A 63-year-old man comes to the emergency department due to sudden-onset right-sided weakness that resolved spontaneously within 30 minutes. Medical history includes hypertension and an early-stage sigmoid colon cancer that was resected 5 years ago; follow-up colonoscopy showed no recurrence. The patient takes lisinopril. He has a 20-pack-year history and quit smoking 10 years ago. Blood pressure is 130/80 mm Hg and pulse is 74/min. Examination shows a left carotid bruit. Neurologic examination is normal. ECG shows normal sinus rhythm. CT scan of the head is normal. Lipid panel results are as follows:
| Fasting lipid panel | ||
| Total cholesterol | 240 mg/dL | |
| Low density lipoprotein | 160 mg/dL | |
Echocardiography is unremarkable. Carotid duplex ultrasonography and follow-up CT angiography show 80% stenosis in the left internal carotid and 40% stenosis in the right internal carotid artery. Which of the following is the most appropriate next step in preventing a further stroke in this patient?
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This patient with temporary right-sided motor weakness without evidence of infarction on MRI had a transient ischemic attack (TIA), and subsequent evaluation for a source demonstrated 80% stenosis of the left carotid artery. Without intervention, patients such as this one with symptomatic carotid atherosclerotic disease—defined as causing sudden, focal neurologic symptoms attributable to the distribution of the affected vessel within the previous 6 months—are at high risk of stroke within the first year. Therefore, all such patients should receive intensive medical therapy (ie, aspirin, statin, blood pressure control), counseling on lifestyle changes (eg, exercise, smoking cessation), and evaluation for carotid revascularization.
In patients with symptomatic disease, the recommendation for carotid revascularization depends on the degree of stenosis:
Other factors, including the presence of persistent disabling neurologic defects or a short life expectancy (eg, <5 years), are also considered when analyzing benefits versus risks for CEA in an individual patient. Carotid artery stenting (CAS) may be a revascularization alternate to CEA in select patients but has a higher periprocedural (ie, 30-day) risk of stroke and death.
(Choices A and E) CEA has not shown benefit for carotid stenosis <50%, whether symptomatic or asymptomatic. Therefore, revascularization is not recommended for this patient's right carotid artery, which has only 40% stenosis.
(Choices C and D) Medical therapy (eg, aspirin, statin, blood pressure control) should be initiated in all patients with carotid atherosclerotic disease. However, anticoagulation (eg, heparin, oral anticoagulant) is less effective than antiplatelet therapy (eg, aspirin) for secondary prevention of stroke in patients with carotid stenosis unless there is an alternate indication for anticoagulation (eg, atrial fibrillation).
Educational objective:
All patients with carotid atherosclerotic disease should receive intensive medical management (ie, aspirin, statin, blood pressure control) and counseling on lifestyle changes to reduce future stroke risk. Carotid endarterectomy is also generally recommended for patients with symptomatic stenosis of 70%-99%.