A 71-year-old man is brought to the emergency department by his daughter for evaluation of an episode of slurred speech and right upper extremity weakness. The symptoms began approximately 3 hours ago and lasted an hour. He had no associated headache, chest pain, palpitations, shortness of breath, or syncope. The patient has had no similar episodes in the past. He now feels well. Medical history is significant for hypertension. He has a 60-pack-year smoking history but quit 8 years ago. The patient's mother had atrial fibrillation. Blood pressure is 162/96 mm Hg and pulse is 92/min. BMI is 33 kg/m². Auscultation of the upper anterior cervical triangle on the left side of the neck reveals a bruit. Neurologic examination is normal. No lower extremity edema is present. Low-density lipoprotein cholesterol is 110 mg/dL. ECG shows normal sinus rhythm and nonspecific ST-segment and T-wave changes. MRI of the brain shows mild age-related changes but no areas of restricted diffusion. MR angiogram reveals 75% stenosis of the proximal left internal carotid artery and normal intracerebral vessels. Echocardiography shows left ventricular hypertrophy, normal left ventricular function, and mild left atrial enlargement. A patent foramen ovale is detected via agitated saline study. Lower extremity ultrasound is negative for deep vein thrombosis. He is started on aspirin and rosuvastatin. Which of the following is the best management strategy for this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient developed transient right-sided motor weakness and slurred speech with no evidence of infarction on MRI, suggesting a transient ischemic attack (TIA). Right-sided motor symptoms usually indicate a lesion in the vascular distribution of the left middle cerebral artery, a branch of the left internal carotid artery. MR angiogram of this vessel demonstrated significant stenosis, indicating symptomatic carotid artery disease. Symptomatic carotid artery disease is diagnosed when a patient with carotid stenosis develops a TIA or nondisabling stroke in the vascular distribution of the diseased vessel. Manifestations typically arise due to either low-flow states (obstructing lesions) or embolic disease. Patients with symptomatic carotid artery disease who have high-grade (eg, 70%-99%) stenosis and a life expectancy ≥5 years should undergo carotid endarterectomy (CEA) to reduce future risk of stroke. However, the risks of CEA likely outweigh any potential benefits for patients who are poor surgical candidates (eg, multiple medical comorbidities), those with an ipsilateral stroke with persistent disabling neurologic deficits, and those with 100% occlusion of the internal carotid artery. Surgical management of lower-grade (<70%) lesions is debated among expert panels and depends on sex of the patient and the presence or absence of symptoms. In many cases, patients with such lesions are managed medically only. For all patients with carotid artery disease, medical management includes aspirin, statin, and the control of atherosclerotic risk factors (eg, hypertension, hyperglycemia, smoking). (Choice A) Clopidogrel can be used in the medical management of patients with carotid stenosis who cannot tolerate aspirin (first-line therapy). This patient requires aspirin and surgical treatment with CEA. (Choice C) Extended ambulatory ECG monitoring can determine whether an intermittent arrhythmia (eg, atrial fibrillation) may be the underlying cause of TIA or stroke. However, patients do not typically require this test if there is a clear cause of TIA or stroke during initial evaluation (eg, brain imaging, carotid vessel imaging, ECG). (Choice D) Anticoagulation (eg, warfarin) is not generally recommended for patients with carotid artery stenosis. Anticoagulation is often used in patients with left ventricular thrombus or atrial fibrillation. (Choice E) Patent foramen ovale closure is recommended for patients with embolic-appearing cryptogenic strokes. However, closure is not required in patients who have a clear inciting cause (eg, symptomatic carotid artery disease) of TIA. Furthermore, this patient does not have evidence of deep vein thrombosis, and patent foramen ovale closure is currently recommended only in patients age <60. Educational objective: Symptomatic carotid artery stenosis is a common cause of stroke and transient ischemic attack. Patients with symptomatic high-grade (70%-99%) carotid lesions and life expectancy ≥5 years should be evaluated for carotid endarterectomy. Lower-grade (<70%) lesions may be managed either medically (eg, aspirin, statins, antihypertensives) or surgically, depending on the degree of stenosis and sex of the patient. References: Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. (http://www.ncbi.nlm.nih.gov/pubmed/18774746) Best evidence for medical therapy for carotid artery stenosis. (http://www.ncbi.nlm.nih.gov/pubmed/24075112)

A 71-Year-Old Man Is Brought to the Emergency Department by His