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Wave 2: Module 4: Carotid, Vascular access and Venous – Week 1 – Case 1
- September 8, 2025
- Posted by: admin
- Category: Uncategorized
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?
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Q1
TIAs
Q2
More than 70 %
Q3
Personal history
Medical history
History of carotid terriority symptoms
Occular symptoms
Further attacks of TIAS
Other co morbidity
Q4
Investigation
Cbc
Hba1c
Lipid profile
Pt ptt aptt
S creat
Alt ast
Crp
Radiology
According to ESVS guidelines
CTA/mRA required
ECho
Management:
According to ESVS guide line
Symptomatic carotid disease with stenosis > 70%
BMT+ control modifiable risk factors + revascularization by CEA 1 st or CAS
Q1: What is the symptom the patient presented with?
TIA
total resolved neurologic symptoms less than 24 hrs
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).
based on symptoms and history
the patient has symptomatic carotid artery stenosis
and he needs an intervention either CEA or CAS
to reduce stroke risk at the future
Best approach is CEA +BMT and risk factors control
Q4: How will you manage the patient? (any further investigation, what is your treatment –Medical vs surgical vs both).
full labs investigation
cardiac assessment
CT angio of aortic arches and great vessels
my plan of treatment is CEA
Q5: How can you support your answer with evidence?
based on RCTs SAPPHIRE CREST SPACE ACST and esvs guidelines
A1: TIA in the ICA territory.
A2: Stenosis 70–79%.
A3: From the clinical picture and duplex findings, the patient has significant carotid disease with critical stenosis (>70%) and plaque ulceration. This requires intervention in the form of BMT, risk factor control, and carotid endarterectomy. The aim is prophylactic, to reduce the risk of future cerebrovascular events.
A4 & A5: Work-up should include CBC, coagulation profile, lipid profile, liver and kidney function tests, ECG, and TCD.
According to ESVS guidelines, ICA stenosis >70% is an indication for BMT plus CEA.
A1:
TIA focal ICA territory
A2:
70-79%
A3:
According to symptoms and duplex findings he had, the patient is likely to have carotid artery disease with critical stenosis more than 70% with plaque ulceration which indicates intervention in the form of
BMT RF control and CEA
The dicision is a prophylactic one to decrease the future incidences
A4,5:
Investigations include
cbc coagulation lipid profile LFT KFT
ECG
TCD
according to ESVS guidelines the ICA stenosis >70% this ptn should undergo BMT+ CEA
Q1
The patient had TIA
Q2
The degree of stenosis in this patient is ≥70%
Q3
You experienced a “mini-stroke” (TIA). despite of symptoms went away, it is a warning sign.
The narrowing in your left neck artery (carotid artery) is severe and increases the risk of a major stroke.
That’s why you were referred us to manage this risk.
Risk factor control and lifestyle modification are essential.
Q4
i will start BMT immediately, and ask for the routine lab investigations + lipid profile
also I will ask forECG and Echocardiography to exclude other causes of embolic events
as this patient is symptomatic + severe stenosis i will recommend CEA (provided that the patient is fit)
Q5
NASCET showed benefit of CEA in symptomatic patients with >70% stenosis, reducing stroke risk
For all candidates, Q5 regarding the supporting evidence is reflective on Q4. Evidence supporting your management plan.
A1) Transient Ischemic Attack (TIA).
Definition of TIA (Guideline-Based)
AHA/ASA 2009:
“Transient episode of neurological dysfunction caused by focal ischemia without acute infarction.”
ESO 2021:
Sudden-onset focal neurological deficit, resolves within 1 hour, no imaging infarction.
ESVS 2023:
Sudden unilateral weakness, speech disturbance, or vision loss <24 hours → classify as TIA if no infarction.
NICE 2022:
Sudden neurological deficit 5 years.
NASCET Trial:Symptomatic patients with ≥70% stenosis had absolute risk reduction of 17% for stroke over 2 years after CEA.
Thank you Dr Ahmed for answering Q1, one level 1 evidence is enough to support the answer.
What about the remaining questions, please answer then all in one comment.
Q5: How can you support your answer with evidence?
Society for Vascular Surgery (SVS) 2021:For patients with symptomatic carotid stenosis ≥70%, CEA is strongly recommended within 14 days of the event.”
European Society for Vascular Surgery (ESVS) 2023:Symptomatic ICA stenosis ≥70% → CEA preferred if life expectancy >5 years.
NASCET Trial:Symptomatic patients with ≥70% stenosis had absolute risk reduction of 17% for stroke over 2 years after CEA.
Thank you Dr Eslam for the detailed answer, few points:
. Next time please try to answer all questions in one comment.
. Single level 1 evidence is enough to support your answer.
. When counselling the patient, TIA and stroke happens mainly due to the athero-embolism from the atheromatous plaque not due to brain hypo-perfusion.
. The surgery is an add to the Best Medical Therapy to REDUCE the risk of future stroke, BMT remains the main treatment for these cases.
Ok thanks my dear prof
Q4) Management:
MRI Brain + DWI → to rule out silent infarction.
CTA / MRA Neck & Brain → confirm degree, length, and plaque morphology.
ECG & Echocardiography → exclude cardioembolic source.
Basic labs: lipid profile, HbA1c, renal function.
Because this patient had symptomatic severe ICA stenosis:
1. Medical Management for All Patients
Antiplatelet: Aspirin 81–325 mg OR Clopidogrel 75 mg daily.
Statin therapy: High-intensity (Atorvastatin 40–80 mg or Rosuvastatin 20–40 mg).
Strict BP control: Target <130/80 mmHg, optimize antihypertensive regimen.
Smoking cessation.
Glycemic control if diabetic.
2.Surgical / Endovascular Intervention
First-line if patient is fit for surgery.
Best performed within 2 weeks of TIA/stroke (per SVS guidelines).
Consider if patient is high-risk for surgery (e.g., severe cardiac disease)
Q3. Counseling the Patient (Key Points)
If the patient doesn’t know why he was referred:
Q1: What is the symptom the patient presented with?
transient ischemic attack (TIA) (Symptoms relived completely)
Q2: What is the degree of stenosis in this patient?
70-99% (ulcerated plaque increases the risk).
Q3: How will you counsel the patient if he does not know why was he referred to you? (only key points)
Dear, “You had a mini stroke (TIA) caused by severely narrowed artery in your neck”, “The narrowing is about 70-90% blocked with a plaque (lipid mass in its wall) that can break off“, “Without treatment, you have high risk of major stroke”, “We specialize in treating blocked arteries to prevent strokes”, “There are effective treatments available (both medical and surgical options)”, “Your smoking significantly increases stroke risk and must be addressed” + I can summarize the benefit of intervention from NASCET and ECST briefly for planning for intervention and consenting.
Q4: How will you manage the patient? (any further investigation, what is your treatment –Medical vs surgical vs both).
cardiovascular risk assessment (Preop. fitness), Cardiac assessment (ECG, echo if indicated)Lipid profile, HbA1c, renal function, CBC, Alt, ASTCT angiography or MRA (as surgery planned)/Treatment approach:
Medical management:
Dual antiplatelet therapy, statin (atorvastatin 80mg), or azitimib if not tolerated, Control blood pressure, Smoking cessation (essential) + RF control
Surgical management:
Carotid endarterectomy preferred as our patient is: (Symptomatic 70-99% stenosis, Recent TIA, Suitable anatomy, fit for surgery).
Q5: How can you support your answer with evidence?
RCTs as:
NASCET and ECST demonstrated that CEA reduces 2-year stroke risk from 26% to 9% (absolute risk reduction of 17%).
Thank you Dr Abdulla for the concise answer, only one comment, the TIA/stroke occurs mainly due embolic phenomenon from the atheromatous plaque rather than from hypoperfusion. If it is hypoperfusion, how can you justify the guidlines recommendations against performing surgery in trickle flow or total carotid occlusion.
Q2) degree of stenosis:
PSV = 255 cm/s → Above 230 cm/s → Severe stenosis ≥70%
St. Mary’s Ratio = 25 → Extremely high (normal less 2 ) → Supports critical stenosis.
Ulcerated plaque → Adds higher embolic risk.
St. Mary’s Ratio = 25 → Extremely high → Supports critical stenosis. 80-89%
Q1) The patient had sudden right arm and leg weakness lasting for 5 minutes, which completely resolved.
This is consistent with a Transient Ischemic Attack (TIA).
Definition of TIA (Guideline-Based)
AHA/ASA 2009:
“Transient episode of neurological dysfunction caused by focal ischemia without acute infarction.”
ESO 2021:
Sudden-onset focal neurological deficit, resolves within 1 hour, no imaging infarction.
ESVS 2023:
Sudden unilateral weakness, speech disturbance, or vision loss <24 hours → classify as TIA if no infarction.
NICE 2022:
Sudden neurological deficit <24 hours, ischemic origin, no infarction
So diagnosis is TIA