68-year-old man with brief slurred speech and 78% stenosis
A 68-year-old man with hypertension and hyperlipidemia is evaluated 2 days after a 15-minute episode of slurred speech and right hand clumsiness that resolved completely. He did not seek care at the time. Today he is neurologically normal. Blood pressure is 146/84 mm Hg, and ECG shows normal sinus rhythm. MRI of the brain shows no acute infarction. CT angiography demonstrates 78% stenosis of the left internal carotid artery. He takes aspirin and atorvastatin. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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A
Explanation
Clinical Pearl:
Symptomatic extracranial carotid stenosis warrants urgent revascularization when severe, especially if symptoms occurred within the past 2 weeks. In most standard-risk older adults, carotid endarterectomy is preferred over stenting for 70% to 99% symptomatic stenosis.
Explanation:
This patient had a transient ischemic attack in the left carotid territory and has severe ipsilateral extracranial carotid stenosis, making carotid endarterectomy the standard next step if surgical risk is acceptable, ideally performed within 14 days of symptoms. Adding clopidogrel can be appropriate short term after high-risk TIA or minor stroke, but it does not replace needed revascularization for severe symptomatic carotid disease. Intravenous alteplase is not indicated because his neurologic deficits resolved 2 days ago and he is outside the treatment window. Carotid artery stenting is generally reserved for patients with unfavorable surgical anatomy or high operative risk, and in older adults it carries a higher periprocedural stroke risk than endarterectomy. Apixaban is used for cardioembolic stroke prevention, such as in atrial fibrillation, which is not present here. Current stroke prevention guidance supports urgent evaluation and carotid revascularization for recently symptomatic severe carotid stenosis to reduce early recurrent stroke risk.
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