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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.
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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.

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Figure 1. Views of a Computed Tomography Angiogram in Mr V
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A, Anteroposterior view. B, Lateral view. The internal carotid artery lumen is severely narrowed (arrowheads).

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Figure 2. Mr V's Diffusion-Weighted and T2*-Weighted MRI Scan
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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).

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Figure 3. Anatomy of Internal Carotid Artery and Intracranial Branching
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