年會壁報論文
1.單側頸動脈炎個案報告與頸動脈超
音波長期性追蹤
陳帝亢、何玉品、陳柏霖、黃金安
台中榮民總醫院神經內科
Isolated Unilateral Carotid Vasculitis:
A Case Report and Longitudinal
Follow-up of Carotid Duplex Study
Ti-Kang Chen, Yu-Pin Ho, Po-Lin Chen,
Jin-An Huang
Department of Neurology, Neurological Institute,
Taichung Veterans General Hospital
Background: Arteritis in the carotid artery
remains a challenging disease entity that
requires clinical judgement and supportive
angiographic evidence. Here we reported
a case of isolated carotid arteritis with
longitudinal follow-up for two years using
duplex ultrasound, computed tomography
angiogram, and magnetic resonance
imaging.
Methods and Results: We presented a
30-year-old female suffering from a three-
month history of painless neck mass in the
right side. She was characterized by lumen
narrowing in the right common carotid
artery (CCA), therapeutic effects to steroid
and anti-IL6 monoclonal antibodies, and
absence of other comorbid autoimmune
disease. She underwent intravenous
methylprednisolone pulse therapy of 500
mg per day followed by metholone 8 mg
QD (prednisolone 0.2 mg/kg/day) and 6
courses of Tocilizumab (Actemra) every 8
weeks. The serial assessment for disease
activities using carotid duplex in the
following two years revealed regression of
irregular lumen narrowing but still presence
of concentric 40-50% diameter stenosis over
the right middle CCA. The unprecedented
isolated carotid vasculitis did not meet the
current diagnostic criteria of vasculitides
(CHCC2012) and EULAR (European
League Against Rheumatism), including
Takayasu arteritis, giant cell arteritis,
polyarteritis nodosa, and Behcet’s disease.
Conclusion: Long-term follow-up for
disease activities and further investigations
are warranted to clarify the underlying
pathology and classification of isolated
carotid vasculitis.
2.經 由穿顱彩色都卜勒超音波檢測蓋
倫靜脈阻塞
李香盈 1、劉子菁 1、盛文鴦 1、林浚仁 1、
胡漢華 2
1
台北榮民總醫院
2
臺北醫學大學神經醫學研究中心
Detection of Galen Vein Stenosis using
Transcranial Color-coded Sonography
Hsiang-Ying Lee1, Tzu-Ching Liu1,
Wen-Yung Sheng1, Chun-Jen Lin1, Han-Hwa Hu2
1
Department of Neurology Taipei Veterans
general Hospital
2
Taipei Medical University Neuroscience
Research Center
Case report: A 43-year-old male patient
had a fever of 39.3°C one day after being
vaccinated with the COVID-19 vaccine
(AstraZeneca) on August 6, 2021, and
fainted the next day. He denied having head
noise, tinnitus, headaches, vision defects
and sleep problems. Later, he went to the
emergency department of Taipei Veterans
General Hospital and his vital signs were
stable and within the normal ranges. He
was mentally clear without objective focal
neurological deficits. The electrocardiogram
showed sinus rhythm. Blood test results
including platelet count (182 k/ul) and
D-dimer (0.236 ug/ml) were all within the
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normal ranges. A computed tomography
(CT) scan of the brain showed a slightly
dilated appearance of the Galen vein and
distal inferior sagittal sinus with mildly
higher density. In case of suspected cerebral
venous thrombosis, we arranged brain CT
venography (CTV) and transcranial color-
coded ultrasound (TCCS) to evaluate
the Galen vein. TCCS showed a high-
velocity (-113/-58 cm/sec) turbulent flow
in the Galen vein. CTV also showed Galen
stenosis with abnormal collateral vessels and
retrograde flow through the superior vermian
vein was suspected, and no evidence of
venous thrombosis. We considered that
Galen vein narrowing was chronic, and just
an accidental finding. Magnetic resonance
venography (MRV) will be arranged to
further evaluate the anatomy of the relevant
venous system.
Discussion: As far as we know, this is the
first case of Galen vein stenosis detected by
TCCS. Cerebral venous sinus stenosis is a
common pathology that can be idiopathic or
related to enlarged arachnoid granulation,
idiopathic intracranial hypertension, or
arteriovenous fistula. However, a two-
case report of Galen vein stenosis with
retrograde flow through the superior
vermian vein caught our attention. Patients
with Galen vein stenosis are likely to be at
risk of perimesencephalic nonaneurysmal
hemorrhage due to venous hypertension in
the future. In this case, we first identified the
basal vein of Rosenthal, and then turn the
probe counterclockwise to track the BVR to
a depth of approximately 8 cm. As a result,
the Galen vein with high-velocity turbulent
flow and the midline structure of the skull
can be seen. The stenosis of Galen vein
was considered, which was later confirmed
by CTV. We believe that TCCS seems to
be a useful tool for observing real-time
232
hemodynamic changes in cerebral veins.
3. C OVID-19疫苗接種後血栓併血小
板低下症候群與腦靜脈竇栓塞
曾士耘、鄭之光
林口長庚紀念醫院神經內科部
Case Reports on Thrombosis with
Thrombocytopenia Syndrome Related
Cerebral Venous Sinus Thrombosis
after Vaccination against COVID-19
Shih-Yun Tseng, Chih-Kuang Cheng
Department of Neurology, Chang Gung Memorial
Hospital, Linkou
Introduction: During current era of
COVID-19 pandemic, vaccination against
S A R S - C o V- 2 i n f e c t i o n h a s b e c o m e
common worldwide. However, rare cases
of thrombosis with thrombocytopenia
syndrome (TTS) have been reported after
vaccination with adenovirus vector vaccines,
such as ChAdOx1-S (Oxford-AstraZeneca)
vaccine. TTS might result from an immune-
mediated response associated with platelet-
activating antibodies against platelet factor
4 (PF4). Cerebral venous sinus thrombosis
(CVST) is one of the manifestations of this
TTS, which is potentially life-threatening.
Case Report: We here describe 3 cases
of TTS related CVST after vaccination
against COVID-19, with 2 females and 1
male, aged 38 in average (29–47), all had
received Oxford-AstraZeneca vaccine, with
symptoms onset 8 days later in average (6–
10). Symptoms included headache (2 cases),
dizziness (2 cases), nausea and vomiting
(2 cases), consciousness disturbance (2
cases), seizure (1 case), and focal weakness
(1 case). Initial blood analyses revealed
severe thrombocytopenia (12000–21000/

μL) and elevated serum D-dimer level (all
>10000 ng/mL FEU). Cerebral venous sinus
thrombosis was confirmed by Computed
Tomography (CT) and Magnetic Resonance
(MR) images, with angiography and
venography included. Anti-PF4 antibodies
(by ELISA) later revealed positive in all 3
cases.
As treatment, intravenous immunoglobulinin
(IVIg, 1–2 g/kg daily for 2 days), intravenous
steroid (with Methylprednisolone
or Dexamethasone), and direct oral
anticoagulant (DOAC, with Apixaban
10mg daily separately) were provided, with
selective cryoprecipitate transfusion for
hypofibrinogenemia. Thrombocytopenia
in all 3 patients became better after
management; 2 of which were more
significant. Clinical condition of these
patients, however, improved barely. One
patient received left parietal craniotomy for
progression of intracranial hemorrhage and
cerebral edema with midline-shift, whereas
another patient was later expired.
Discussion: As increasing vaccination
accessibility in recent months in Taiwan,
TTS became a diagnosis that should not
be left behind. Current studies, despite
limitation in cases, revealed a greater
incidence in people aged <60 years, with
females outnumbered. Delay onset after
vaccination is a specific characteristic of
TTS, with median time from vaccination
to symptoms onset 8–9 days, which is
compatible with which of our cases. Our
diagnoses are based on WHO classification
of TTS of current WHO guideline, while
our 3 cases are all categorized into level
1 as confirmed cases. Current consensus
of management included IVIg and non-
heparin-based anticoagulants. The timing
to start IVIg and the dosage given are
still controversial, as awaiting anti-PF4
年會壁報論文
antibodies data before IVIg infusion due
to lack of accessibility to analyses might
result in delayed treatment. Further studies
are required to determine the incidence
of different races or regions, possible risk
factors, and management for TTS related
CVST.
4.探 討心房纖維顫動病人edoxaban血
中濃度之影響因子
林欣儀 1, 2、郭錦樺 2、賀立婷 3、劉言彬 3、
黃織芬 1, 2、湯頌君 4、鄭建興 4
1
台大醫院藥劑部
2
臺灣大學藥學專業學院藥學系
3
台大醫院內科部暨心血管中心
4
台大醫院神經部暨腦中風中心
Factors Associated with Edoxaban
Concentration among Patients with
Atrial Fibrillation
Shin-Yi Lin1, 2, Ching-Hua Kuo2, Li-Ting Ho3,
Yen-Bin Liu3, Chih-Fen Huang1, 2,
Sung-Chun Tang4, Jiann-Shing Jeng4
1
Department of Pharmacy, National Taiwan
University Hospital, Taipei, Taiwan
2
School of Pharmacy, College of Medicine,
National Taiwan University, Taipei, Taiwan
3
Cardiovascular Center and Division of
Cardiology, Department of Internal Medicine,
National Taiwan University Hospital, Taipei,
Taiwan
4
Stroke Center and Department of Neurology,
National Taiwan University Hospital, Taipei,
Taiwan
Background and Purpose: Edoxaban
exposure varies across different ethnicities.
The purpose of our study was to examine
the risk factors associated with high or
low edoxaban concentrations in Asian
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 年會壁報論文
populations.
Methods: Participants with atrial fibrillation
who were undergoing edoxaban therapy
were enrolled. Peak (1–4 h after edoxaban
administration) and trough (24 ± 4 h from
the last edoxaban dose) blood samples
were collected to measure edoxaban
concentrations using ultrahigh-performance
liquid chromatography with tandem mass
spectrometry. The edoxaban concentrations
were compared to those observed in
clinical trials to define a higher- or lower-
than-expected range. Multivariate logistic
regression was used to analyze the risk
factors associated with high or low edoxaban
concentrations.
Results: Eighty participants (49 men,
61.3%) were enrolled and provided 78
trough and 76 peak samples. Twenty
participants (25.6%) were determined to
have low trough concentrations, which was
associated with higher creatinine clearance
and the use of the 30 mg regimen (odds ratio
[OR] and 95% confidence interval [CI],
1.06 [1.01, 1.11], p = 0.01 and 5.77 [1.34,
24.75], p = 0.02, respectively). In contrast,
21 participants (27.6%) had high peak
concentrations, which was associated with
an off-label overdosing regimen (OR = 4.68
[1.23, 17.70], p = 0.02).
Conclusion: Our study identified factors
associated with increased or decreased
edoxaban exposure. The measurement
of edoxaban concentration may be
recommended for patients with selected
characteristics.
5.壁 眼雙側核間性眼肌麻痹：案例報
告與文獻回顧
周鴻杰、楊立宇、莊介森
彰化基督教醫院神經科
234
Wall-Eyed Bilateral Internuclear
Ophthalmoplegia: A Case Report and
Literature Review
Hong-Jie Jhou, Li-Yu Yang, Chieh-Sen Chuang
Department of Neurology, Changhua Christian
Hospital, Changhua, Taiwan
Background and Purpose: Wall-eyed
bilateral internuclear ophthalmoplegia
(WEBINO) is a rare manifestation including
a bilateral adduction impairment and primary
gaze exotropia. Herein, we present a young
Taiwanese male presented with sudden onset
dizziness and blurred vision.
Case Report: A 59-year-old right-handed
male had a history of type II diabetes
mellitus with poor control. He came to
emergency department (ED) because of
sudden onset diplopia. On ED, He was alert
and vital signs were stable. On neurological
examination, no visual field defects were
observed. In primary gaze position, he
showed exotropia on the right side without
ptosis and nystagmus. Bilateral adduction
deficits of the eyes with convergence
impairment was noted. Function of cranial
nerve was intact. The motor function,
coordination, and sensory and autonomic
nervous systems were not involved. Initial
laboratory investigation demonstrated
hyperglycemia and mild hyponatremia.
To confirm the localization, and highly
suspect brainstem lesions, brain magnetic
resonance imaging (MRI) was arranged and
revealed a small lesion in the median dorsal
pons with a faint signal hyper-intensity
on diffusion weighted imaging and a low
value on apparent diffusion coefficient
mapping. The intracranial MR angiography
study shows no apparent intracranial great
vessels occlusion or blood flow interruption.
Echocardiography showed trivial mitral
regurgitation with normal ejection function

(74%). 24-hour Holter showed sinus
rhythm. Carotid echography showed mild to
moderate carotid atherosclerosis. The patient
discharged with stable condition.
Discussion: In 1971, Lubow and colleagues
precisely introduced the term “Wall-eyed
bilateral internuclear ophthalmoplegia”,
a rarely reported manifestation resulted
from a midbrain lesion involving the
medial rectus subnuclei and bilateral
medial longitudinal fasciculus (MLF).
Inflammatory, toxin, infection, degeneration,
trauma, demyelination and cancer are
common etiology; however, cerebral
ischemia might be more commonly related
to unilateral internuclear ophthalmoplegia,
whereas multiple sclerosis is more
frequently associated with bilateral
internuclear ophthalmoplegia. In our case,
we believed that the acute onset pontine
infarction was likely to the diagnosis
according to the presence of vascular risk
factors. Importantly, the other diagnoses
such as the one and-a-half syndrome
presenting unilateral horizontal gaze palsy
and internuclear ophthalmoplegia should
be considered to make a more precise
diagnosis.
6.利 用智慧型手機應用程式增進院際
交班以縮短急性腦中風病人到院至
治療時間
王其聖 1、白晏瑋 1、崔源生 2、陳柏霖 1、
黃金安 1
1
台中榮民總醫院神經醫學中心神經內科
2
台中榮民總醫院神經醫學中心神經外科
To Shorten the Door-to-puncture
Time by the Usage of a Smartphone
Application for Inter-hospital Shift
Change: A Case Report
年會壁報論文
Chi-Sheng Wang1, Yen-Wei Pai1, Yuang-Seng
Tsuei2, Po-Lin Chen1, Jin-An Huang1
1
Department of Neurology, Neurological
Institute, Taichung Veterans General Hospital
2
Department of Neurosurgery, Neurological
Institute, Taichung Veterans General Hospital
Background: Large artery occlusion (LAO)
is a common cause of ischemic stroke, and
ischemic stroke due to LAO predominates
as a cause of disability, institutionalized,
and costs to healthcare and society. The
most important therapeutic strategy for
LAO is recanalization in hyper-acute stage.
Every 10-minutes delay of recanalization
can decrease one’s chance of functional
independence. Nowadays, many large-
scale clinical trials confirmed the benefit
of endovascular treatment (EVT) for
recanalization. However, EVT is a highly
technical and facility-dependent procedure.
Primary hospitals need to transfer patients
to comprehensive stroke centers to perform
EVT. During inter-hospital transfer, the
communication barriers may prolong door-
to-puncture (DTP) time and decrease the
chance of the patient’s proper recovery.
To shorten the DTP time of inter-hospital
transfer patients, we began using a
smartphone application, “LINE,” to facilitate
inter-hospital shift change since September,
2020. Here we report a case of inter-hospital
transfer for EVT. We successfully shorten
the DTP time by the usage of a smartphone
application for inter-hospital shift change.
Case Report: Mrs. Lai, a 71-year-old
female, presented with sudden onset right
limbs weakness with no verbal output at
17:20 on July 14, 2021. She was sent to
regional hospital by ambulance. Tracing
back, she had medical history of early stage
colon cancer status post surgical resection,
and traumatic intracerebral hemorrhage
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 年會壁報論文
(ICH) status post surgical treatment on 2011.
There were no obvious sequelae and her
baseline condition was totally independent.
We initially received a message from the
LINE encrypted group about this patient’s
condition. At regional hospital, NE showed
global aphasia, right central type facial palsy
and right hemiparesis. National Institute of
Health Stroke Scale (NIHSS) score was 15.
Brain non-contrast CT revealed no ICH. IV
rt-PA was contraindicated due to previous
traumatic ICH. Then brain CT angiography
(CTA) and perfusion scan was carried out by
RAPID system and simultaneously contact
our hospital, Taichung Veterans General
Hospital (VGHTC), a comprehensive stroke
centers in middle Taiwan. While our duty
neurologist obtained the current condition,
we confirmed the request of transfer and
started to contact the EVT team, including
operator, anesthesiologist, radiologist
and operating room nurses. The CTA and
perfusion scan was done and upload to the
LINE encrypted group, which revealed left
MCA M2 occlusion, infarction core 0 ml and
penumbra volume 86 ml. We also checked
the blood test including renal function and
PT/aPTT was all within normal range. Then
patient promptly transfer to our hospital and
arrived at 20:30.
At arrival, the EVT team was well standby.
We re-evaluated the NIHSS score was
18 (right limbs MRC grade 1 and global
aphasia). We only arranged brain non-
contrast CT to confirm no ICH during
transfer because we had obtained the full
image of CTA. After informed consent was
obtained, EVT was performed immediately
and the groin puncture was prescribed
at 21:32. The DTP time was 62 minutes.
Successful recanalization was achieved, with
mTICI scored 3. The NIHSS consequently
improved from 18 to 8 and the muscle power
236
of right limbs improved from MRC grade
1 to 4+. Besides, she could chat with others
and walk independently.
Conclusion: In VGHTC, we had
approximately 600 acute ischemic stroke
patients and we served around 80 EVT
cases each year. The mean DTP time in our
hospital was 127.77 minutes in 2021. In this
case, the usage of smartphone application
made us overcome the communication
barrier and build up inter-hospital
connection, thus we achieved the ultra-brief
DTP time. This experience demonstrated the
importance of inter-hospital communication
in hyper-acute stroke care, especially in
inter-hospital transfer for EVT.
7.抗 磷脂症候群引起反覆缺血性腦中
風之個案報告
湯仕安、鍾芷萍
台北榮民總醫院神經醫學中心神經內科
A Case of Recurrent Ischemic Stroke
due to Antiphospholipid Syndrome
Shih-An Tang, Chih-Ping Chung
Department of Neurology, Neurological Institute,
Taipei Veterans General Hospital
A 51-year-old man was admitted in Sep
2020 due to stepwise progression of
unsteady gait and cognitive decline. In April
2009, the patient suffered from vertigo and
sought medical attention at another center.
Brain MRI showed acute infarction in right
cerebellar hemisphere and lab analysis
revealed the presence of antiphospholipid
antibodies. Primary antiphospholipid
syndrome was later diagnosed and aspirin
100mg QD was prescribed as the patient
was reluctant to take anticoagulants. In
Nov 2010, the patient suffered from acute

blurred vision. MRI showed infarction in
the left occipital lobe. He continued to take
aspirin then. In March 2011, he visited
our hospital for the first time. He was
recommended to take warfarin with an INR
target of 2-3. In March 2012, the patient was
hospitalized to our nephrology ward due
to acute kidney injury and abdominal pain.
His INR level was 1.87 upon presentation.
During hospitalization, right lower limb
weakness developed. Brain MRI showed
multiple small foci of restricted diffusion
in bilateral frontal, right parietal, and right
cerebellar hemisphere. Lab analysis revealed
high levels of anti-cardiolipin IgG and anti-
b2GP1 IgG. Although abdominal sonography
and CT scan showed no significant renal
or mesenteric thrombosis, mycophenolate
mofetil and cyclosporin were added for fear
of catastrophic APS. In the following year,
he received warfarin, mycophenolate mofetil
and cyclosporin. However, he suffered yet
another episode of acute kidney injury and
abdominal pain, and was hospitalized in
Oct 2014. Imaging, once again, showed no
evidence of mesentery or renal thrombosis.
Ataxic gait also developed during this
hospitalization. His INR level then was
1.50. MRI revealed tiny foci of restricted
diffusion at bilateral frontoparietal regions
and left cerebellum. His warfarin dosage
was successfully titrated to target INR 2.5-3
during hospitalization. Since 2014, warfarin,
mycophenolate mofetil and cyclosporin
were prescribed on a regular basis. However,
his INR level remained suboptimal (ranging
from 1 to 2) as he did not take warfarin
regularly. Anti-phospholipid antibodies
titers also remained high. He suffered from
a stepwise progression of unsteady gait
and cognitive decline in the past five years,
and became dependent on the activities of
daily living in 2019. In September 2020,
年會壁報論文
the patient was admitted due to progressive
unsteady gait and cognitive decline.
Neurological examination revealed poor
short-term memory, bilateral hemianopia,
right central facial palsy, right hemiparesis
(MRC 4 of 5), and wide-based gait. MRI
showed multiple old infarcts at bilateral
frontal, parietal, occipital, and cerebellar
hemispheres, as well as significant atrophy
of bilateral cerebrum and cerebellum.
Lab analysis revealed high levels of anti-
cardiolipin IgG and anti-b2GP1 IgG, and an
INR level of 1.61. We added aspirin 100mg
QD to the patient’s medication and adjusted
the dosage of his warfarin to target an INR
level of 2-3 before he was discharged.
We emphasized the importance of taking
warfarin regularly. His latest INR levels
were 2.15 and 1.99 upon follow-up in March
and April 2021. The patient remained stable
with a mRS of 3 and suffered no further
decline of neurological deficits.
8.雲 林縣區域醫療聯防機動取栓概念
應用-頸動脈支架術後併發大血管梗
塞取栓：個案報告
葉哲君 1、蕭又仁 2、楊博凱 3
1
國立成功大學附設醫院斗六分院神經科
2
國立台灣大學附設醫院雲林分院神經部
3
國立成功大學附設醫院斗六分院心臟內科
The Yunlin County Regional Medical
Joint Defense-The Concept Application
of Mobile Interventional Stroke Team:
A Case Report of IA for Post Carotid
Stent Complicated with MCA Stroke
Che-Chun Yeh1, Yu-Jen Hsiao2, Po-Ka Yang3
1
Division of Neurology, department of internal
medicine, National Cheng Kung University
Hospital Dou-Liou Branch
2
Department of Neurology, National Taiwan
237
 年會壁報論文
University Hospital Yunlin Branch
3
Division of Cardiology, department of internal
medicine, National Cheng Kung University
Hospital Dou-Liou Branch
Background: After 2015, series of studies
showed the efficacy of IA thrombectomy
superior than IV tPA alone. More and
more stroke patients got the benefit from
IA thrombectomy in the world including
Taiwan while the area seemed to be more
timely available in the medical center or
large local hospital due to the limited IA
specialists and facility. Therefore, different
treatment models were discussed including
traditional drip-and-ship model and trip-
and-treat model. We also faced the same
dilemma in our hospital.
Case Report: This is a 67-year-old man with
severe left internal carotid artery stenosis
(>70%), he was admitted for carotid stent on
2020/3/12. The procedure was smooth and he
was normal as baseline at 13:40. However,
acute onset of right hemiplegia, nearly global
aphasia and eye deviation to left side were
observed at 14:30. Brain CT showed dense
artery signs in left MCA. NIHSS: 25. Left
MCA stroke was impressed. Due to concern
of bleeding tendency of heparin used during
stent placement, IA thrombectomy was
suggested. However, patient transfer to the
hospital nearby for IA thrombectomy was
unavailable due to his critical status and full
load of the hospital nearby.
After discussion with IA specialist of
NTUH-Yunlin branch, he came to perform
IA for this patient. We also informed local
health bureau for trans-hospital service
immediately. Puncture time was at 16:29.
Left ICA occlusion of the left distal M1 with
filling defects suggested of intraluminal
thrombosis. Then, we shifted to IA rt-PA
injection because the thrombus migrated
238
to the distal MCA, which couldn’t be
removed by aspiration or stent retriever.
Residual IV rt-PA was kept for 1 hour.
Total recanalization of the left M1 could be
obtained and the residual occlusion of the
left MCA distal branches was noted (TICI
2A).
We arranged brain CT follow on 3/13 and
recent ischemic lesion in left corona radiata,
left parietal area and right cerebellar limited
amount hemorrhage were noted. The sequela
were verbal deficit and right hemiplegia
but gradually improved after aggressive
rehabilitation. He could verbal fluently and
walk independent without any assist after 3
months but residual mild right clumsy hand.
(MRS:2). The brain image follow up after
one month and one year showed stationary
ischemic lesion and well circulation in
intracranial vessels.
Conclusion: According to the patient
outcome, we are really inspired by this
mobile intervention application. The shorter
treatment times can be accomplished.
Although, many difficulty should be
overcome including the integrated
communication, medical law and insurance
payment in different hospital, it is really an
important alternative way for promoting IA
thrombectomy as first aid for every acute
large territory stroke patient.
9.台 灣全民健保申報資料腦靜脈竇栓
塞國際疾病分類碼第十版之陽性預
測值
謝鎮陽 1, 2、廖書晨 3, 4、邵時傑 2, 5、賴嘉鎮 2、
林素真 6、黃薇伊 7
1
台南新樓醫院神經內科
2
國立成功大學藥學系暨臨藥所
3
長庚大學醫學系
4
基隆長庚醫院急診醫學科

5
基隆長庚醫院藥劑科
6
美國伊利諾伊州大學芝加哥分校藥學院
7
財團法人藥害救濟基金會
Positive Predictive Value of ICD-
10 Codes for Crebral Venous Sinus
Thrombosis in Taiwan’s National Health
Insurance Claims Database
Cheng-Yang Hsieh1, 2, Shu-Chen Liao3, 4,
Shih-Chieh Shao2, 5, Edward Chia-Cheng Lai2,
Swu-Jane Lin6, Wei-I Huang7
1
Department of Neurology, Tainan Sin Lau Hospital
2
School of Pharmacy, Institute of Clinical
Pharmacy and Pharmaceutical Sciences, College
of Medicine, National Cheng Kung University
3
Chang Gung University College of Medicine
4
Department of Emergency Medicine, Keelung
Chang Gung Memorial Hospital
5
Department of Pharmacy, Keelung Chang Gung
Memorial Hospital
6
Department of Pharmacy Systems, Outcomes
and Policy, College of Pharmacy, University of
Illinois at Chicago, Chicago, IL, USA
7
Taiwan Drug Relief Foundation
Background and Purpose: This study aims
to determine the positive predictive value
(PPV) of case definitions for cerebral venous
sinus thrombosis (CVST) in Taiwan’s
National Health Insurance claims database
based on the International Classification
of Diseases, 10th Revision, Clinical
Modification (ICD-10-CM) diagnostic
codes.
Methods: Inpatient records with ICD-
10-CM codes of G08, I629, I636, or I676
were retrieved from the claims data of all
hospital branches of Chang Gung Medical
Foundation. Manual review of the medical
records and images was performed in
order to ascertain the diagnosis. The PPV
of various case definitions for CVST were
estimated.
年會壁報論文
Results: Of the 380 hospitalizations, 166
and 214 were determined to be true-positive
and false-positive episodes of acute CVST,
respectively. The PPV of the ICD-10-
CM codes of G08, I629, I636, and I676
were 88.2%, 2.0%, 100.0%, and 91.3%,
respectively. The PPV generally increased
when acute CVST was defined as a primary
diagnosis or as ICD-10-CM codes plus
anticoagulant use. Miscoding in other
conditions, tentative diagnosis, and remote
episode of CVST were determined as the
main reasons for false-positive diagnosis of
acute CVST.
Conclusion: This study determined the PPV
of ICD-10-CM codes for identifying CVST,
which may offer a reference for future
claims-based research.
10.人工智慧神經類網路模型預測急性
缺血性腦中風預後之文字探勘研究
謝孟倉 1、陳益君 2、黃瑞初 2
1
義大醫院神經科暨腦中風中心
2
義守大學電機工程學系
Artificial Intelligence with Neural
Network Modeling Optimizes Outcome
Prediction by Text Mining in Acute
Ischemic Stroke Patient
Meng-Tsang Hsieh1, I-Chun Chen2,
Rey-Chue Hwang2
1
Stroke center and Department of Neurology,
E-Da Hospital, Kaohsiung, Taiwan
2
Department of Electrical Engineering, I-Shou
University, Kaohsiung, Taiwan
Background and purpose: The discharge
modified Rankin Scale (dis-mRS) of in-
hospital stroke patients is a good parameter
to determine the functional outcome and
prognosis in clinical practice. The dis-mRS
239
 年會壁報論文
is also useful in clinical decision making,
such as programing in rehabilitation and
long-term care. In our previous study, we
had average 65% accuracy rate in predicting
dis-mRS when using artificial neural
network (ANN) and text mining of brain
magnetic resonance imaging (MRI) report.
In this study, we aimed to improving the
accuracy of dis-mRS prediction in our model
by enrolling text of admission history and
clinical information.
Methods: This study used the stroke
registry from 2016/10 to 2021/02 in E-Da
Hospital. Patients hospitalized due to
acute ischemic stroke within 10 days were
identified, and the textual reports of MRI
and present illness of admission note were
retrieved during hospitalization. The clinical
information about stroke risk factors, such
as age, hypertension, diabetes mellitus,
hyperlipidemia, smoking, atrial fibrillation,
coronary artery disease, and previous
stroke, was recorded from the stroke
registry of E-Da hospital. The mRS were
evaluated when discharged by experienced
neurologists.
We used each of the texts of MRI, text
for admission present illness, clinical
information, both of any two, or all as input
(total six categories) for model training. We
divided output as two categories: good (mRS
0-2) and poor functional outcome (mRS 3-6).
The artificial neural network (ANN) models
were built by using the context of the MRI
report, text of admission present illness, and
clinical information as input and dis-mRS as
output. We randomly selecting 25% of input
information 5 times to build the training
model. The text was used Continuous Bag of
Words (CBOW) model to transform words
to 100-dimension coding. We used BiLSTM-
CNN model architecture to combine
of recurrent and convolutional cells for
240
learning. The final architecture also includes
clustering information obtained from user
IDs.
Results: There were 2125 hospitalized
records with AIS during the study period.
There were 4999 words collected in the text
input. When using the text of MRI report
or clinical information alone to predict dis-
mRS, the accuracy was 67% and 66%. When
adding text of admission present illness, the
accuracy had a 7.4% and a 7.5% increase.
The accuracy was 72% in combination text
of MRI report and admission present illness.
Conclusion: The accuracy of our ANN
model was 72% when combining text of
MRI report and admission present illness.
Using admission present illness as input, can
improve the accuracy of predicting dis-mRS
in our ANN model.
11.依病理組織診斷顳動脈炎：超音波
特徵
葉育雯、廖乃毅、陳韋達、鍾芷萍
臺北榮民總醫院神經內科
Sonographic Characteristics in a Case
of Tissue-proof Temporal Arteritis
Yu-Wen Yeh, Nai-Yi Liao, Wei-Ta Chen,
Chih-Ping Chung
Department of Neurology, Neurological Institute,
Taipei Veterans General Hospital
Background: This is a case report of
temporal arteritis.
Results: A 78-year-old lady presented
with two weeks of non-pulsatile severe
headache over right temporal area (numeral
rating scale of pain [NRS] 10/10). There
were associated symptoms including
visual changes (visual torsion like looking
through heat waves), photophobia and poor

appetite. There was no phonophobia and
nausea/vomiting. She had no vascular risk
factors but a past history of sudden left ear
deafness in 2016. On admission, her blood
pressure, heart rate and body temperatures
were normal. However, a tortuous temporal
artery on her right side was noted. The
neurological examinations did not show
any focal neurological deficit. Her blood
examinations revealed WBC: 8000/cubic
mm with differential count segmented
neutrophil 89.1% and lymphocyte 6.3%,
Hgb: 11.8g/dL, Platelet: 344X103 cubic
mm and a significantly elevated erythrocyte
sedimentation rate (ESR): 83 mm/hr. She was
then received color-coded ultrasonography
and the result showed typical hypoechoic
wall thickening (halo sign) in right temporal
artery. Under the tentative diagnosis of
temporal arteritis, a biopsy of right temporal
artery was performed. The pathological
findings confirmed the diagnosis: neointima
hyperplasia and significant immune cell
infiltration including lymphocytes and giant
cells in the media. Patient was prescribed
methylprednisolone i.v. 1000 mg for five
days and her headache and associated
symptoms were subsided on the third day of
pulse therapy.
C o n c l u s i o n : Te m p o r a l a r t e r i t i s i s a
rare disease and mostly responsive to
prednisolone therapy. In clinical-suspected
cases, color-coded ultrasonography is a
useful tool for early diagnosis.
12.顱內椎基底動脈剝離合併無症狀快
速進展
邱詡懷 1, 2、鍾芷萍 2, 3、張豐基 2, 3、劉虹余 2, 4
1
衛生福利部桃園醫院神經內科
2
國立陽明交通大學醫學系
3
臺北榮民總醫院神經醫學中心神經內科
年會壁報論文
4
台北榮民總醫院放射線部神經放射線科
Intracranial Vertebrobasilar Artery
Dissection with Silent Rapid Progression
Hsu-Huai Chiu1, 2, Chih-Ping Chung2, 3,
Feng-Chi Chang2, 3, Hung-Yu Liu2, 4
1
Department of Neurology, Taoyuan General
Hospital, Ministry of Health and Welfare,
Taoyuan, Taiwan
2
School of Medicine, National Yang Ming Chiao
Tung University College of Medicine, Taipei,
Taiwan
3
Department of Neurology, Neurological Institute,
Taipei Veterans General Hospital, Taipei, Taiwan
4
Department of Radiology, Taipei Veterans
General Hospital, Taipei, Taiwan
Purpose: Intracranial vertebrobasilar artery
dissection (iVBD) is a potentially lethal
disease, and progression of the dissected
vessels is not uncommon. Our report is aimed
at providing further clinical experience of
the timing of follow-up vascular imaging or
endovascular intervention in iVBD patients.
Case Report: We report a case of iVBD
with silent rapid progression. The 48-year-
old woman presented as transient right
limbs weakness. Brain MRI showed a
small acute infarct over the left cerebellum,
and MRA revealed a short segment of
dissection over the left distal vertebral artery
extending to proximal basilar artery and
right distal vertebral artery. With no new
clinical symptoms and signs, follow-up of
vascular imaging within 1 week showed
progressive critical narrowing of the dissected
vertebrobasilar arteries. The blood flow of
the vertebrobasilar system was restored by
endovascular stenting.
Conclusion: iVBD might progress without
clinical manifestations. Early follow-up of
vascular imaging should be considered in the
patients with high risk for progression.
241
 年會壁報論文
13.處 置COVID-19疫苗引起的腦部靜
脈竇血栓：台灣經驗
廖誼佳 1、何泰宏 2、李怡姿 2、李怡慧 1
1
台北榮民總醫院 神經醫學中心 神經內科
2
台北榮民總醫院 急診醫學部
Management of COVID-19 Vaccine-
associated Cerebral Venous Thrombosis
in Taiwan
Yi-Chia Liaw1, Tai-Hung Ho2, Yi-Tzu Lee2,
I-Hui Lee1
1
Department of neurology, Neurological Institute,
Taipei Veterans General Hospital
2
Department of Emergency medicine, Taipei
Veterans General Hospital
C a s e re p o r t : A 2 1 - y e a r- o l d h e a l t h y
policeman developed a newly-onset
headache after vaccinated with ChAdOx1
nCoV-19 four days ago. His headache
was explosive and bilateral, accompanied
with nausea and vomiting. There was a
nocturnal predilection of the headache
which characteristically built up after
lying down or Valsalva maneuver such
as coughing. Hence, he visited our
emergency department, where his vital
signs and neurological examinations were
unremarkably fine. However, the laboratory
blood test revealed thrombocytopenia and
a prothrombotic status. Brain CT showed a
small hematoma at right frontal lobe, and
subsequent MR venogram demonstrated
multifocal cerebral sinus filling defects
at the superior sagittal sinus and left
transverse sinus, which were indicative of
cerebral venous thrombosis (CVT). After
the confirmative test for positive anti-
PF4 (platelet factor 4) auto-antibody, the
diagnosis of vaccine induced thrombotic
thrombocytopenia (VITT)-induced CVT
was made. After admission, a standard dose
of intravenous immunoglobulin (IVIG)
242
1g/kg/day as well as apixaban 5mg twice
daily were applied. His symptoms rapidly
relieved on the second day. The level of
anti-PF4 antibody was below the reference
level when tested on the third day, and his
hemogram returned to normal ranges on
the fifth day. Follow-up brain MRI two
weeks later showed a resolved hematoma
as well as patent cerebral sinuses. VITT has
been reported mostly in adenoviral vector-
based COVID-19 vaccine. As of August,
2021, the incidence of VITT in Taiwan
was 0.7/100,000, and 13.7% of them were
cerebral venous thrombosis. The clinical
features are systemic prothrombotic state and
involvement of cerebral and/or splanchnic
venous thrombosis, leading to consuming of
platelets and thrombocytopenia. Its patho-
mechanism resembles heparin induced
thrombocytopenia (HIT) as an immune-
mediated disease contributed by anti-PF4
auto-antibody. The mainstay treatment
was IVIG and non-vitamin K antagonist
anticoagulants. A timely treatment of VITT-
associated CVT results in rapid recovery and
good outcome.
14.疑似腦血管疾病的鑑別診斷：非運
動性癲癇發作
薛頌儒、張楷杰
台大醫院雲林分院神經部
台大醫院神經部
Seizure-related Focal Neurological
Deficits as a Stroke Mimic: Non-motor
Ictal Presentation of Epilepsy
Sung-Ju Hsueh, Kai-Chieh Chang
Department of Neurology, National Taiwan
University Hospital Yunlin Branch
Department of Neurology, National Taiwan
University Hospital

Background: In order to administer
adequate secondary preventive treatment to
patients with ischemic stroke and transient
ischemic attack (TIA,) many risk-prediction
models had been proposed. However,
presence of stroke/TIA mimics may result
in incorrect diagnosis and complicate risk
estimation.
Case Description: A 37-year-old right-
h a n d e d l a d y v i s i t e d t h e e m e rg e n c y
department after experiencing 2 episodes
of acute onset hypoesthesia and apraxia
involving the right side, along with mixed
aphasia, lasting up to 10 minutes. Recovery
to baseline condition could be achieved
after each episode. These episodes were
accompanied with non-pulsatile headache
and dizziness without vertigo, while no loss
of consciousness, visual disturbance, spasm
of the limbs, seizure, or dystonia were noted.
She had no previous seizure, head injury,
or chronic underlying condition. There was
no history of cerebrovascular disease in her
family.
The initial tentative diagnosis was transient
ischemic attack or minor sensory motor
lacunar infarction involving the left
supratentorial areas. However, survey of
risk factor revealed no significant findings,
while brain MRI revealed no vascular
abnormalities or diffusion restriction. On
the other hand, awake EEG revealed sharp
waves and rhythmic slow waves with
suspected phase reversal at F3, which was
associated with recurrence of the symptoms.
Focal neurological deficits due to non-motor
seizure was thus diagnosed.
Discussion: Seizure was known to be a
stroke mimic, making up about 20% of all
cases. Post-ictal neurological deficits (Todd’s
Paralysis) and motor seizures mimicking as
stroke had been frequently reported. Seizure
with atypical presentation or without motor
年會壁報論文
component, on the other hand, could be more
difficult to differentiate from cerebrovascular
diseases at the initial encounter. This could
be challenging in clinical practice since it
could be a typical finding in frontal lobe
seizure.
Neuroimaging studies could be valuable
in the diagnosis of ischemic stroke and to
exclude other diagnoses. However, this is
complicated by the fact that up to 20% of
all ischemic stroke could be MRI negative,
with younger patients and female patients
being prone to have this misleading finding.
Recent studies had shown that CT perfusion
studies may be helpful in differentiating
seizure from ischemic stroke.
Conclusion: While dealing with patient
presented with an acute onset focal
neurological deficit, non-vascular symptoms
such as non-motor seizure should be
considered in the differential diagnosis.
Advanced vascular neuroimaging study may
be helpful in the diagnosis of the condition.
15.採用多專科團隊照護於鼻胃管放置
的患者中之有效性：社區長期居家
照護計劃之執行
吳明峰 1, 2、吳佳倩 1, 3、鍾維軒 1, 4、
侯孟伶 1, 5、蔡昀純 1, 2、楊珊慈 3, 6、
李易珊 6、謝升文 1, 6, 7
1
高雄市立小港醫院咀嚼吞嚥機能重建中心
2
高雄市立小港醫院復健科
3
高雄市立小港醫院護理部
4
高雄市立小港醫院影像醫學科
5
高雄市立小港醫院營養部
6
高雄市立小港醫院神經科
7
高雄醫學大學附設醫院神經部
Effectiveness of Multidisciplinary Team
Practice in Patients with Nasogastric
Tu b e P l a c e m e n t : A P r a c t i c e o f
243
 年會壁報論文
Long-term Home Care Program in
Community
Ming-Feng Wu1, 2, Chia-Chien Wu1, 3,
Wei-Shiuan Chung1, 4, Meng-Ling Hou1, 5,
Yun-Chun Tsai1, 2, Shan-Chi Yang3, 6,
Yi-Shan Li6, Sun-Wung Hsieh1, 6, 7
1
Dysphagia Functional Reconstructive Center,
Kaohsiung Municipal Siaogang Hospital,
Kaohsiung Medical University, Kaohsiung, Taiwan
2
Department of Rehabilitation Medicine, Kaohsiung
Municipal Siaogang Hospital, Kaohsiung, Taiwan
3
Department of Nursing, Kaohsiung Municipal
Siaogang Hospital, Kaohsiung Medical University,
Kaohsiung, Taiwan
4
Department of Medical Imaging, Kaohsiung
Municipal Siaogang Hospital, Kaohsiung
Medical University, Kaohsiung, Taiwan
5
Department of Nutrition, Kaohsiung Municipal
Siaogang Hospital, Kaohsiung Medical
University, Kaohsiung, Taiwan
6
Department of Neurology, Kaohsiung Municipal
Siaogang Hospital, Kaohsiung Medical University,
Kaohsiung, Taiwan
7
Department of Neurology, Kaohsiung Medical
University Hospital, Kaohsiung Medical University,
Kaohsiung, Taiwan
Background and Purpose: Enteral feeding
tube placements partly prevent pneumonia
for patients after stroke or with progressive
neurodegenerative diseases. About 10%-
15% of the patients require long-term enteral
tube feeding during chronic stage of stroke.
The time point for nasogastric (NG) tube
removing for such patients is often difficult to
predict. Besides, some psychosocial reasons
and misbelieves regarding NG tube feeding
disturbed the patients and their caregivers.
Herein, we aim to investigate the effectiveness
of multidisciplinary team practice in long-term
home care program in community in removing
rate of NG tube.
Methods: We recruited patients with stroke
244
or neurodegenerative diseases in their chronic
stage in our out-patients department of
Neurology from November, 2019 to May, 2021
in Kaohsiung Municipal Siaogang Hospital.
Dysphagia Function Reconstructive Center is
an allied organization with multidisciplinary
specialist including neurology, nursing,
nutrition, dentistry, oto-rhino-laryngology
and speech-language therapy. We had the
protocol in oral health assessment, dysphagia
screening, swallowing evaluation, instrumental
assessment and training intervention to
improve the dysphagia. We also had the
protocol of long-term care program in
community and speech-language therapy. We
calculated the rate of NG removing rate after
interventions.
Results: A total of 47 participants with
NG tube in community with stroke or
neurodegenerative diseases in their chronic
stage were recruited in our study.
They completed the speech and language
therapy and nutrition evaluation. The outcome
showed 17% (8 participants) of NG removing
rate after training programs.
Conclusion: Different variables related to
long-term NG tube use were associated with
clinical aspects, including overall disease
status, baseline characteristics of patients,
and severity of stroke events. The choice
of long-term enteral feeding tube differs
among countries and cultures. The practice of
gastrostomy tube varies from within 1 week
to several months after stroke in different
countries. In Taiwan, gastrostomy tube
placement following stroke is typically delayed
by years. In Taiwan, the NG tube removal
rate reached a plateau at around 12-16 weeks
after stroke onset. Psychosocial problems and
caregiver burdens are important issues. Our
study revealed 17% of NG removing rate after
training programs. Further practice focusing
on NG tube removal trends under adequate

rehabilitation and multidisciplinary medical
support is required.
16.血中長鏈神經醯胺可以預測急性缺
血性腦中風接受動脈血栓移除治療
的預後
湯頌君 1、李宗恒 2、鄭芷寧 2、郭錦樺 2、
鄭建興 1
1
台大醫院神經部暨腦中風中心
2
臺灣大學藥學系
Plasma Long Chain Ceramides
Predicting Outcome of Endovascular
Treatment for Acute Ischemic Stroke
Sung-Chun Tang1, Tsung-Heng Lee2,
Chih-Ning Cheng2, Ching-Hua Kuo2,
Jiann-Shing Jeng1
1
Department of Neurology, National Taiwan
University Hospital, Taipei, Taiwan.
2
School of Pharmacy, College of Medicine,
National Taiwan University, Taipei, Taiwan
Background/Purpose: Our previous
studies indicated that long chain ceramides
are associated with the mechanisms and
outcomes of acute ischemic stroke (AIS).
This study aimed to investigate the plasma
levels of ceramides and sphingosine-1-
phosphate (S1P) in AIS patients undergoing
endovascular thrombectomy (EVT) and their
associations with functional outcomes.
Methods: Plasma samples were collected
from 75 AIS patients who underwent EVT
before (T1), immediately after (T2), and
24 hours after (T3) the procedures and 19
age-sex matched controls. The levels of
ceramides and S1P of different fatty acyl
chain lengths were measured by the ultra-
high-pressure liquid chromatography-
electrospray ionization tandem mass
spectrometry. A poor functional outcome
年會壁報論文
was defined as a modified Rankin Scale
score of 3 to 6 at 3 months after stroke.
Results: The plasma levels of long-chain
ceramides that Cer(d18:1/16:0) at all three
time points, Cer(d18:1/18:0) at T1 and T3
and Cer(d18:1/20:0) at T1, and very-long-
chain ceramide that Cer(d18:1/24:1) at T1 in
AIS patients were significantly higher than
those in controls. By contrast, plasma levels
of S1P in AIS patients were significantly
lower than those in control at all three time
points. Among AIS patients, 34 (45.3%)
had poor functional outcomes at 3 months
post stroke. Multivariable analysis showed
that higher levels of Cer(d18:1/18:0) at T1
and T2, and Cer(d18:1/16:0) at T2 remained
significantly associated with poor functional
outcome after adjustment for potential
confounding factors.
Conclusion: Plasma ceramides were
elevated early in AIS patients with acute
large artery occlusion. Furthermore, levels
of plasma long chain ceramides, especially
Cer(d18:1/18:0), could be early prognostic
indicators for AIS patients undergoing EVT.
17.血栓病理分析於取栓術之中風病人
有助於腫瘤栓塞之診斷：系列病例
報告
傅傳修 1、陳志昊 1、林彥亨 2、李崇維 2、
蔡力凱 1、湯頌君 1、孫家棟 3、鄭建興 1
1
台大醫院神經部
2
台大醫院影像醫學部
3
台大醫院病理科及台大醫學院法醫學研究所
Thrombus Analysis in Stroke
Patients Receiving Endovascular
Thrombectomy Assists the Diagnosis
of Tumor Embolization: A Case Series
Chuan-Hsiu Fu1, Chih-Hao Chen1,
Yen-Heng Lin2, Chung-Wei Lee2, Li-Kai Tsai1,
245
 年會壁報論文
Sung-Chun Tang1, Chia-Tung Shun3,
Jiann-Shing Jeng1
1
Department of Neurology, National Taiwan
University Hospital, Taipei, Taiwan
2
Department of Medical Imaging, National
Taiwan University Hospital, Taipei
3
Department of Pathology, National Taiwan
University Hospital and Institute of Forensic
Medicine, College of Medicine, National
Taiwan University, Taipei, Taiwan
Background and Purpose: Histological
characteristics of retrieved thrombi from
endovascular thrombectomy provided clinical
implication of stroke etiology. Platelet-rich
thrombi have been reported to be associated
with cancer-related hypercoagulability in
stroke patients with active cancer. Direct
tumor embolization may be another etiology
of ischemic stroke with large vessel occlusion
in patients with active cancer, which may be
the initial presentation before the diagnosis
of primary cancer. Here, we would like to
share 3 cases with direct tumor embolization
diagnosed by routine histological analysis
of retrieved emboli of endovascular
thrombectomy.
Cases: Case 1: A 32-year-old woman, with
epitheloid rhabdomyosarcoma of the left
thigh and multiple lung metastases, presented
with acute onset left upper limb weakness
and disorganized speech. Brain imaging
showed right distal MCA M1 occlusion
with suspected brain metastases at the right
temporo-parietal lobe. Suction thrombectomy
to right M1 was performed and TICI2b was
achieved. Pathological report of retrieved
embolus revealed metastatic epitheloid
rhabdomyosarcoma.
Case 2: A 77-year-old woman, with lung
lymphoepithelioma-like carcinoma (LELC)
and known left atrial invasion and liver
metastases, manifested with acute left side
246
weakness and right preferential gaze. Brain
imaging showed right MCA occlusion.
Endovascular thrombectomy to right MCA
with TICI 3 was achieved. Pathological
report of retrieved emboli was compatible
with lymphoepithelial carcinoma from lung
through special staining.
Case 3: A 83-year-old women, without
known vascular risk factors nor cancer
diagnosis, pr esented with r ight sid e
weakness and conscious disturbance. Brain
imaging revealed left distal ICA occlusion.
Endovascular thrombectomy was performed
and TICI2b was achieved. Pathology of
retrieved emboli reported vascular sarcoma
after special staining. However, no primary
cancer was found by whole body CT.
Conclusion: Routine pathological reviews of
emboli in all patients receiving endovascular
thrombectomy are highly recommended
to assist early diagnosis of direct tumor
embolization and cancer.
18.膽鹼路徑上的白質病變與e4基因型
者的失智程度相關
余敏君 1、吳淑菁 1、周家如 1、劉議謙 1, 2, 3
1
天主教新店耕莘醫院神經內科
2
輔仁大學醫學系
3
日本東北大學高齡認知神經學組
White Matter Hyperintensity on
Cholinergic Pathways is Associated
with Dementia Severity in e4 Carriers,
not in Non-carriers
Ming-Chun Yu1, Shu-Ching Wu1, Chia-Ju Chou1,
Yi-Chien Liu1, 2, 3
1
Department of Neurology, Cardinal Tien
Hospital, New Taipei, Taiwan
2
School of Medicine, Fu-Jen Catholic University,
New Taipei, Taiwan
3
Geriatric Behavioral Neurology Project, Tohoku

University New Industry Hatchery Center
(NICHe), Sendai, Japan
Objective: In this study, we explore
the relationship between white matter
hyperintensity on cholinergic pathways
and the severity of cognitive impairment,
with special focus on the difference
across APOE e4 carriers and non-carriers.
We hypothesized that more lesions on
cholinergic pathways would correlate to
worse cognitive function and more daily
impairment, particularly in e4 carriers.
Method: From 2018 to 2021, we recruited
subjects from the Memory Clinic of
Cardinal Tien Hospital in Taiwan. Subjects
with subjective or objective memory
impairment, above the age of 50 years,
underwent MRI, neuropsychological testing,
and APOE e4 genotyping. Exclusion criteria
are subjects with reversible causes or other
medical conditions, such as brain tumor,
CNS infection, and chronic psychiatric
history. This study specifically investigates
white matter hyperintensities (WMH) on
cholinergic pathway, using Cholinergic
Pathways HyperIntensity Scale (CHIPS)
-- a visual rating scale developed based on
published immunohistochemical tracings
of the cholinergic pathways in humans.
Severity of dementia was graded based on
standardized Mini-Mental State Examination
(MMSE), Clinical Dementia Rating (CDR),
and Clinical Dementia Rating – Sum of
Boxes (CDR-SB) score. The total CHIPS
score and dementia severity were evaluated
between e4 carriers and non-carriers, as well
as statistic interactions. All analyses were
performed using STATA, version 16 (College
Station, TX, USA).
Results: A total of 136 subjects (37 carrier,
99 non-carrier) were recruited. The age,
gender, education, MMSE, CDR, CHIPS
年會壁報論文
scores are not statistically different between
carriers and non-carriers. There were 53
male and 83 female in our study. The
educational level is 9.7 ± 5.8 versus 9.8 ± 4.8
(years) in carriers and non-carriers (p=0.92).
Baseline MMSE average score is 21.1 ± 8.3
versus 23.4 ± 6.5 (p=0.09). CDR distribution
in 0, 0.5, 1, 2 are insignificant between two
groups using Chi Square Independent Test
(p=0.12). However, CDR-SB are marginally
significant (3.2 ± 3.8 versus 2.1 ± 2.7)
among carriers and non-carriers (p=0.04).
The average CHIPS scores for carriers and
non-carriers are 14.9 ± 12.3 versus 15.0 ±
13.3 (p=0.8), which means no differences
were found across groups in white matter
hyperintensity. Yet it is significant that
CHIPS correlates with CDR-SB in carrier
group (r=0.36, p=0.02), whereas similar
correlation is not found in non-carrier
group (r=-0.005, p=0.59). In contrast,
MTA demonstrates solid correlation in
non-carriers (r=0.36, p < 0.01) and in all
participants (r=0.31, p p<0.01), it does not
statistically correlate with CDR-SB in the
carrier group (r=0.28, p=0.1). There is a
significant e4 interactive effect on CHIPS
and CDR-SB (p<0.01).
Discussion: Despite having similar CHIPS
values, carriers and non-carriers are
statistically different in average CDR-SB
scores. Based on our statistic results, carriers
and non-carriers present distinct correlations
of CHIPS and dementia severity. In carrier
group, white matter hyperintensity on
cholinergic pathways positively correlates
with CDR-SB, whereas medial temporal
lobe atrophy only correlates with CDR-SB
in the non-carrier group. The interactive
effect of APOE e4 gene on CHIPS and
CDR-SB was statistically supported by our
analysis. The above findings suggest that, in
e4 carriers, more lesions on the cholinergic
247
 年會壁報論文
pathways are related to worse cognition
performance and that e4 plays a statistically
significant role in the development of
cognitive impairment. For non-carriers, in
contrast, natural aging seems to be one of
the etiology and influencers to developing
cognitive decline.
19.以神經影像特徵預測NOTCH3突變
之腦出血
朱永載 1、陳志昊 1、陳雅芳 2、程郁文 3、
鄭建興 1、湯頌君 1
1
臺大醫院神經部暨腦中風中心
2
臺大醫院影像醫學部
3
臺大新竹分院神經部
Neuroimaging Markers Identifying
NOTCH3-mutation Related
Intracerebral Hemorrhage
Yung-Tsai Chu1, Chih-Hao Chen1,
Ya-Fang Chen2, Yu-Wen Cheng3,
Jiann-Shing Jeng1, Sung-Chun Tang1
1
D epartment of Neurology, National Taiwan
University Hospital, Taipei, Taiwan
2
Department of Medical Imaging, National
Taiwan University Hospital, Taipei, Taiwan
3
Department of Neurology, National Taiwan
University Hospital Hsinchu Branch, Hsinchu,
Taiwan
Background: Hereditary cerebral small
vessel disease (CSVD), such as NOTCH3-
mutation, is an important differential
diagnosis of spontaneous intracerebral
hemorrhage (ICH). We aim to identify
clinical and imaging characteristics
discriminating NOTCH3-mutation from non-
genetic causes of ICH.
Methods: This study is based on a
prospectively follow-up CSVD cohort. Next
248
generation sequencing for the common
genes of CSVD were performed in patients
with ICH and suspicious hereditary causes,
such as more severe features of CSVD,
positive family history or younger age of
onset. Neuroimaging markers of CSVD,
including white matter lesion (WML),
lacunes, enlarged perivascular spaces,
and cerebral microbleeds (CMB) were
compared between patients with and without
NOTCH3-mutation.
Results: From 661 patients who had
received genetic screening, 48 NOTCH3-
mutation and 84 non-genetic patients with
ICH were enrolled. Compared with the
non-genetic group, patients with NOTCH3-
mutation were older, had higher frequency
of family history of stroke, thalamus ICH,
overwhelmingly more severe neuroimaging
markers of CSVD, especially more CMB in
the hippocampus (5.0±8.3 vs 0.3±0.7) and
thalamus (8.4±8.2 vs 2.4±4.7, both P<0.001).
Besides, patients with NOTCH3-mutation
and higher risk of recurrent stroke (HR 3.0,
95% CI 1.04–8.60). We further constructed
a NOTCH3-ICH score consisting of history
of stroke in the siblings, severe deep WML,
higher number of hippocampus CMB (≥2),
thalamus CMB (≥7) and multiple enlarged
perivascular space in basal ganglia. The
sensitivity and specificity were 0.84 and 0.64
for a cut-off score of 2 points, and the area
under the receiver operating characteristics
was 0.78 (95% CI 0.68–0.88).
Conclusion: Patients with NOTCH3-
mutation related ICH had characteristic
higher burden of CMB in the hippocampus
and thalamus compared with non-genetic
causes of ICH. A NOTCH3-ICH score can
be used to identify potential genetic causes
of CSVD.

20.皮質下缺血性腦中風併發單側忽略
症之個案報告與分析
章國政、陳廷斌、黃金安
台中榮民總醫院神經醫學中心
Hemineglect: An Uncommon
Manifestation of Subcortical Cerebral
Infarction
Kuo-Cheng Chang, Ting-Bin Chen,
Jin-An Huang
Department of Neurology, Neurological Institute,
Taichung Veterans General Hospital
Background: Hemineglect is an acquired
neuropsychological deficit following a non-
dominant hemispheric damage. Individuals
with hemineglect fail to detect, attend, or
respond to the stimuli on the side of the
body contralateral to a brain lesion. It is
classically deemed as a “cortical deficit”
attributed to damages to right inferior
parietal lobe, temporo-parietal junction, and
superior temporal gyrus. The description of
hemineglect of subcortical origin is scant.
Case Presentation: A 73-year-old was
admitted to our hospital with acute left
hemiparesis, left homonymous hemianopia,
and left central-type facial palsy. Above
all, neurological examinations showed left
tactile and auditory extinction on bilateral
simultaneous stimulation. Brain magnetic
resonance angiography (MRA) demonstrated
diffusion restriction predominantly located
at the internal border zone of right middle
cerebral artery (MCA) territory as well as
significant stenosis of the M1 segment of
the right MCA. To thoroughly evaluate
cerebral hemodynamic status, we arranged
cerebral perfusion single photon emission
tomography (SPECT), which displayed
decreased radioactivity in the right entire
cerebral hemisphere and right striatum.
Additionally, computed tomography (CT)
年會壁報論文
perfusion of the brain also showed huge
penumbra within the right MCA territory
and a small proportion of core infarct.
Conclusion: Although hemineglect
is mostly attributable to damage to
cortical or subcortical gray matter of
non-dominant hemisphere, our case
demonstrated that subcortical white
matter lesions accompanied by profound
cerebral hypoperfusion may contribute to
hemineglect.
21.三 個 月 連 續 血 壓 紀 錄 可 預 測
CADASIL病患腦中風
陳志昊 1、廖翊筑 2、程郁文 1、鍾芷萍 2、
李宜中 2、湯頌君 1
1
台大醫院神經部
2
台北榮民總醫院神經醫學中心
Three-month Daily Blood Pressure
Monitoring Predicts Incident Stroke in
CADASIL
Chih-Hao Chen1, Yi-Chu Liao2, Yu-Wen Cheng1,
Chih-Ping Chung2, Yi-Chung Lee2,
Sung-Chun Tang1
1
Department of Neurology, National Taiwan
University Hospital, Taipei, Taiwan
2
Department of Neurology, Taipei Veterans
General Hospital, Taipei, Taiwan
Introduction: CADASIL is a hereditary
small vessel disease caused by NOTCH3
mutations. Whether superimposed
hypertension had harmful effects on these
populations was unknown.
Methods: We recruited 100 participants in
the prospective cohort of Taiwan CADASIL
Registry with documented NOTCH3
mutations, as well as 18 age- and sex-
matched controls. Daily blood pressure
249
 年會壁報論文
(BP) and heart rate (HR) were recorded by
the participants with a standardized home-
based sphygmomanometer for consecutive
90 days. Linear analysis of the variability
parameters was done. Neuroimaging markers
of small vessel disease on brain magnetic
resonance imaging and any incident stroke
was documented.
Results: Participants with NOTCH3
mutations are more likely to have
stroke history and use antithrombotic or
antihypertensive medications than controls.
However, the systolic, diastolic BP, and pulse
pressure were comparable, except for higher
mean HR (77.3±10.0 vs 70.7±8.3, P =0.01)
in the NOTCH3 group. In participants with
NOTCH3 mutations, higher 90-day mean
systolic and diastolic BP correlated with
more cerebral microbleeds, while the mean,
standard deviation, coefficient of variation,
and average real variability of 90-day HR
positively correlated with number of lacunes.
During median follow-up of 24 months,
there were 8 stroke events (5 ischemic, 3
hemorrhagic). Participants with persistent
hypertension (90-day mean systolic/diastolic
BP > 130/80 mmHg) were more likely to
have incident stroke (log-rank P = 0.04), and
the effects persisted (hazard ratio 5.29, 95%
CI 1.12−25.1) after adjustment of number of
cerebral microbleeds.
Conclusions: In participants with NOTCH3
mutations, persistent hypertension had
detrimental effects on the severity of cerebral
microbleeds as well as incident stroke.
Aggressive blood pressure control seems
beneficial in hereditary small vessel disease.
22.依病理組織診斷顳動脈炎：超音波
特徵
葉育雯、廖乃毅、陳韋達、鍾芷萍
250
臺北榮民總醫院神經內科
Sonographic Characteristics in a Case
of Tissue-proof Temporal Arteritis
Yu-Wen Yeh, Nai-Yi Liao, Wei-Ta Chen,
Chih-Ping Chung
Department of Neurology, Neurological Institute,
Taipei Veterans General Hospital
Background: This is a case report of
temporal arteritis.
Results: A 78-year-old lady presented
with two weeks of non-pulsatile severe
headache over right temporal area (numeral
rating scale of pain [NRS] 10/10). There
were associated symptoms including
visual changes (visual torsion like looking
through heat waves), photophobia and poor
appetite. There was no phonophobia and
nausea/vomiting. She had no vascular risk
factors but a past history of sudden left ear
deafness in 2016. On admission, her blood
pressure, heart rate and body temperatures
were normal. However, a tortuous temporal
artery on her right side was noted. The
neurological examinations did not show
any focal neurological deficit. Her blood
examinations revealed WBC: 8000/cubic
mm with differential count segmented
neutrophil 89.1% and lymphocyte 6.3%,
Hgb: 11.8g/dL, Platelet: 344X103 cubic
mm and a significantly elevated erythrocyte
sedimentation rate (ESR): 83 mm/hr. She was
then received color-coded ultrasonography
and the result showed typical hypoechoic
wall thickening (halo sign) in right temporal
artery. Under the tentative diagnosis of
temporal arteritis, a biopsy of right temporal
artery was performed. The pathological
findings confirmed the diagnosis: neointima
hyperplasia and significant immune cell
infiltration including lymphocytes and giant
cells in the media. Patient was prescribed

methylprednisolone i.v. 1000 mg for five
days and her headache and associated
symptoms were subsided on the third day of
pulse therapy.
C o n c l u s i o n : Te m p o r a l a r t e r i t i s i s a
rare disease and mostly responsive to
prednisolone therapy. In clinical-suspected
cases, color-coded ultrasonography is a
useful tool for early diagnosis.
23.動脈內取栓術治療急性缺血性中風
成效與年紀效應：一北部醫學中心
2008−2020登錄資料
黃蕙琦 1、蔡瑞窈 1、林靜薇 1、林姿君 2、
劉子菁 1、戴千淑 1、林小玲 1、梁穎 1、
李怡慧 2, 3、鍾芷萍 2, 3
1
臺北榮民總醫院護理部
2
神經醫學中心神經內科
3
國立陽明交通大學醫學系
Efficacy of Endovascular Thrombectomy
for Patients with Acute Ischemic
Stroke Admitted between 2018 and
2020 in a Northern Medical Center:
Total Patients and Patients Aged ≥ 80
Years Old
Hui-Chi Huang1, Jui-Yao Tsai1, Ching-Wei Lin1,
Tzu-Chun Lin2, Tzu-Ching Liu1, Chien-Shu Tai1,
Shir-Ling Lin1, Ying Liang1, I-Hui Lee2, 3,
Chih-Ping Chung2, 3
1
Department of Nursing, Taipei Veterans
General Hospital, Taipei, Taiwan
2
Department of Neurology, Neurological
Institute, Taipei Veterans General Hospital,
Taipei, Taiwan
3
School of Medicine, National Yang Ming Chiao
Tung University College of Medicine, Taipei,
Taiwan
Background: Endovascular thrombectomy
(EVT) has been proven as a standard acute
年會壁報論文
treatment for ischemic stroke (IS) with
large vessel occlusion. However, whether
it is equally effective in the elder patients is
controversial.
Purpose: The study aimed to evaluate the
3-month good and poor functional outcomes
in IS patients who received MT for acute
treatment and analyzed the effect of age on
the outcomes.
Methods: We retrogradely retrieved
patients’ data from Stroke Registry of Taipei
Veterans General Hospital. We included IS
patients who were admitted and received
EVT between January 2018 and December
2020 (EVT+ group). Patients who did not
receive EVT and were age/sex/admission
NIHSS-matched with EVT+ patients
were serving as controls (EVT- group).
Demographics, stroke severity and 3-month
functional outcomes of all subjects were
analyzed. Student’s t-test was used for group
comparison and multivariate regression
analyses were performed to validate the
efficacy of EVT.
Results: There were 138 IS patients who
received EVT between January 2018 and
December 2020 in our Medical Center.
EVT+ group had higher prevalence of
diabetes mellitus (DM) and atrial fibrillation
(Af) than EVT- group. In addition, EVT+
group had more patients with good
functional outcome and less patients
with poor functional outcome at 3 month
compared with EVT- group. Multivariate
analyses adjusting for age, stroke severity
and the presence of DM and Af showed that
EVT was independently and significantly
associated with better 3-month outcomes.
We further performed subgroup analyses to
evaluate the effect of age on the outcomes of
EVT for acute IS. The comparisons between
EVT+ and EVT- groups in patients aged ≥
80 years old showed that EVT+ group had
251
 年會壁報論文
less patients with poor functional outcome
than EVT- group. Multivariate analyses
adjusting for age and stroke severity showed
that EVT was also independently and
significantly associated with better 3-month
outcomes.
Conclusion: The present study revealing the
real-world data of a Medical Center showed
that EVT was effective for acute IS in all
patients and also in the elderly patients. The
limitations of the present study included
a relative small sample size and potential
selection bias for the EVT- group. A future
multi-center study in Taiwan would validate
the present results.
24.基底動脈梗塞且NIHSS超過30分的
病人難以達到良好的預後
蔡昇達 1、邱于禎 2、林育廷 3、楊家麗 4、
王韋竣 1、黃虹瑜 1
1
中國醫藥大學附設醫院神經部
2
中國醫藥大學附設醫院安南院區神經部
3
中國醫藥大學附設醫院大數據中心
4
中國醫藥大學附設醫院麻醉部
Basilar Artery Occlusion Patients with
National Institutes of Health Stroke
Scale Higher than 30 were Difficult to
Reach Favorable Outcome at 90 Days
Sheng-Ta Tsai1, Yu-Chen Chiu2, Yu-Ting Lin3,
Jia-Li Yang4, Wei-Chun Wang1, Hung-Yu Huang1
1
Department of Neurology, China Medical
University Hospital, Taichung, Taiwan
2
Department of Neurology, An Nan Hospital,
China Medical University, Tainan, Taiwan
3
Big Data Center, China Medical University
Hospital, Taichung, Taiwan
4
Department of Anesthesiology, China Medical
University Hospital, Taichung, Taiwan
Background: Basilar artery occlusion
252
(BAO) is devastating form of acute ischemic
stroke. Previous research showed that 80%
of patients had unfavorable outcomes.
However, there are relatively few clinical
investigations and treatment suggestions
compared with the anterior circulation
stroke. Furthermore, most of the existing
studies are of populations in western
countries, highlighting the need for clinical
studies of BAO in other populations, such as
Asian.
Aims: Our goal was to determine the clinical
characteristics and the factors related to
the 90- day clinical outcome of BAO in an
Asian study population.
Methods: We performed a retrospective
case review of patients admitted between
2015 and 2019 to a tertiary stroke center. We
used international Classification of Diseases
10 criteria to identify cases of posterior
circulation stroke. For those, cases of BAO
were verified by a neurologist using brain
images according to the criteria defined in
the BASICS study. We analyzed patients’
characteristics, clinical course, and factors
related to favorable or unfavorable outcome
at 90 days.
Results: We identified 99 patients as real
BAO cases. Only 33 of these 99 patients
(33%) had a favorable outcome at 90 days
(mRS 0–3). 72 patients received intra-
arterial thrombectomy (IAT), while 27
received medical treatment alone. In the IAT
group, the initial NIH stroke scale (NIHSS)
and BAO symptoms of tetraparesis were
correlated with unfavorable outcomes (mRS
4–6) at 90 days. In the non-IAT group, initial
NIHSS, BAO symptoms of consciousness
change, and pupillary abnormalities were
associated with unfavorable outcomes. The
best cutoff value of NIHSS was 30 based on
the Youden index, with 43% sensitivity and
95% specificity for discriminating patients

with unfavorable outcome.
Conclusions: In our BAO cases series,
only one-third of patients reached the
favorable outcome at 90 days. The most
important predictor of unfavorable outcome
was the initial NIHSS score. The patients
with NIHSS more than 30 were difficult to
reach favorable outcome, even after IAT.
BAO symptoms, including tetraparesis,
consciousness disturbance, and pupillary
abnormality, were also related to unfavorable
outcome. Larger, prospective clinical studies
are needed for further understanding of this
devastating disease.
25.來源不明之栓塞型中風成人診斷違
法布瑞氏症
侯宗緯、周政達、陳柏霖、黃金安
台中榮民總醫院
A Case of Embolic Stroke of
Undetermined Source at first with
Fabry Disease as Final Diagnosis
Tsung-Wei Hou, Cheng-Ta Chou, Po-Lin Chen,
Jin-An Huang
Department of Neurology, Neurological Institute,
Taichung Veterans General Hospital
Introduction: Fabry disease (FD) is a rare
X-linked lysosomal storage disease. FD
is characterized by a mutation in the GLA
gene, leading to the deficiency of alpha-
galactosidase A enzyme. The deficiency
then resulted in the accumulation of
globotriaosylceramide and its derivatives
in many cell types, including vascular cells
(endothelial and smooth muscle cells),
cardiac cells (cardiomyocytes and valvular
cells), a variety of renal cells (tubular and
glomerular cells, and podocytes), and nerve
cells. This inappropriate accumulation then
年會壁報論文
resulted in organ damage to the kidneys,
heart, and the brain. Stroke is one of the
main presentations in the patient with FD.
In this article, we presented an acute stroke
case highly related to the FD with the past
history of cardiac disease.
Case report: A 66-year-old male presented
with left hemiplegia and slurred speech after
waking up in the morning. Tracing back
his past history, he had hypertension and
complete atrioventricular (AV) block with
syncope status post permanent pacemaker
(PPM) implantation. This time, he woke up
at around 04:30 first with normal situation.
Then he woke up at 05:30 again and found
left hemiplegia with slurred speech. With
the situations above, he was brought to
our emergency room (ER) for help. On
admission, the neurological examination
showed slurred speech, left central facial
palsy, decreased muscle power over left
extremities (upper limb predominant),
and impaired pin-prick sensation over
left extremities. The brain CT showed
low attenuation change over right frontal
lobe. Under the suspect of acute cerebral
infarction over right frontal lobe with
National Institutes of Health Stroke Scale
(NIHSS) score 8, we then arranged rTPA
administration. The left side weakness
and decreased sensation improved and the
NIHSS score was back to 2 after 24 hours.
We then followed the brain MRI and the
result showed diffusion restriction change
at right frontal lobe. According to the
embolic like cerebral infarction over the
cortical area. We arranged further studies
for the stroke risk survey. According to the
records of PPM, there was only some non-
sustained VT noted and it was less likely to
be related to cerebral ischemic event. There
was also no atrial fibrillation or flutter found
in the report. Cardiac sonography revealed
253
 年會壁報論文
left ventricle ejection fraction (LVEF) 45%
with apical and inferior wall hypokinesia.
Negative result was noted in the lab data
related to the autoimmune or metabolic
disease. Micro-bubble test was also arranged
and showed negative finding. With the
diagnosis of embolic stroke of undetermined
source, we also arrange Fabry screening test.
Positive finding over the screening test and
the sequential confirm test were then noted.
The patient was then diagnosed as a stroke
with Fabry disease related to the mutation of
c.640-801G>A.
Conclusion: Fabry disease is a rare
lysosomal storage disease involving kidneys,
heart, and brain. In these patients, there are
multiple clinical presentation and related
diseases. Stroke was also considered as a
special presentation. We now take the Fabry
disease as a routine survey of young stroke
and there was also few cases with mutation
over IVS4+ 919G>A(c.640-801G>A) in
Taiwan. Here we presented a 66-year-old
patient with final diagnosis of Fabry disease
related stroke. Based on this case, we should
keep Fabry disease in mind when we meet
similar type of patients.
26.心臟黏液瘤：毀滅性的年輕栓塞型
中風之來源
劉一宏 1、廖誼佳 1、李怡慧 1, 2
1
臺北榮民總醫院神經內科
2
國立陽明交通大學腦科學研究所
Cardiac myxoma: A Devastating
Embolic Source of Young Stroke
Yi-Hong Liu1, Yi-Chia Liaw1, I-Hui Lee1, 2
1
Department of Neurology, Taipei Veterans
General Hospital
2
Institute of Brain Science, National Yang Ming
254
Chiao Tung University
We report a 23-year-old overweight woman
presenting with sudden-onset aphasia,
right central facial palsy, right hemiparesis,
and left leg weakness during sex. The
head and neck computed tomography
angiography (CTA) revealed left middle
cerebral artery occlusion, which was
recanalized successfully after mechanical
thrombectomy. However, her legs became
painful swollen and paraparesis persisted.
Another CTA of the chest to lower abdomen
disclosed extensive arterial occlusion from
abdominal aorta to bilateral common iliac
arteries, as well as bilateral renal infarctions.
Under the suspicion of cardiogenic
systemic embolism, the echocardiography
confirmed a 5-centimeter villous myxoma
in the right atrium. The patient underwent
emergent intracardiac tumor resection, intra-
arterial thrombectomy, and fasciotomy
for leg compartment syndrome after
revascularization. After a few months of
rehabilitation, the patient walked without
aids and had residual left foot drop. Cardiac
myxoma is a devastating cause of young
stroke characterized by systemic embolism,
heart failure, syncope, fever, neurological
deficits, and sudden death, warranting
an early beside echocardiography in this
population. The first-line management is
surgical resection, and the recurrence rate is
low. In the setting of acute ischemic stroke,
patients with cardiac myxoma may still
benefit from both intravenous thrombolysis
and mechanical thrombectomy.
27.六十二歲女性雷擊性頭痛住院後合
併急性腹痛，藉由腎動脈攝影證實
為栓塞性中風

江宏基
衛福部桃園醫院神經科
A 62-year-old Female had a
Thunderclap Headache with
Subsequent Abdominal Cramping
Pain- Finally Proved Embolic Stroke
and Renal Infarction
Hung-Chi Chiang
Division of Neurology Medicine, Department of
Internal Medicine, Taoyuan General Hospital,
Ministry of Health and Welfare
This 62-year-old female had no major
systemic disease. She was brought to ER
for sudden onset of thunderclap headache
noted on 2021/03/18. The NIHSS was 3 (left
hemianopia and mild left leg weakness).
Brain MRI showed acute right temporo-
parietal infarction. Right flank pain with
mild fever up to 37.7 degree and jaundice
occurred on 03/24. Physical exam suggested
negative Murphy’s sign but positive right
flank knocking tenderness. Abdomen echo
excluded the possibility of renal/urinary
tract stone or gall bladder stone. Lab data
showed leukocytosis, elevated LDH, AST,
ALT and proteinuria. Emergent abdominal
CT on 03/26 revealed right renal infarction
finally. Cardiologist was consulted and
right renal angiogram on 03/30 showed
occlusion of the posterior division of renal
artery and stenosis of the anterior division
branch. Anticoagulant was suggested, but
we hesitated to administer the drug for the
risk of hemorrhagic transformation because
of large infarct core. Subsequently, another
stroke episode developed on 04/08.
Discussion: Renal infarction is classified
into 2 types of category including in situ
thrombosis and thromboembolic infarction.
The diagnosis of renal infarction usually
delays for its scarcity and mimics condition
年會壁報論文
such as pyelonephritis and nephrolithiasis.
Treatment includes medical care and
revascularization. Factors associated with
outcome from revascularization include
size of kidney parenchyma threatened by
the infarction, renal function and severity of
the occluded renal vessel. Most of patients
with renal infarction had relatively good
outcome for compensatory hypertrophy of
another kidney, though some of them may
still develop end stage renal disease. Hence,
early recognition of clinical presentations
of renal infarction is important. Further
embolic events may be prevented by early
use of anticoagulant or revascularization.
28.酒精成癮患者的仿中風表現
徐湘婷、許立奇
臺北榮總神經內科
Alcoholism Patient Presenting with
Stroke Mimic─A Case Report
Hsiang-Ting Hsu, Li-Chi Hsu
Department of Neurology, Taipei Veterans
General Hospital, Taipei, Taiwan
Background: The clinical presentation of
acute ischemic had high diversity. Stroke
mimics account for 20-25% of suspected
stroke cases, and are caused by a variety
of different etiologies. The misdiagnosis
may be harmful because of delaying timely
appropriate treatment. Here, we presented
a case of alcoholism mimicking acute
ischemic stroke.
Case report: A 60-year-old alcoholic man
presented with acute onset of weakness at
left upper and lower limbs. Neurological
examination revealed right hemianopia, mild
left central facial palsy, mild dysarthria and
decreased muscle power at left upper limb
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 年會壁報論文
(MRC grade: 2/5) and left lower limb (MRC
grade: 4-/5). Computed tomography of brain
demonstrated no intracranial hemorrhage. So
recombinant tissue plasminogen activator (rt-
PA) was administered under the impression
o f a c u t e i s c h e m i c s t r o k e . H o w e v e r,
convulsions at left upper and lower limbs
with impaired consciousness occurred for
5-10 minutes after bolus infusion of rt-PA
for 5 minutes. No hemorrhage was found on
the follow-up head computed tomography.
After he regained his consciousness, muscle
power was intact without focal neurological
deficits. But, he suffered from severe visual
and auditory hallucinations and became
agitated. Brain MRI revealed restricted
diffusion at parasagittal right inferior
cerebellum, which was not compatible
with his initial neurological deficits. Old
infarcts at bilateral thalami was also found.
Doppler ultrasound showed no significant
stenosis over intracranial and extracranial
arteries. Electroencephalography reported
no epileptiform discharge. Considering
alcohol withdrawal syndrome by consulting
psychiatrist, he received lorazepam and
hallucinations and agitation gradually
improved. There were no convulsions
afterwards. Aspirin was still prescribed in
case of the evidence of old infarcts.
Conclusion: In our case, the overuse of
alcohol caused stroke mimics presenting
as weakness at left side, left facial palsy
and dysarthria. The following convulsions,
hallucinations and agitation were the
symptoms of alcohol withdrawal syndrome.
This case implied that the distinction from
stroke mimics and acute ischemic stroke
is important, which helps the patients
avoiding the risk of hemorrhage caused by
thrombolytic therapy.
256
29.合併腦海綿狀血管瘤與多囊腎疾病
之一家族遺傳報導
謝沛峰 1、劉士嶢 2、陳志昊 1、湯頌君 1
1
台大醫院神經部
2
台大醫院基因醫學部
Coexistence of Novel CCM2 and PKD2
Pathogenic Variants in a Family
Presenting with Cerebral Cavernous
Malformations and Polycystic Kidney
Disease
Pei-Feng Hsieh1, Shih-Yao Liu2,
Chih-Hao Chen1, Sung-Chun Tang1
1
Department of Neurology, National Taiwan
University Hospital, Taipei, Taiwan
2
Department of Medical Genetics, National
Taiwan University Hospital, Taipei, Taiwan
Background: Hereditary cerebral cavernous
malformations (CCMs) are characterized by
clustered dilated capillary-like vessels in the
brain devoid of intervening neural tissue.
Autosomal dominant polycystic kidney
disease (ADPKD) is a multisystem disorder
characterized by renal cysts and extrarenal
abnormalities, including intracranial
aneurysms. We report a Taiwanese family
with coexisting manifestations of both
phenotypes and their genetic studies.
Methods: Comprehensive panels for
cerebral vascular malformation (including
183 genes) were investigated by whole
genome sequencing in the index case with
coexisting CCMs and polycystic kidneys.
Following that, identified variants were
further investigated in other family members
by direct DNA sequencing.
Results: The index case is a 55-year-old
woman with known PKD. She developed
intracerebral hemorrhage in right medulla,
despite long follow-ups for multiple cerebral
microbleeds. Radiological CCMs were
suspected given the lack of other imaging

markers for small vessel disease. Whole
genome sequencing revealed a novel
CCM2 frameshift variant (c.607_608delCT,
p.L203Vfs*53) causing pathogenic
premature stop codon, and a known PKD2
frameshift variant (c.2407C>T, p.R803*)
simultaneously. Segregation analysis
showed four siblings were affected either by
isolated PKD2 or CCM2 variant identified
above. Notably, radiological CCMs were
exclusively found in those who harbored this
CCM2 variant, whereas bilateral internal
carotid artery aneurysms were restricted to
one sibling with PKD2 variant but without
CCM2 variant.
Conclusion: Our study expands the genetic
spectrum of CCM2 mutations and also
demonstrates unambiguous co-segregation
of CCM2 and PKD2 genetic variants with
their respective phenotypes. A lesson to learn
is that radiological multiple tiny microbleeds
could be an early manifestation of hereditary
CCM.
30.放射治療導致之嚴重頸動脈狹窄的
長期結果−單一醫學中心之世代研
究 stent restenosis for ≥50% in patients who
朱傛華 1、張豐基 2、林浚仁 1
1
臺北榮民總醫院神經醫學中心
2
臺北榮民總醫院放射線部
Long-term Outcomes of Severe Radiation
Induced Carotid Stenosis-A Single
Center Cohort Study
Yung-Hua Chu1, Feng-Chi Chang2,
Chun-Jen Lin1
1
Neurological Institute, Taipei Veterans General
Hospital, Taipei, Taiwan
2
Department of Radiology, Taipei Veterans
General Hospital, Taipei, Taiwan
年會壁報論文
Background and Aims: Head and neck
cancer is a prevalent disease in Asia, causing
significant morbidities and mortalities.
Radiotherapy (RT) has shown to improve
the survival outcomes in extensive head and
neck cancer; however, recent studies have
reported an association between RT and
carotid stenosis. We aimed to evaluate the
characteristics and long-term outcomes of
severe carotid stenosis between patients who
received RT on the carotid area and those
without.
Methods: A prospective cohort study in
a tertiary medical center of Taiwan was
conducted. Patients diagnosed with severe
extracranial carotid stenosis (≥70%) were
enrolled from August 2007 to May 2021.
Participants were divided into two groups
according to the presence of RT history for
head and neck cancer before enrollment
(RT group, and atherosclerotic (AS)
group). Basic demographics, vascular risk
factors, and treatments for carotid stenosis
were recorded in both groups. Patients
were followed up for at least one year.
The primary endpoint was progression of
vessel stenosis, defined as ≥10% increase
of stenotic degree in the index vessel or in-
received carotid artery stenting during the
follow-up period. The secondary endpoints
included ischemic stroke events, myocardial
infarction, and all-cause mortality.
Results: A total of 154 patients with severe
extracranial carotid stenosis were recruited
(86 in the RT group, and 68 in the AS
group). The median duration of follow-
up was 48.5 months. Patients in the RT
group were significantly younger, having
a higher incidence of previous ischemic
stroke and transient ischemic attack, and
less concomitant hypercholesterolemia
and coronary artery diseases compared
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 年會壁報論文
with patients in the AS group. A higher
proportion of multiple vessels and bilateral
extracranial carotid involvement was
found in the RT group. Patients in the RT
group had a significantly higher proportion
of progression of vessel stenosis overall
(35.9% versus 14.1%; p<0.01) and in-stent
restenosis (27.8% versus 12.5%; p=0.038),
comparing with the patients in the AS group.
No significant difference within both groups
was found regarding occurrence rates of
ischemic stroke, myocardial infarction,
and mortality. Further univariate and
multivariate regression analysis showed
RT is significantly associated with the
progression of stenosis. (HR 3.538, 95% CI
1.505-8.315, p<0.01)
Conclusion: In patients with carotid
stenosis, those with RT history had more
extensive vessels involvement, less
traditional vascular risk factors, but a higher
rate of stenosis progression and in-stent
restenosis, comparing with those without
RT history. Clinicians should be aware of
this discrepancy, and frequent follow-up
with vascular imaging is warranted. A lower
threshold for early intervention may be
considered in patients with carotid stenosis
and history of RT, given that a high risk of
progression in this setting is observed.
31.比較癲癇病患與中風病患發生後續
中風的風險：台灣健保資料庫分析
林伯昱、張育銘、陳志弘、宋碧姍
國立成功大學醫學院附設醫院神經部
Comparing the Risk of Stroke in
Patient with Epilepsy and Patient with
History of Stroke: A Population-based
Cohort Study
Po-Yu Lin, Yu-Ming Chang, Chih-Hung Chen,
258
Pi-Shan Sung
Department of Neurology, National Cheng
Kung University Hospital, College of Medicine,
National Cheng Kung University, Tainan, Taiwan
Background: Patients with epilepsy have an
increased risk of stroke. This study aims to
investigate whether epilepsy is a stroke risk
equivalent for subsequent stroke.
Methods: This nationwide retrospective
cohort study utilized data from the National
Health Insurance Research Database
(NHIRD) in Taiwan. We classified adult
patients with newly diagnosed epilepsy
from 2003 to 2016 as the epilepsy cohort.
Patients in the nonepilepsy cohort were
selected with index-year matching at a case:
control ratio of 1:100 after exclusion of the
diagnosis of epilepsy, the use of anti-seizure
medication, the history of head injury
or traumatic brain injury. In the epilepsy
cohort, epileptic patients with stroke were
identified (E/S group). Then we selected the
epileptic patients without stroke (E group),
nonepileptic patients with stroke (S group)
and nonepileptic patients without stroke
(C group) with index-year-, age- and sex-
matching at a ratio of 1:2:2:10 in E/S, E, S,
C groups, respectively. The incidence and
adjusted hazard ratio (aHR) of stroke or
recurrent stroke after index diagnosis in the
four cohorts were analyzed.
Results: We enrolled 25125 patients in the
epilepsy cohort and 2512500 persons in the
nonepilepsy cohort. After matching process,
there were a total of 110, 220, 220 and 1100
in the E/S, E, S, and C groups, respectively.
There were no differences regarding the
distribution of sex, age, and urbanization
level between four groups, but comorbidities
were more common in patients in the E/
S and S group. The stroke event rate was
22.73%, 2.73%, 21.36% and 0.45% in E/S,

E, S and C group, respectively. The adjusted
HRs of stroke or recurrent stroke after index
diagnosis in the E/S group (aHR: 47.93,
95% CI: 17.03-134.89, p<0.001) was highest
among the four cohorts, followed by S group
(aHR: 45.85 , 95% CI: 16.96-123.96, p<
0.001), and then E group (aHR: 5.56, 95%
CI: 1.66-18.59, p=0.005) compared with the
stroke risk in the C group as a reference.
Conclusion: Epilepsy patients have
increased risk of stroke. However, the stroke
risk following epilepsy is not as high as the
risk following a stroke history.
32.輔 酉每 Q10濃度變化於急性缺血性腦
中風及其預後之影響
王淳民
成功大學醫學院附設醫院
The Impact of Serial Changes of
Coenzyme Q10 after Acute Ischemic
Stroke on Post-stroke Outcome
Chun-Min Wang
Department of Neurology, National Cheng Kung
University Hospital
Background and Objectives: The oxidative
stress secondary to acute ischemic stroke
(AIS) may consume the body storage of
anti-oxidative micronutrients, such as
coenzyme Q10 (CoQ10). This study aimed
to investigate the serial changes of CoQ10 at
the acute and subacute stage of AIS and the
correlation between the changes of CoQ10
and post-stroke functional outcome.
Method: We conducted a prospective
cohort study from Mar. 2020 to Sep. 2020
enrolling patients with first-ever ischemic
stroke onset within 48 hours. We serially
measured the serum level of CoQ10
during hyperacute stage (within 3 days of
年會壁報論文
onset) and subacute stage (within 21-28
days) of AIS. The patient’s characteristics,
comprising demographic data, medical
history, comorbidities, stroke severity,
the presence of stroke-in-evolution (SIE),
stroke recurrence (SR) and functional
outcome at 90 days were recorded. Due
to nonparametric distribution of our data,
the correlation between the serum level of
CoQ10 at hyperacute/subacute period, and
the changes between this period and baseline
stroke severity/SIE/SR were evaluated
by Spearman’s rank-order correlation or
Mann-Whitney U test. Multivariate logistic
regression analysis was performed to
investigate the predictability of the CoQ10
level and 90 days poor functional outcome
(defined as mRS > 2).
Results: A total of 32 patients with male
predominance (72%) were enrolled. The
mean age was 61.8 ± 9.4 years. The median
NIHSS was 7 (IQR 3-13). The baseline
sex, age, BMI, and stroke severity were
not associated with the cross-sectional
serum level of CoQ10 at hyperacute stage
or subacute stage, respectively. In addition,
CoQ10 level at hyperacute and subacute
stage was not correlated with the occurrence
of SIE/SR during hospitalization and 90-
day poor functional outcome. Higher stroke
severity and the presence of SIE/SR did not
result in significant changes of CoQ10 level
between hyperacute and subacute period.
However, reduced CoQ10 level during this
period independently increase the possibility
of the poor 90-day functional outcome, even
after adjusting age, sex and stroke severity
(aOR) 1.012, 95% CI 1.002-1.023), in this
small series.
Conclusions: In this small series, the cross-
sectional serum levels of CoQ10 at separate
time points at hyperacute/subacute stage
of AIS did not correlate with patient’s
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 年會壁報論文

demographics, stroke severity or 90-day severity, coagulopathy, common vascular

functional outcome. However, the changes of risk factors, pre-stroke medication and acute
CoQ10 levels during AIS may be a potential treatment of stroke were also assessed.
influencing factor for stroke outcome. Results: Of the 2314 patients, 302 (13.1
%) had concomitant cancer (cancer-
associated stroke). The top 3 cancer types
are colorectal cancer (N=62; 20.5%), head
33.癌症對於中風病人預後之影響 and neck malignancy (N=59; 19.5%) and
李剛伯 1、黃蕙琦 2、蔡瑞窈 2、許立奇 3 lung cancer (N=45; 14.9%). Prostate cancer
1
義大醫院神經科 and breast cancer got 29 each in male and
2
台北榮總護理部 female patients, ranked as the 4th most
3
台北榮總神經醫學中心神經內科 cancer types. Stroke patients with pancreatic
cancer, liver cancer, gastric cancer, lung
Do Cancers Influence the Outcome of cancer, urothelial cancer and head and neck
the Stroke Patients? A single Center cancer predicted the worst survival rates.
Study Older age, anemia, CKD and prior stroke
Kang-Po Lee1, Hui-Chi Huang2, Jui-Yao Tsai2, also independently and negatively predicted
Li-Chi Hsu3 the outcome in stroke patients with cancer.
1
Department of Neurology, E-DA hospital, However, dyslipidemia is a protective factor
Kaohsiung, Taiwan in our study.
2
Department of Nursing, Taipei Veterans General Conclusion: Patients with cancer-associated
Hospital, Taipei, Taiwan stroke had worse short-term and long-
3
Department of Neurology, Taipei Veterans term outcome compared with those without
General Hospital, Taipei, Taiwan cancer.

Background: Whether patients with

concomitant stroke and cancer exhibit
specific characteristics have remained 34.毛毛樣疾病患者接受單側間接血流
controversial. In addition, the impact of 重建手術後之雙側顱內外血管變化
individual cancer type on stroke outcome is 葉馨喬 1、湯頌君 1、蔡力凱 1, 2、陳姿菁 1、
also largely unknown. 李佩玲 1、陳雅芳 3、郭夢菲 4、鄭建興 1
1
Materials and Methods: A total of 2314 臺大醫院神經部
2
patients were recruited in the Taipei 新竹臺大分院神經部
3
Veterans General Hospital Stroke Registry 臺大醫院影像醫學部
4
(TVGHSR) retrospectively from January, 臺大醫院小兒神經外科
2016 to December, 2018. Patients were
classified according to history of cancer or Changes of Bilateral Intra- and
not and types of cancer. Discharge mortality Extracranial Arteries after Unilateral
rate, 1-year mortality rate and 1-year stroke Indirect Revascularization Surgeries
recurrence rate of cancer subgroup compared in Patients with Moyamoya Disease
to non-cancer patients were analyzed. Shin-Joe Yeh1, Sung-Chun Tang1, Li-Kai Tsai1, 2,
Multiple clinical characteristics and Tzu-Ching Chen1, Pei-Lin Li1, Ya-Fang Chen3,
comorbidities, such as age, gender, stroke Meng-Fai Kuo4, Jiann-Shing Jeng1

260

1
Department of Neurology, National Taiwan
University Hospital, Taipei
2
Department of Neurology, National Taiwan
University Hospital Hsin-Chu Branch, Hsin-Chu
3
Department of Medical Imaging, National
Taiwan University Hospital, Taipei
4
Department of Pediatric Neurosurgery, National
Taiwan University Hospital, Taipei
Research purpose: Indirect revascularization
surgery is a promising treatment for
Moyamoya disease (MMD). The
postoperative ultrasonographic parameters of
ipsilateral superficial temporal artery (STA)
are known to correlate with Matsushima
collateral grades on external carotid
angiography. Prior MR perfusion study has
revealed bilateral perfusion improvement
after unilateral surgery in MMD patients,
but it remains elusive about the influence
of unilateral surgery on bilateral intra- and
extracranial arteries. Whether ultrasound
can predict long-term reduction of vascular
events after indirect revascularization
remains unknown.
Material and methods: MMD patients
who would undergo the first unilateral
indirect revascularization surgeries were
prospectively included, receiving pre- and
postoperative ultrasound examinations at
1, 3, 6 months. The pre- and postoperative
examinations before contralateral-side
operation were analyzed, focusing on the
hemodynamic changes in the extracranial
and intracranial arteries. The frequencies
of vascular events before and after surgery
were recorded.
Results: A total of 51 patients (24 pediatric,
24 male) were enrolled, with 51 pre-
operative and 82 post-operative ultrasound
年會壁報論文
examinations. All the parameters (peak-
systolic velocity [PSV], end-diastolic
velocity [EDV], resistance index [RI],
and flow volume [FV]) of ipsilateral STA
were significantly different between pre-
and post-operation (all P<0.001). Besides,
the EDV and FV of the contralateral STA
also significantly increased after operation
(P=0.003 and 0.041, respectively).
Abnormal flow direction was observed as
bidirectional flow in middle cerebral artery
(MCA) M1 and reversed or bidirectional
flow in M2, which both markedly increased
after operation (P=0.01 and P<0.001,
respectively). The factors associated with
abnormal flow direction were older age and
surgical procedures in ipsilateral MCA, and
older age, female sex, and reduced STA RI
in contralateral M2. Emerging flow sign
(absence of flow before surgery and presence
of flow after surgery) was associated with
poor Matsushima grades and higher STA RI.
Finally, good Matsushima grades, low STA
RI, and no emerging flow sign in MCA were
significant predictors for long-term reduction
of ischemic events. The predicting efficacies
of the two ultrasonographic features were
compatible with Matsushima grades in the
comparison of areas under receiver operating
characteristic (ROC) curves.
Conclusions: This study showed bilateral
hemodynamic changes in extra- and
intracranial arteries after unilateral indirect
revascularization surgeries in MMD patients,
with increased abnormal flow directions in
MCA after operation, and ultrasonography
has a compatible role with angiography in
predicting the reduction of vascular events
after surgeries.
261