Question

A 65-year-old male presented with history of TIA, transient right upper limb weakness, diagnosed to have bilateral carotid artery stenosis on colour doppler.
How would you manage him?

Hint:

In patients with symptomatic carotid stenosis, the goal is to reduce the risk of stroke through a combination of medical management and, if necessary, surgical intervention.

Answer 1

Step 1: Goals of management.
The primary goal of managing this patient is to reduce the risk of stroke and manage the carotid artery stenosis. Management strategies can be medical or surgical, depending on the severity of the disease and the patient's symptoms.

Step 2: Medical management.
- Antiplatelet therapy: Aspirin or clopidogrel should be prescribed to prevent platelet aggregation and reduce the risk of thrombosis. In some cases, dual antiplatelet therapy (aspirin + clopidogrel) may be considered for higher-risk patients.
- Statins: Statin therapy should be initiated to reduce cholesterol levels and stabilize the plaque. Statins also have an anti-inflammatory effect on the arterial wall, which may prevent further progression of atherosclerosis.
- Blood pressure control: Aggressive management of hypertension is crucial to reduce the risk of stroke and further damage to the carotid arteries.
- Glycemic control: If the patient is diabetic, optimizing blood glucose levels is essential to prevent progression of atherosclerosis.

Step 3: Surgical management.
- Carotid endarterectomy (CE: This procedure may be considered if the stenosis is severe (typically greater than 70%) and the patient is symptomatic. CEA removes the plaque from the artery and improves blood flow to the brain.
- Carotid artery stenting (CAS): This may be an option for patients who are not candidates for endarterectomy, particularly those with high surgical risk or those with anatomically unfavorable carotid arteries.

Step 4: Conclusion.
Management should focus on medical therapy (antiplatelet, statins, blood pressure control) as first-line treatment. If the patient remains symptomatic or has severe stenosis, surgical options like carotid endarterectomy or stenting should be considered.