像是他很仔細的說明下圖的城垛射孔，上排的孔是打山丘上下來的敵軍、下方的是打已經靠近城牆邊緣的，每個孔裡面站了三位士兵，每位射擊完後要清槍、重新裝彈藥，約要 20 秒，此時輪其他兩位射擊，持續不斷，而整個堡壘駐守 450 人，12 小時換一班，下班的軍人回馬斯垂克城裡的家，而此設計在 18 世紀時很有用，堡壘蓋好後共發生了兩次戰爭(法軍入侵)，但皆順利守住，保全了馬斯垂克城。
聖彼得堡壘的城垛射孔 (Loopholes at Fort Sint Pieter)
而地下洞窟，是早期蓋房子需要石灰岩(Lime stone)，故至地下挖，人為挖出來的，總共有超過兩萬條通道，後來已無使用石灰岩的需要，做了整治、請藝術家畫了些壁畫，改為文化古蹟、開放觀光。解說員也提到，萬億年前，此區域曾是溫暖的海底，故岩層中發現過著名的滄龍(Mosasarus)化石。
地下洞窟地圖 (Map of the underground caves)
恐龍壁畫 (Dinosaur mural)
English version:
Maastricht is one of the oldest cities in the Netherlands. Its name derives from the Latin Trajectum ad Mosam, meaning “crossing point on the Meuse River.” The Romans built bridges and settlements here, turning it into an important trading hub connecting Cologne and the North Sea. In the 17th century, because there were only two bridges crossing the Meuse River, Maastricht became a highly strategic military target. In 1673, King Louis XIV of France took advantage of the high ground of Sint-Pietersberg and bombarded the city, capturing Maastricht with relative ease. To prevent history from repeating itself, the Dutch later constructed Fort Sint Pieter on the hilltop.
However, what most people are more familiar with is probably the Maastricht Treaty from history textbooks. Signed here in 1992, the treaty formally established the European Union and introduced the common currency, the euro. In many ways, Maastricht can truly be considered the birthplace of the EU.
The greatest takeaway from this conference was seeing the gap between Taiwan and the rest of the world. Two years ago, when I first arrived at the Mayo Clinic, I discussed stroke treatment with a neurologist on the same team, Dr. Hawkes. He told me that Mayo Clinic had already stopped using alteplase and had completely transitioned to tenecteplase (TNK). I remember being quite surprised. After asking him more about the topic, he analyzed the world’s three major stroke conferences for me — ESOC, ISC, and WSC — and told me that ESOC was the highest-level meeting among them and highly worth attending. Thanks to Dr. Hawkes’ recommendation, I registered for this conference without hesitation.
During a lunchtime session on the first day, an Argentinian physician, Matías Alet, shared how hospitals across Argentina were using thrombolytic agents. Since around November 2024 — roughly a year and a half ago — hospitals there had begun adopting TNK, and the nationwide conversion rate has already reached approximately 30%. The lecture was excellent, but it also made me acutely aware of the gap between Taiwan and the international medical landscape. According to 2024 data, Taiwan’s GDP per capita was USD 34,238, while Argentina’s was USD 13,970. Taiwan’s figure is about 2.45 times higher. Yet in Taiwan, TNK is still available only through research protocols. This suggests that, from a pharmaceutical company’s perspective, introducing the drug into Argentina may actually be more profitable than introducing it into Taiwan. Taiwan’s world-renowned National Health Insurance system is certainly admirable, but it also affects the introduction of new drugs and medical devices — not to mention the resources and funding required to independently develop innovative therapies and technologies.
After two and a half days of intensive sessions, I updated a great deal of my knowledge regarding stroke diagnosis and treatment. At lunch on the second day, a middle-aged Dutch physician asked me a simple but profound question:
“What is one thing from this conference that you can immediately bring back and apply to your patients?”
It was an excellent question. After all, the ultimate purpose of attending conferences and courses is to come away with something actionable — a true “call for action.” Reflecting carefully, my three biggest takeaways were:
1. Following mechanical thrombectomy, systolic blood pressure during the first 24 hours should generally be maintained between 130–180 mmHg. Lowering it below 130 mmHg may actually be harmful by reducing cerebral perfusion. If the blood pressure drops below 130 mmHg, vasopressors are not recommended as the first response; increasing intravenous fluid volume to improve intravascular volume should be considered first.
2. After successful thrombectomy and vessel recanalization, intra-arterial administration of alteplase (0.225 mg/kg) or TNK (0.125 mg/kg) on the affected side appears not to increase the risk of symptomatic intracranial hemorrhage, while potentially improving patient outcomes — particularly excellent outcomes (mRS 0–1). Patients with mTICI 2b reperfusion may especially benefit. This recommendation is supported by nine major randomized controlled trials: CHOICE (2022), PEARL (2025), POST-TNK (2025), ANGEL-TNK (2025), DATE (2025), POST-UK (2025), ATTENTION-IA (2025), IAT-TOP (2026), and CHOICE2 (2026 ISC).
3. The use of intravenous tirofiban during and after thrombectomy appears to be safe, supported by multiple large randomized controlled trials (such as ATILA). In cases of severe vascular stenosis, infusion may even be considered before the procedure begins.
Beyond acute treatment, I also attended sessions on prehospital stroke care, mobile stroke units, rehabilitation, and nursing care, all of which provided tremendous inspiration. One particularly fascinating example involved bringing ultrasound equipment onto helicopters to diagnose middle cerebral artery occlusion. Reported diagnostic accuracy reached as high as 90% (Cerebrovascular Diseases. 2012;33(3):262–271).
One amusing observation during the Q&A sessions was that the venue’s microphones were all set remarkably high. Even while standing, I still had to tilt my head slightly upward to reach them. It was a subtle reminder that Europeans really are tall on average — the default height honestly felt calibrated for someone around 180 cm tall.
I also presented a poster on our hospital’s stem cell research. I was fortunate to receive encouragement from a senior physician from Florida, who told me: “You should keep going. This is really impressive.”
After the conference, I visited the previously mentioned Fort Sint Pieter and the underground caves nearby. I deeply admired the professionalism and depth of the tour guides’ explanations, especially regarding the region’s history and culture. One particularly memorable example was the detailed explanation of the fortress loopholes shown below. The upper openings were designed to target enemies descending from the hillside, while the lower openings targeted enemies who had already approached the city walls. Three soldiers were stationed at each loophole. After firing, each soldier needed approximately 20 seconds to clean and reload the musket, during which the other two soldiers continued firing in rotation, creating uninterrupted defensive fire.
The fortress housed 450 soldiers in total, working in 12-hour shifts. After duty, the soldiers would return to their homes inside Maastricht. This design proved highly effective in the 18th century. After the fortress was completed, two wars involving French invasions occurred, yet the fortress successfully defended the city both times, preserving Maastricht from capture.
As for the underground caves, they were originally man-made limestone quarries. Limestone was extensively needed for construction, so people excavated underground, eventually creating more than 20,000 interconnected tunnels. Once limestone was no longer needed, the site was restored, artists were invited to create murals, and the caves were transformed into a cultural heritage site open to tourism.
The guide also mentioned that millions of years ago, this region was once part of a warm prehistoric sea. As a result, fossils of the famous Mosasaurus were discovered within these rock layers.
