Presentation + Anatomy

Signs and Symptoms

• 1st branch: Ophthalmic A → Amaurosis fugax of ipsilateral eye
• 2ed branch: MCA, ACA → Rest of the !MCA Stroke symptoms

Branches of Internal Carotid

Investigation

• Serial ultrasound: the stenosis, morphology and progression of the plaque
• Stroke work-up (CT, CTA, CTV +/- MRA)

Management

Best Medical Management

1. Anti-Platelet
   1. ASA (Asprin) for asymptomatic
   2. DAPT (aspirin + clopidogrel) for symptomatic, inclu. TIA
      • 21 days for most TIA
      • 90 days for intra-cranial atherosclerosis TIA
2. RF management
   1. Vascular Protection Checklist (ABCDES)
      1. DM → Metformin
      2. HTN → ACEi(-pril)
      3. DLD - Dyslipidemia ↑ → Statins, also stabilize the plaque

Surgery

1. CEA - Carotid endarterectomy → superior
2. TCAR

Risk-benefit analysis for CEA

• Surgery indicated if risk of stroke (pre-op) >>> risk of complication

Pre-op risk

• Population risk: 2%

• Asymptomatic stenosis risk: 2%

• TIA risk: 20%

• Decision Making Flow Chart

• Asymptomatic stenosis: 2% risk of stroke → No Surgery

• Complete Occlusion → No surgery

• Symptomatic stenosis (>50%)

• TIA