We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Clinical Crossroads | Clinician's Corner

A 70-Year-Old Man With a Transient Ischemic Attack Review of Internal Carotid Artery Stenosis

Louis R. Caplan, MD, Discussant
JAMA. 2008;300(1):81-90. doi:10.1001/jama.299.21.jrr80004.
Text Size: A A A
Published online

Mr V, a man with severe coronary, aortic, and peripheral artery disease, had an episode of brain ischemia caused by severe preocclusive carotid artery disease in the neck. The major treatment options for his symptomatic carotid artery disease are optimizing medical treatment, carotid endarterectomy, and carotid artery stenting. Selection of treatment must take into consideration his severe symptomatic coronary artery disease as well as Mr V's concerns about surgery. Carotid endarterectomy presents a risk of myocardial infarction unless his coronary disease is treated effectively before surgery. Carotid stenting is problematic because the severity of the preocclusive arterial narrowing makes passing a protective device beyond the stenosis difficult without first performing potentially hazardous angioplasty. Optimizing medical treatment may be the best option for his severe systemic atherosclerosis. Treatment decisions in complex patients like Mr V require weighing the particular risks and benefits of available options, and the patient's own wishes and fears. These decisions, in this and other complex patients, often cannot be directly informed by results from randomized trials.

Figures in this Article


Place holder to copy figure label and caption
Figure 1. Views of a Computed Tomography Angiogram in Mr V
Graphic Jump Location

A, Anteroposterior view. B, Lateral view. The internal carotid artery lumen is severely narrowed (arrowheads).

Place holder to copy figure label and caption
Figure 2. Mr V's Diffusion-Weighted and T2*-Weighted MRI Scan
Graphic Jump Location

Diffusion-weighted magnetic resonance imaging (MRI) shows white hyperintense foci (restricted diffusion) that represent infarction (arrowheads) in the cerebral cortex of the right frontal lobe (A) and the parietal lobe (B). C, T2*-weighted MRI shows a cylindrical dark region that represents a thrombus in a middle cerebral artery branch (arrowhead).

Place holder to copy figure label and caption
Figure 3. Anatomy of Internal Carotid Artery and Intracranial Branching
Graphic Jump Location




You need to register in order to view this quiz.


Some tools below are only available to our subscribers or users with an online account.

5 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Updated Literature Search

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Evidence Summary and Review 5