A man in his early seventies was presented with mild weakness in his left leg. He didn’t have a severe headache but numbness in his right head. He came to the hospital a day after the onset of symptoms. A brain MRI revealed an infarct in the right medial frontal lobe due to occlusion of the distal anterior cerebral artery. I diagnosed him with atherosclerotic infarction and started administering aspirin, prasugrel, ozagrel, rosuvastatin and edaravone. It is important to differentiate from arterial dissection of the anterior cerebral artery which is referred to a high prevalence among Japanese patients. If the etiology is arterial dissection, antithrombotic therapy may increase the risk of cerebral hemorrhage. Unfortunately, his symptoms worsened soon after he was admitted. A nurse told me this on the phone, and I immediately ordered a brain CT as brain MRIs are not easily performed. There was no hemorrhage. I suspected expansion of the infarct. I administered argatroban too. His risk factors are current smoking and hypertension. He is single – is it important? He has not attended a clinic since leaving his job. I told his brother on the phone the fact and the risk of hemorrhage associated with antithrombotic therapy. He said, “he could move at the ER.”
A day after admission, the left-sided hemiparesis deteriorated further. He acknowledged he could not move his left leg at all, but he answered “yes” when asked to move his left arm even though actually he could not. He had said at the ER, “I want to go home as soon as possible. Do I really have to quit smoking?” He was far from home and smoke.
WILLPOWER MELTDOWN SOMETIMES 