Nicotine replacement therapy and ischaemic stroke

Abstract

A52-year-old right-handed businessman developed sudden onset of non-fluent dysphasia, weakness and sensory disturbance on the right side of his body 3 weeks after starting Nicorette patches (21 mg). He continued to smoke 3–5 cigars a day while on these patches. The patient had a history of depression and excessive alcohol intake. Examination confirmed an expressive dysphasia with verbal fluency limited to five words beginning with ‘C’ or ‘S’ but with no problems in comprehension, naming or praxis. Rapid alternating movements were impaired on the right and reflexes were brisker on the right side, although both planters were flexor. Cardiovascular and general examination was unremarkable. Magnetic resonance imaging (MRI) brain scan confirmed a left anterior cerebral artery territory infarct. The following blood tests were normal or unhelpful: erythrocyte sedimentation rate (ESR), C-reactive protein, protein culture and sensitivity, antithrombin, antiphospholipid coagulant, treponemal serology, thyroid screen and autoantibody screen. The patient was found to have mildly raised triglyceride (2.42 mmol/l) and low density lipoprotein (LDL) cholesterol (4.61 mmo/l). Electrocardiogram (ECG), echocardiography and carotid Dopplers were all normal. Two previous cases of stroke following nicotine patches have been reported by Jackson (1993) and Pierce (1994). In addition, the Medicines and Healthcare products Regulatory Agency (MHRA) have received 12 further cases of cerebrovascular disorders following nicotine replacement (Table 1).