How to manage a 70-year-old chronic smoker and alcoholic with resting tremors in the right hand and a non-contrast computed tomography (NCCT) scan showing posterior cerebral artery (PCA) territory infarct?

Management of a 70-Year-Old Male with PCA Territory Infarct, Resting Tremor, and Chronic Alcohol Use

The management of this patient should focus on immediate stroke care, addressing the resting tremor which may be alcohol-related, and implementing aggressive secondary stroke prevention measures including smoking and alcohol cessation, antiplatelet therapy, and statin therapy.

Initial Assessment and Imaging

• Non-contrast CT (NCCT) has already identified a posterior cerebral artery (PCA) territory infarct, which is crucial for distinguishing between hemorrhagic and ischemic stroke 1
• Further vascular imaging with CTA or MRA should be performed to evaluate the severity of stenosis and identify any additional intracranial or extrathoracic vascular lesions 2
• When symptoms suggest posterior cerebral or cerebellar ischemia, MRA or CTA is recommended over ultrasound for evaluation of vertebral arteries 2

Management of Resting Tremor

• The patient's resting tremor in the right hand may be related to:

  • Alcohol withdrawal tremor (8-12 Hz postural tremor with higher amplitude compared to anxiety-related tremor) 3
  • Chronic alcoholism-related tremor (occurs in 47% of chronic alcoholics even after 21 days of abstinence) 4
  • Stroke-related tremor (due to PCA territory infarct potentially affecting thalamic or cerebellar pathways) 5

• For alcohol withdrawal tremor, appropriate management includes:

  • Close monitoring for progression of withdrawal symptoms 6
  • Beta-adrenergic blocking agents may help control tremor and potentially prevent alcohol relapse in patients using alcohol for tremor self-medication 7, 4

Secondary Stroke Prevention

Antiplatelet Therapy

• Administer aspirin 75-325 mg daily as part of initial management for secondary prevention 2, 6
• In patients with ischemic stroke or TIA with obstructive or nonobstructive extracranial cerebrovascular atherosclerosis, antiplatelet therapy is recommended 2

Blood Pressure Management

• Antihypertensive treatment is recommended to maintain blood pressure below 140/90 mmHg 2
• For patients with symptomatic extracranial carotid or vertebral atherosclerosis, antihypertensive treatment should be carefully managed to avoid exacerbating cerebral ischemia 2

Lipid Management

• Statin therapy is recommended for all patients with extracranial carotid or vertebral atherosclerosis to reduce LDL cholesterol below 100 mg/dL 2
• For patients with atherosclerotic ischemic stroke, it is reasonable to target LDL-C reduction of at least 50% or a target level of <70 mg/dL for maximum benefit 2
• High-intensity statin therapy (atorvastatin 80 mg) is recommended for patients with ischemic stroke and LDL-C >100 mg/dL 2

Lifestyle Modifications

• Smoking Cessation:

  • The patient should be strongly advised to quit smoking with appropriate counseling and pharmacological support 2
  • Smoking cessation interventions including counseling, nicotine replacement products, and oral medications should be offered 2

• Alcohol Reduction:

  • The patient should be strongly counseled to reduce or eliminate alcohol consumption 2
  • Referral to specialized services for alcohol use disorder is recommended 2
  • Complete cessation is preferable given his chronic alcoholism and unwillingness to quit 2

• Physical Activity:

  • At least 30 minutes of moderate-intensity physical exercise 1-3 times per week should be encouraged as tolerated 2
  • For patients with disability after stroke, a supervised therapeutic exercise regimen is recommended 2

Follow-up Care

• Serial non-invasive imaging of the extracranial vertebral arteries is reasonable to assess progression of atherosclerotic disease 2
• Regular monitoring of lipid levels 1-3 months after treatment initiation, followed by assessments every 3-12 months 2
• Implement a transdisciplinary team approach for comprehensive management, especially if diabetes is present 2

Pitfalls and Caveats

• The patient's unwillingness to quit drinking poses a significant challenge to stroke recovery and prevention of recurrence 2
• Alcohol withdrawal symptoms should be monitored closely as they may worsen during hospitalization 3
• Focusing solely on the stroke without addressing chronic alcoholism and smoking will significantly increase the risk of recurrent stroke 2
• The combination of PCA territory infarct with thalamic involvement (if present) carries a worse prognosis and requires more aggressive management 5