Case Details

General Medicine Cardiology

Indian Doctors Network posted a case

over 1 year ago


Courtesy: 100 cases in surgery

A 71-year-old man presents to the emergency department with weakness and numbness in his left arm. The symptoms came on suddenly while he was in the garden 2 h ago. His vision was not affected and he thinks the weakness in his arm has now resolved. He has had no previous episodes and has no history of trauma to his head or neck. He is currently
on medication for hypertension and is a lifelong smoker.

The blood pressure is 130/90 mmHg and the pulse rate is regular at 90/min. Heart sounds are normal and the chest is clear. Abdominal examination is normal. Neurological examination does not show any neurological deficit. A right-sided carotid bruit is heard.

• What is the diagnosis?
• What are the risk factors?
• How should this patient be investigated?
• What are the complications of surgery?

A transient ischaemic attack (TIA) refers to a focal neurological deficit which lasts less than 24 h. A stroke is a deficit lasting more than 24 h. Eighty per cent of cerebrovascular incidents are caused by emboli, with the majority of infarctions in the carotid territory.

Risk factors !
• Hypertension
• Smoking
• Diabetes mellitus
• Atrial fibrillation
• Raised cholesterol

Patients should undergo the following investigations:
• full blood count, erythrocyte sedimentation rate
• electrocardiogram
• imaging of the carotid, which can be done by:
• duplex ultrasonography: this technique combines B mode ultrasound and colour Doppler flow to assess the site and degree of stenosis. This is now the investigation of choice in most centres
• angiography: intra-arterial angiography is the gold standard but is invasive and is associated with a 1–2 per cent risk of stroke. Intravenous digital subtraction angiography is used in some centres
• magnetic resonance angiography
• spiral computerized tomography (CT) angiography
• CT head scan: to delineate areas of infarction and exclude haemorrhage in an acute presentation with stroke.

A stenosis of more than 70 per cent in the internal carotid artery is an indication for carotid endarterectomy in a patient with TIAs .

Neck haematoma (5 per cent)
• Cervical and cranial nerve injury (7 per cent): hypoglossal, vagus, recurrent laryngeal, marginal mandibular and transverse cervical nerves
• Stroke (2 per cent)
• Myocardial infarction
• False aneurysm: rare
• Infection of prosthetic patch: rare
• Death (1 per cent)

• Symptoms in a transient ischaemic attack last less than 24 h.
• Symptomatic carotid stenosis of 70 per cent should be considered for carotid

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