Welcome to module 3 week 1, please make sure you watch the educational video before answering the questions. hope you all will enjoy the Module .
Week 1 – Case 1
65 Yrs old male patient, he smokes 15 cigarettes/day and he suffers hypertension. He presented to the
neurologist with history of right arm and leg sudden weakness that lasted for 5 minutes and then resolved
completely 5 days ago. He is only on amlodipine 10 mg/day. CT head did not show any area of infarction
and carotid doppler showed patent right ICA, ECA and CCA. The left ICA showed area of ulcerated plaque
causing narrowing of the origin of the ICA, the PSV at that area was 255 cm/s and St Mary ratio was 25. The
neurologist referred the patient to your clinic for vascular specialist input.
Q1: What is the symptom the patient presented with?
Q2: What is the degree of stenosis in this patient?
Q3: How will you counsel the patient if he does not know why was he referred to you? (only key points).
Q4: How will you manage the patient? (any further investigation, what is your treatment –Medical vs
surgical vs both).
Q5: How can you support your answer with evidence?
Q1: TIA
Q2: stenosis 80-89
Q3: I’ll tell him that he had TIA because there is carotid artery stenosis which needs further assessment and intervention to prevent more TIAs or strokes in the future
Q4: another duplex may be needed, CTA or MRA
Life style modification
Diet and smoking cessation
Control RF
BMT and CEA
Q5: according to ESVS guidelines 2023 Recommendations : For patients reporting carotid territory symptoms within the preceding 6 months and who have 70-99% stenosis, CEA is recommended provided the 30 day risk of death/ stroke rate is <6%
Q1: What is the symptom the patient presented with?
Transient ischaemic attack
Q2: What is the degree of stenosis in this patient?
80-89%
Q3: How will you counsel the patient if he does not know why was he referred to you? (only key points).
->I will begin by explaining the cerebral circulation and how the carotid arteries are responsible for cerebral perfusion.
-> I will explain that this patient suffering from atherosclerosis disease which is a systemic desease affecting the blood vessels of the whole body including carotid artery which in his case is severely stenosed causing insufficient blood supply to the brain.
-> I will explain that the neurologist referred him so that the vascular surgery team could enhance the blood supply to the brain by medical treatment only , removal of the plaque ( carotid End Arterectomy) or by dilatation and stenting
Q4: How will you manage the patient? (any further investigation, what is your treatment –Medical vs
surgical vs both).
-I will ask for repeating the DUS or CTA or MRI according to hospital protocol and kidney function tests.
-I will start conservative treatment while preparing the patient for carotid end arterectomy.
This conservative treatment include
Life style modification, smoking cesation , starting dual antiplatlet to be reduced to single antiplatlet after the CEA, I will start full dose statin if the patient could tolerate it with follow up lipid profile.
-Then I will do Carotid End arterectomy with lower risk of Perioperative stroke <3% for high specialized centers, risk for nerve injury 1-5% and risk for MI and Death <3%
Q5: How can you support your answer with evidence?
European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease
Sorry for my late response
Q1: TIA
Q2: stenosis 80-89
Q3: I’ll tell him that he had TIA because there is carotid artery stenosis which needs further assessment and intervention to prevent more TIAs or strokes in the future
Q4: another duplex may be needed, CTA or MRA
Life style modification
Diet and smoking cessation
Control RF
BMT and CEA
Q5: according to ESVS guidelines 2023 Recommendations : For patients reporting carotid territory symptoms within the preceding 6 months and who have 70-99% stenosis, CEA is recommended provided the 30 day risk of death/ stroke rate is <6%
Well done Dr Mohamed, I would use the word REDUCE rather than PREVENT to be more accurate. I would like also to highlight the importance when counselling the patient for CEA to mention all risks with % e.g Peri-op stroke risk (should be less than 3% for any centre offering CEA, Cranial nerve injury 1-5% and the usual risks from GA like MI or death which should not be more than 3% in a standard risk operation as per EVES guidelines.
Q1 TIA
Q2 80 – 89 % as mary ratio 22 – 29
Q3 explain to pt that his TIA is mostly fue to catotide rtery stenosis and ulcerated paque that may also cause more TIAs or strokes in future and we should assess you and choise the pt ttt for prevent you from thise psoblem.
Q4 full labs
Other duplex by other operator on bilateral carotid or CTA extra and intra cania arteries.
ECG ECHO..
Ttt life style modifiction also start medical therapy and prepare pt for CEA after counsilling with pt and familly risk of op vs benefit ( if pt is fit )
Q5.
For patients reporting carotid territory symptoms within the preceding six months and who have a 70e99% carotid stenosis, carotid endarterectomy is recommended provided the 30 day risk of death/stroke rate is <6% class 1 A
Well said Dr Andullah,
I will correct one point:
When couselling the patient, CEA+ BMT will REDUCE the risk( not prevent), as per the systematic review I shared in the presentation >70% stenosis is associated with 34% risk or recurrent stroke with BMT alone and 17% with CEA+ BMT, so the surgery will halves the risk.
Q1: What is the symptom the patient presented with?
TIA, as the patient developed focal neurological carotid territory symptoms that totally resolved within 24 h.
Q2: What is the degree of stenosis in this patient?
ICA PSV origin 255 cm/s, St Mary ratio 25 >>> 80-89% stenosis
Q3: How will you counsel the patient if he does not know why was he referred to you?
-Explaining that he went through TIA like a “mini-stroke” or a warning stroke and although the symptoms had completely resolved, other steps should be taken to avoid major stroke.
-Life style modification (exercise, smoking cessation), high dose statin, BP control, DAPT
Q4: How will you manage the patient? (any further investigation, what is your treatment –Medical vs surgical vs both).
Q5: How can you support your answer with evidence?
According to ESVS 2023 guidelines;
-History: ask about history of bleeding to identify bleeding risk.
-Investigations:
Full bloods, ABG, ECG, Echo, peri-operative risk assessment.
CT brain was already done, assuming brain Hge was excluded.
As the patient has symptomatic carotid stenosis, about 80-89% as estimated by Duplex US, it is recommended that duplex US stenosis estimation be corroborated by CTA/MRA (class IB evidence).
-TTT plan:
-Life style modification (exercise, smoking cessation), high dose statin, BP control, DAPT
-CEA or CAS according to patient’s surgical risk.
Well done Dr Asmaa, very informative answer. If I am the patient and I asked you:
What is the % of me having stroke again if I do not have the surgery?
Will the surgery prevent any stroke completely or just reduce the risk?
Which intervention is better CEA or CAS?
Also, if do not have the facility to arrange for CTA or MRA, is there alternative? Is duplex alone enough to arrange for intervention?
1.tia
2more than70℅
3
Thank you Dr Eman for your comment.
Regarding the degree of stenosis, you have PSA and St Mary ratio in the scenario which you can use to determine the exact degree of stenosis, it need to be range rather than just one number e.g (30-39%…this is not the answer just for demonstration)
I am waiting to hear your thoughts about Q3,4 and 5
For Q3 if it is not clear, I want you to mention the important quesntions the patient may ask you and how will you answer him e.g do I need to have surgery? is the surgery going to PREVENT any future TIA/Stroke.
Dear candidates
We emphasise the importance of your engagement and contribution to benifit from the course and it works towards your assessment as well
Regards