You are assessing a 73 year old male who has been referred by the stroke team for an episode of (Lt Arm and leg weakness that completely recovered). He has history of undergoing a thyroidectomy 10 year ago for Ca thyroid for which he also underwent post-operative radiotherapy.
Discuss your management and consent process.
3 Comments
Ahmed Nasr Mohammed Abdelfattah Ahmed Osman
management carotid duplex to assess stenosis brain ct or mri to rule out bleed or confirm infarct ct angiography if duplex not clear ecg and echo for cardiac source routine labs check vocal cord function because of thyroidectomy and radiotherapy airway will be difficult so early discussion with anesthesia if significant stenosis and symptomatic plan carotid endarterectomy within 2 weeks if not suitable consider stenting or medical therapy
consent explain aim is stroke prevention risks are stroke death myocardial infarction cranial nerve palsy especially higher with previous thyroid surgery and radiotherapy neck haematoma airway compromise infection restenosis need for shunt or patch anesthetic risks alternative is best medical therapy only
Confirm diagnosis & stroke workup: Brain MRI (DWI) or CT to rule out completed infarct.
ECG, echocardiography for cardiac embolic source.
Carotid assessment: Carotid duplex ultrasound first-line.
CTA/MRA for detailed anatomy — especially to assess scarring, distorted planes, calcification.
If significant stenosis (>50–70%) and patient fit → urgent revascularization within 2 weeks.
Choice of intervention:
Carotid Endarterectomy (CEA): Standard of care, but technically more challenging after thyroidectomy + radiotherapy (dense scarring, friable tissues, higher cranial nerve injury risk).Carotid Artery Stenting (CAS): Considered if surgical access is hostile (radiotherapy field, “hostile neck”) or patient has high surgical risk.Decision individualized based on imaging and MDT consensus
Optimise medical therapy: Antiplatelet (aspirin ± clopidogrel), statin, blood pressure and diabetes control, smoking cessation.Consent
Benefits: Stroke risk reduction after symptomatic carotid stenosis.Risks: Stroke/death (2–5%), cranial nerve injury (higher after thyroidectomy/radiotherapy), neck hematoma/bleeding with airway risk, wound healing problems, restenosis, anesthetic/cardiac risks.Special considerations: Previous thyroidectomy + radiotherapy → difficult dissection, higher complication risk, may require stenting instead.Alternatives: Best medical therapy alone, or carotid artery stenting.Other: Emphasize urgency (within 2 weeks), recovery expectations.
management carotid duplex to assess stenosis brain ct or mri to rule out bleed or confirm infarct ct angiography if duplex not clear ecg and echo for cardiac source routine labs check vocal cord function because of thyroidectomy and radiotherapy airway will be difficult so early discussion with anesthesia if significant stenosis and symptomatic plan carotid endarterectomy within 2 weeks if not suitable consider stenting or medical therapy
consent explain aim is stroke prevention risks are stroke death myocardial infarction cranial nerve palsy especially higher with previous thyroid surgery and radiotherapy neck haematoma airway compromise infection restenosis need for shunt or patch anesthetic risks alternative is best medical therapy only
the preferred management would be CAS as the patient has hostile neck
if not feasible carotid bypass is advised as the ica may be fibrosed
Multidisciplinary discussion (MDT): Stroke team, vascular surgery, anesthesia.
Investigations:
Confirm diagnosis & stroke workup: Brain MRI (DWI) or CT to rule out completed infarct.
ECG, echocardiography for cardiac embolic source.
Carotid assessment: Carotid duplex ultrasound first-line.
CTA/MRA for detailed anatomy — especially to assess scarring, distorted planes, calcification.
If significant stenosis (>50–70%) and patient fit → urgent revascularization within 2 weeks.
Choice of intervention:
Carotid Endarterectomy (CEA): Standard of care, but technically more challenging after thyroidectomy + radiotherapy (dense scarring, friable tissues, higher cranial nerve injury risk).Carotid Artery Stenting (CAS): Considered if surgical access is hostile (radiotherapy field, “hostile neck”) or patient has high surgical risk.Decision individualized based on imaging and MDT consensus
Optimise medical therapy: Antiplatelet (aspirin ± clopidogrel), statin, blood pressure and diabetes control, smoking cessation.Consent
Benefits: Stroke risk reduction after symptomatic carotid stenosis.Risks: Stroke/death (2–5%), cranial nerve injury (higher after thyroidectomy/radiotherapy), neck hematoma/bleeding with airway risk, wound healing problems, restenosis, anesthetic/cardiac risks.Special considerations: Previous thyroidectomy + radiotherapy → difficult dissection, higher complication risk, may require stenting instead.Alternatives: Best medical therapy alone, or carotid artery stenting.Other: Emphasize urgency (within 2 weeks), recovery expectations.