You are assessing a 65 year old lady who has been referred by the stroke team for an episode of TIA (Rt arm and leg weakness that completely recovered ). She has history of undergoing a thyroidectomy 10 year ago for multi nodular goitre.
Discuss what investigations you would request and why.
Discuss your consent process
4 Comments
Ahmed Nasr Mohammed Abdelfattah Ahmed Osman
investigations carotid duplex to confirm stenosis brain ct or mri to rule out bleed or show infarct ct angiography if duplex not clear ecg and echo to look for cardiac source routine blood tests for surgery and vocal cord check because of previous thyroidectomy
consent explain that aim is to prevent stroke risks include stroke death heart attack cranial nerve injury bleeding or neck hematoma airway compromise infection restenosis anesthetic risks need for shunt or patch alternative is medical therapy only
A. CT brain to assess brain status
Carotid duplex to detect carotid stenosis
b. if found indicated i will consent for CAS as the patient has hostile neck
A1:
Labs with thyroid profile
ECG
ECHO
neck us
Carotid duplex
CTA for anatomical considerations regarding the arch anatomy in case for CAS
TCD
Brain imaging
A2:
Consenting the ptn for CAS due to previous neck surgery and probability for radiation to the neck with complications of CAS including stroke HPS thrombosis of the stent pseudoanurysm groin hematoma bleeding AKI
1- Brain imaging: MRI (DWI) ± CT to exclude silent infarction and assess for small embolic lesions.
2-Carotid imaging:
Duplex US as first line to assess degree of stenosis,plaque morphology,and flow velocities.
CTA/MRA if duplex suggest significant stenosis or if complex anatomy as previous thyroidectomy, also for operative planning
3-Cardiac workup: ECG , Echocardiography to exclude embolic source.
4-Blood tests: CBC, PT, INR, Renal & Liver function tests, lipid profile, HbA1c, thyroid function tests.
5-Chest X-ray: For anesthesia/operative assessment.
Consent process :
Benefits: Stroke risk reduction after symptomatic carotid stenosis.
investigations carotid duplex to confirm stenosis brain ct or mri to rule out bleed or show infarct ct angiography if duplex not clear ecg and echo to look for cardiac source routine blood tests for surgery and vocal cord check because of previous thyroidectomy
consent explain that aim is to prevent stroke risks include stroke death heart attack cranial nerve injury bleeding or neck hematoma airway compromise infection restenosis anesthetic risks need for shunt or patch alternative is medical therapy only
A. CT brain to assess brain status
Carotid duplex to detect carotid stenosis
b. if found indicated i will consent for CAS as the patient has hostile neck
A1:
Labs with thyroid profile
ECG
ECHO
neck us
Carotid duplex
CTA for anatomical considerations regarding the arch anatomy in case for CAS
TCD
Brain imaging
A2:
Consenting the ptn for CAS due to previous neck surgery and probability for radiation to the neck with complications of CAS including stroke HPS thrombosis of the stent pseudoanurysm groin hematoma bleeding AKI
Investigations:
1- Brain imaging: MRI (DWI) ± CT to exclude silent infarction and assess for small embolic lesions.
2-Carotid imaging:
Duplex US as first line to assess degree of stenosis,plaque morphology,and flow velocities.
CTA/MRA if duplex suggest significant stenosis or if complex anatomy as previous thyroidectomy, also for operative planning
3-Cardiac workup: ECG , Echocardiography to exclude embolic source.
4-Blood tests: CBC, PT, INR, Renal & Liver function tests, lipid profile, HbA1c, thyroid function tests.
5-Chest X-ray: For anesthesia/operative assessment.
Consent process :