A 75-year-old man is brought to the emergency department due to right-sided weakness on awakening this morning. The patient has had no headache, nausea, double or blurry vision, or vertigo. Medical history includes type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications include metformin, lisinopril, and atorvastatin.
Temperature is 36.7 C (98 F), blood pressure is 168/96 mm Hg, pulse is 92/min, and respirations are 12/min. Physical examination reveals a carotid bruit on the left. Neurologic examination shows mild dysarthria, right central facial palsy, and mild right hemiparesis.
ECG shows normal sinus rhythm. MRI of the brain reveals multiple acute cortical and subcortical infarcts in the left middle cerebral artery territory, as shown in the image below. CT angiography of the head and neck reveals 80%-90% stenosis at the origin of the left internal carotid artery. Echocardiogram shows mild left atrial enlargement, left ventricular hypertrophy, and left ventricular ejection fraction of 65%. The patient receives low-dose aspirin in the emergency department.

Which of the following is the most appropriate next step in management of this patient?

Question

A 75-year-old man is brought to the emergency department due to right-sided weakness on awakening this morning.  The patient has had no headache, nausea, double or blurry vision, or vertigo.  Medical history includes type 2 diabetes mellitus, hypertension, and hyperlipidemia.  Medications include metformin, lisinopril, and atorvastatin.
Temperature is 36.7 C (98 F), blood pressure is 168/96 mm Hg, pulse is 92/min, and respirations are 12/min.  Physical examination reveals a carotid bruit on the left.  Neurologic examination shows mild dysarthria, right central facial palsy, and mild right hemiparesis.
ECG shows normal sinus rhythm.  MRI of the brain reveals multiple acute cortical and subcortical infarcts in the left middle cerebral artery territory, as shown in the image below.  CT angiography of the head and neck reveals 80%-90% stenosis at the origin of the left internal carotid artery.  Echocardiogram shows mild left atrial enlargement, left ventricular hypertrophy, and left ventricular ejection fraction of 65%.  The patient receives low-dose aspirin in the emergency department.

Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has evidence of acute left middle cerebral artery ischemic stroke associated with ipsilateral, high-grade carotid stenosis. In addition to medical therapy including aspirin, statin, blood pressure control, and risk modification (eg, glucose control, smoking cessation), he also requires consultation to consider carotid revascularization. ischemic stroke Symptomatic patients (ie, transient ischemic attack or ischemic stroke within the distribution of the affected vessel) with a life expectancy of ≥5 years and high-grade stenosis (70%-99%) should be offered a carotid endarterectomy (CEA). Post-hoc analysis of pooled data from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) suggests that CEA within 1-2 weeks of a nondisabling stroke or transient ischemic attack improves outcomes compared with later surgery; very early CEA (<48 hours) is associated with higher risk of recurrent stroke. (Choice A) In very large strokes with associated cerebral edema or hemorrhagic complications, a delay of 4-6 weeks for revascularization is reasonable. However, in most cases, revascularization should be completed within 1-2 weeks. In high-grade stenosis, CEA is preferred to carotid artery stenting due to lower periprocedural mortality and stroke rates. (Choice C) Studies have found no benefit of early anticoagulation in the setting of acute ischemic stroke (whether due to atherosclerotic disease or cardioembolism) due to the significant risk of hemorrhagic transformation. (Choice D) Warfarin is not more beneficial than antiplatelet therapy in atherothrombotic or atherothromboembolic strokes and carries a significant risk of bleeding. (Choice E) Nimodipine is indicated in the treatment of post-aneurysmal subarachnoid hemorrhage to protect against vasospasm. It is not used routinely in ischemic stroke. Educational objective: Early carotid revascularization (within 1-2 weeks) with carotid artery endarterectomy is recommended for patients with symptomatic high-grade carotid stenosis who have transient ischemic attack or stroke; very early revascularization (<48 hours) should be avoided in these patients. __________ References: Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/20966421)

A 75-Year-Old Man Is Brought to the Emergency Department Due