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 2
56 yrs old right-handed patient known with hypertension, ex-smoking and atrial fibrillation for which he is
taking Apixaban 5mg twice daily. He presented to the neurologist with 2-day history of sudden blackout in the
right eye, slurred speech and left arm weakness that lasted 10 minutes and then resolved completely. Brain
MRI showed multiples areas of infarction in both occipital, Rt parietal and both frontal area of the brain.
Carotid doppler scan showed Rt ICA 50-59% stenosis (PSV 130 cm/s) and Lt ICA 30% stenosis (PSV 89). The
neurologist commenced the patient on Atorvastatin 80 mg once daily and referred him to you for
consideration of carotid endarterectomy?
Q1: How will you manage this patient? Please justify your answer.
Q2: Are there any further tests/investigations that can help you make the decision regarding the
management?
Q3: What if the brain MRI did not show any area of infarction, will that make you change your management?
Q1: How will you manage this patient? Please justify your answer.
Q2: Are there any further tests/investigations that can help you make the decision regarding the management?
The patient developed TIA despite being on therapeutic anticoagulation.
History;
-any recent bleeding event.
-thromboembolic Hx? cardiac Hx? previous PCI, CABG, CCU admission?
Investigations;
-Full bloods, ABG, ECG, peri-operative risk assessment.
-MRI brain was already done, excluding brain Hge, showing infarcts in mixed territories (infarcts age?)
-Echo to exclude embolic cardiac source, non/valvular AF
-CTA;
——cuz Duplex US has low sensitivity in (less than 50%) and in (50-69%) stenosis, and the patient has bilateral infarcts.
——also to check proximal arterial disease (aortic arch, SCA)
Q3: What if the brain MRI did not show any area of infarction, will that make you change your management?
I’d do the above mentioned work-up.
According to ESVS 2023 guidelines, for patients with a TIA in the presence of known AF and an ipsilateral 50-99% carotid stenosis, comprehensive neurovascular work up with MDT review is recommended to determine whether carotid revascularisation or anticoagulation alone is indicated.
Yet, this patient developed TIA in the territory ipsilateral to a 50-99% carotid
stenosis while being on anti-coagulation, so after exclusion of cardiac source, CEA or CAS can be considered according to patient’s risk
Q1: How will you manage this patient? Please justify your answer.
I will keep the patient on conservative treatment as the patient is mostly embolic from the AF and there’s multiple distribution of the neurological deficits in multiple arterial branches
Q2: Are there any further tests/investigations that can help you make the decision regarding the
management?
Transesophogeal Echo to detect any intracardiac thrombus
CTA
MRA
Q3: What if the brain MRI did not show any area of infarction, will that make you change your management?
Yes that will make the diagnosis symptomatic TIA which needs CEA or CAS
Nice points in ESVS 2023 Symptomatic patients with > 50% stenosis and atrial
fibrillation
Pragmatic decision making
1. Acute ischaemia/infarction in multiple vascular territories suggests cardioembolism. Patients should be
anticoagulated, and the carotid stenosis considered asymptomatic.
2. Acute ischaemia/infarction in the ipsilateral carotid territory is suggestive of a carotid source of embolism and (in some centres) this would be considered
sufficient to recommend CEA/CAS. However, this diagnosis can be made with greater certainty if supported by ipsilateral embolism on TCD, IPH in the
ipsilateral carotid plaque, and no evidence of left atrial appendage thrombus.
3. If a patient is anticoagulated (on the basis that cardioembolism was the likeliest aetiology) but then suffers recurrent event(s) in the territory ipsilateral t the 50e99% carotid stenosis while on therapeutic anticoagulation, it is reasonable to consider CEA or CAS
see section 4.2.6.3 for management of peri-operativeanticoagulation)
4. If investigations are neither diagnostic nor informative and more complex imaging is unavailable, the MDT will have to make an empirical management decision, following discussion of diagnostic uncertainties and potential implications with the patient
Well done reviewing the updated 2023 ESVS guidlines, I completely agree with pragmatic approach however in this case I disagree with your plan.
In Q1: presence of infarcs in multiple trrotories makes anticoagulation for AF is the first sensiple option.
In Q4: abscence of infarcts in the MRI will make this case is likely TIA related to the carotid stenosis and ofering CEA will be more sensible option.
Offering TCD if available will guid your decision in both Scenarios.
Q1 I will prepare pt for CEA( after counslling with pt and his familly also neurologist and cardiologist ) as pt has multiple silent TIA as showed by MRI when he was anticogulated
For patients who have been started on anticoagulation (on the basis that cardiac embolism was considered the most likely cause of their transient ischaemic attack or stroke) but who then report recurrent event(s) in the territory ipsilateral to a 50e99% carotid stenosis whilst on therapeutic levels of anticoagulation, carotidendarterectomy or carotid artery stenting is recommended 1 c
Q2.There are no definitive diagnostic tests for discriminating between cardioembolic or carotid sources of embolisation and management decisions will have to be based on probability, guided by access to basic or more complex investigative modalities.
More complex imaging strategies might include T1 fat saturated MRI to look for IPH in the carotid plaque, which is associated with acutely symptomatic carotid plaques. Transoesophageal echocardiography can diagnose left atrial appendage thrombus or other cardiac sources of embolism. Transoesophageal echocardiography (plus bilateral TCD) with i.v. microbubble contrast media in conjunction with a Valsalva manoeuvre can diagnose a patent foramen ovale (suggesting paradoxical embolisation). Finally, 30 e 60 minutes of bilateral simultaneous TCD monitoring of both MCAs can diagnose spontaneous embolisation. In a series of 123 recently symptomatic patients with 50e99% stenoses, 40% of patients undergoing 30 minutes of TCD monitoring within seven days of TIA/stroke onset had ongoing ipsilateral MCA embolisation. Bilateral embolisation, however, suggests a cardioembolic source. To date, no guidelines have offered advice regarding the management of patients with recent carotid territory symptoms, an ipsilateral carotid stenosis, and AF ( ESVS 2023)
Q3. Yes medicall ttt only with modification of risk factor and cardiac assessment ( For patients presenting with a transient ischaemic attack or minor ischaemic stroke in the presence of newly diagnosed or known atrial fibrillation and an ipsilateral 50e99% carotid stenosis, comprehensive neurovascular work up with multidisciplinary team review is recommended to determine whether urgent carotid revascularisation or anticoagulation alone is indicated 1C
Q1: How will you manage this patient? Please justify your answer.
Q2: Are there any further tests/investigations that can help you make the decision regarding the management?
The patient developed TIA despite being on therapeutic anticoagulation.
History;
-any recent bleeding event.
-thromboembolic Hx? cardiac Hx? previous PCI, CABG, CCU admission?
Investigations;
-Full bloods, ABG, ECG, peri-operative risk assessment.
-MRI brain was already done, excluding brain Hge, showing infarcts in mixed territories (infarcts age?)
-Echo to exclude embolic cardiac source, non/valvular AF
-CTA;
——cuz Duplex US has low sensitivity in (less than 50%) and in (50-69%) stenosis, and the patient has bilateral infarcts.
——also to check proximal arterial disease (aortic arch, SCA)
Q3: What if the brain MRI did not show any area of infarction, will that make you change your management?
I’d do the above mentioned work-up.
According to ESVS 2023 guidelines, for patients with a TIA in the presence of known AF and an ipsilateral 50-99% carotid stenosis, comprehensive neurovascular work up with MDT review is recommended to determine whether carotid revascularisation or anticoagulation alone is indicated.
Yet, this patient developed TIA in the territory ipsilateral to a 50-99% carotid
stenosis while being on anti-coagulation, so after exclusion of cardiac source, CEA or CAS can be considered according to patient’s risk.
Thank you Dr Asmaa, he has no other source of emboli apart from having AF.
How will you know if the infarcts in the brain are coming from the carotid stenosis not from the AF, how would you justify the infarcts in the occipital hemisphere and in the left partietal and frontal hemisphere.
Is there any test/investigation you can request to rule out or rule in carotid stenosis being the source of emboli not the AF.