8 Comments

• 

  Peter Salib

  
  
  

  Q1: How will you manage this patient? Please justify your answer.

  the patient had ischemic TIA and infarction on both sides despite anticoagulation
  in addition he had rt side parietal infarction on the same territory of rt ICA
  Patient is indicated for CEA

  Q2: Are there any further tests/investigations that can help you make the decision regarding the management?

  CT angio of aortic arch and great vessels
  echo and transesophageal echo to exclude PFO or left atrial appendage thrombus
  TCD to exclude ipsilateral embolism

  Q3: What if the brain MRI did not show any area of infarction, will that make you change your management?

  yes

  one attack of TIA with no recurrence with other cause than atherosclerosis stenosis of ICA which is Atrial fibrillation

  no indication for CEA and we will go for RF control , lifestyle advice and , clopidogreal 75 mg and statin

  September 23, 2025 at 11:37 pm    Log in to Reply
• 

  Ahmed Nasr Mohammed Abdelfattah Ahmed Osman

  
  
  

  A1: Symptomatic ischemic TIA with small infarcts, cardiac or carotid source. Stenosis <60% → BMT + RF modification, follow-up, no surgery if symptoms not recurrent (ESVS).

  A2: Cardiac work-up: ECG, Echo, TEE.

  A3: Non-recurrent, <60% stenosis → BMT only, no CEA/CAS.

  September 17, 2025 at 9:22 pm    Log in to Reply
• 

  Reda Mansy

  
  
  

  A1:
  According to the presentation history and MRI findings the ptn had symptomatic ischemic TIA with brain infarctions could be cardiac or carotid source
  In ptn with symptomatic <60% carotid stenosis BMT with RF modification and follow up the patient with no surgical intervention as far as the symptoms are not recurring according to the ESVS guidelines

  A2:
  ECG ECHO TEE for the cardiac source

  A3:
  As long as it is not recurrent or asymptomatic less than 60% so BMT alone with no need for CEA or CAS

  September 13, 2025 at 12:42 pm    Log in to Reply
• 

  Muhammad AbdElhady Muhammad

  
  
  

  Q1
  This patient has carotid stenosis > 50% with AF and multiple vascular territory affected, so mostly from cardiac source
  so i will continue the anticoagulant and I will add the BMT for carotid stosis
  “if the event happens again, i will consider CEA”

  Q2
  yes in this case we can’t depend on the doppler alone CTA is essential, also i will request Echo searching for cardiac thrombus

  Q3
  no it will not change my management plan

  September 13, 2025 at 9:32 am    Log in to Reply
• 

  Ahmed Said

  
  
  

  A1)
  Continue Apixaban 5 mg BID
  Continue Atorvastatin 80 mg (target LDL <55 mg/dL).
  Strict BP control (<130/80 mmHg).
  Lifestyle changes: smoking cessation, diet, exercise.
  Follow-up carotid duplex in 6–12 months

  As source is cardioembolic source Dt AF
  …………
  A2)
  Neurovascular Imaging : CTA or MRA neck & brain → confirms carotid stenosis and evaluates intracranial vessels.

  Cardiac Evaluation: Transthoracic or Transesophageal Echo → check for: Left atrial thrombus, valvular lesions.

  Blood tests: Lipid profile, HbA1c. Hypercoagulability screen if recurrent infarcts despite anticoagulation.

  ………………..
  A3) Even with a normal MRI, management does not change. Continue medical treatment
  CEA/CAS is not indicated unless stenosis ≥70% or recurrent ipsilateral TIAs.

  September 11, 2025 at 7:49 pm    Log in to Reply
• 

  Eslam Barsim

  
  
  

  Q3: What if the brain MRI did not show any area of infarction, will that make you change your management?

  *if the brain MRI shows no evidence of infarction, this means the patient had a Transient Ischemic Attack (TIA), not a completed stroke.

  The patient remains symptomatic because TIA is defined by clinical symptoms, not imaging findings.

  *Even with a normal MRI, management does not change. Continue medical treatment
  CEA/CAS is not indicated unless stenosis ≥70% or recurrent ipsilateral TIAs.

  September 10, 2025 at 5:47 pm    Log in to Reply
• 

  Eslam Barsim

  
  
  

  Q2) Are there any further tests/investigations that can help you make the decision regarding the
  management?

  *Neurovascular Imaging : CTA or MRA neck & brain → confirms carotid stenosis and evaluates intracranial vessels.

  *Cardiac Evaluation: Transthoracic or Transesophageal Echo → check for: Left atrial thrombus, valvular lesions.

  *Blood tests: Lipid profile, HbA1c. Hypercoagulability screen if recurrent infarcts despite anticoagulation.

  *Risk Stratification: NIH Stroke Scale (NIHSS) and ABCD score for prognosis.

  September 10, 2025 at 5:41 pm    Log in to Reply
• 

  Eslam Barsim

  
  
  

  Q1)How will you manage this patient?

  (Based on AHA/ASA & ESVS 2023 guidelines)

  *Summary of the Case

  56 yrs old, risk factors: HTN, ex-smoker, atrial fibrillation (on Apixaban)
  Presented with TIA-like symptoms, Brain MRI: Multiple bilateral infarcts → suggests cardioembolic source.

  Carotid Doppler: Rt ICA 50–59% stenosis (PSV 130 cm/s) ,Lt ICA 30% stenosis

  *guideline-Based Management

  According to AHA/ASA and ESVS 2023:

  Carotid Endarterectomy (CEA) is recommended only if:

  1-Symptomatic patients + ≥70% stenosis (Class I).
  2-CEA can be considered for 50–69% symptomatic stenosis only if:
  Stroke/TIA symptoms are ipsilateral to the stenosis,No other cause of stroke is found,Surgical risk <6%.

  In this case:

  Stenosis is moderate (50–59%). Infarcts are bilateral, not confined to right ICA territory.
  Patient has atrial fibrillation → strong cardioembolic source.
  Already anticoagulated with Apixaban.

  ➡ Conclusion:
  No CEA or carotid stenting at this stage.
  Management = Optimal medical therapy

  Recommended Plan

  Continue Apixaban 5 mg BID
  Continue Atorvastatin 80 mg (target LDL <55 mg/dL).
  Strict BP control (<130/80 mmHg).
  Lifestyle changes: smoking cessation, diet, exercise.
  Follow-up carotid duplex in 6–12 months

  September 10, 2025 at 4:26 pm    Log in to Reply