Suspected minor stroke in 89 years old patient

Chronic ischemic brain changes and bilateral carotid atherosclerosis in 89 years old patient
Short Summary

Female patient aged 89 years old, suspected of light stroke, underwent Echo colour Doppler Test of the supra-aortic trunks and brain CT scan.
Echo Colour Doppler Test of the supra-aortic trunks presented an picture that would place indication for a surgical operation of thromboendarterectomy (TEA) of the right carotid bifurcation, for the importance and the bilaterality of the lesions besides the specific symptomatology.
However, taking into consideration the patient’s age, an anesthesiology assessment is advised before taking any decisions.  
Brain CT scan showed at supratentorial level, small ischemia foci seemingly of recent origin in the white matter of the radiate crown from the right side.
 

Patient's Questions

1) Do you agree with the indication to carry out TEA surgical operation subject to anaesthetist authorization? If your answer is yes, could you kindly advise in Lombardy one or more than one centers of excellence with the name of the vascular surgeon of reference?
2) Are there any satisfying and less dangerous options to TEA surgical operation?
3) In the event of high surgical risk as to contraindicate the surgical operation which long-term medical therapy would you advise?
4) Do you deem it advisable to carry out further diagnostic medical tests?

Medical Background

Patient aged 89 with no anamnestic and clinical information available. Following a recent appearance of symptomatology linked to a suspect of light stroke, two appropriate diagnostic medical tests were carried out: Echo Colour Doppler Test of the supra-aortic trunks and brain CT scan.

Following, the relevant medical reports are related:
1) Echo Colour Doppler Test of the supra-aortic trunks:
   “Diffuse sclerosis of vessels examined. On the right, fibrous plaque which involves the whole bulb and the origin of the internal carotid artery resulting in a stenosis of 70-75% with acceleration in the flow speed of 140 cm./sec. On the left, fibrocalcific plaque with irregular edges and dishomogeneous structure, with stenosis of 60% of the origin of the internal carotid artery without any flow accelerations. Right vertebral artery within normal limits. Left vertebral artery with flow clearly demodulated and reduced.The picture would place indication for a surgical operation of thromboendarterectomy (TEA) of the right carotid bifurcation, for the importance and the bilaterality of the lesions besides the specific symptomatology. However, taking into consideration the patient’s age, an anesthesiology assessment is advised before taking any decisions.
Keep following the antiaggregant treatment (Ticlopidine). To add, Prisma tablets 50 mg., 1 tablet twice a day for 3 months and then 1 tablet a day for another 6 months.”

2) Brain CT scan:
   “Examination carried out without contrast medium, with axial sections at the apex base. The posterior cranial fossa is normal.
At supratentorial level, small ischemia foci seemingly of recent origin in the white matter of the radiate crown from the right side.
Moderate enlargement on atrophic base of the ventricular system and of sulci. Slight diffuse hypodensity of the lateral and supraventricular white matter of both hemispheres, of non-specific appearance and expression of regressive changes on chronic ischemic vasculopatic basis with regard to age or to possible vascular risk factors.”

Expert's Opinion

This 89 year old woman had undergone brain CT and Carotid duplex examination because of a suspected minor stroke, yet history and clinical findings were not provided.

Brain CT revealed chronic ischemic changes and ischemic foci suspected to be of recent origin in the right corona radiata. Carotid duplex revealed findings of bilateral carotid atherosclerosis, without any flow acceleration on the right ICA and up to 140 cm/sec on the left ICA. Right Carotid Endarterectomy was suggested.

Diagnostic and therapeutic advice:
I strongly recommend first careful history and Neurological assessment to determine if there was a recent ischemic event that is clearly in the distribution of right ICA. If this is the case, I would assess the degree of carotid stenosis by another imaging modality such as CT or MR angiography.
I would recommend right CEA only if all the following are met:
1. A recent clinical ischemic event that is clearly in the distribution of the right ICA.
2. Conformation that stenosis in the right ICA is indeed severe, preferably by CT or MR angiography.
3. No contraindications to surgery.

Suggest in any case continuing antiplatelet therapy, intensive statins to a LDL cholesterol goal of up-to 70 mg/dl and best control of any other medical and lifestyle risk factors.
For carotid stenosis that is asymptomatic or symptomatic in any other vascular distribution, no CEA or carotid artery stenting is recommended given the patient's age. In this case best medical management is the best option.
In case of clearly high grade symptomatic carotid stenosis and high surgical risk, an alternative option could be carotid artery stenting. However, octogenerians carry a particularly high procedural risk from carotid artery stenting, so given the patient's age this option is not desirable.

""