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A 60-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department 24 hours after the onset of right-sided face, arm, and leg weakness. At the time of presentation, the patient believes his symptoms are significantly improved since onset. His physical examination is notable for a mild right facial droop and a right arm pronator drift. A noncontrast head computed tomography (CT) scan is performed that shows a subtle focus of hypodensity within the left frontal lobe and no evidence of hemorrhage (Figure 25-1).

Figure 25-1.

Noncontrast head CT demonstrates a focus of hypodensity (arrow) suggestive of stroke within the left frontal lobe.

What is the next step in the management and workup of this patient?

Brain magnetic resonance imaging (MRI) as well as head and neck MR angiography (MRA) was performed in the emergency department. A left frontal lobe infarct was confirmed on the MRI and MRA and demonstrated high-grade stenosis at the origin of the left internal carotid artery (ICA) (Figure 25-2). The patient was started on aspirin 325 mg once per day and admitted to the neurology stroke/step-down unit equipped with cardiac and blood pressure monitoring. Electrolytes, troponin levels, chest X-ray, electrocardiogram, and transesophageal echocardiogram were ordered. A carotid Doppler ultrasound was obtained confirming origin of 60% to 79% stenosis in the left internal carotid artery.

Figure 25-2.

Diffusion-weighted MR image of the brain showing hyperintensity indicative of infarction in the left frontal lobe (A). MRA of the neck showing stenosis at the origin of the left ICA (B).

Extracranial, large-vessel stenosis should be evaluated by at least two of the following three noninvasive modalities to determine the extent and degree of stenosis: MRA, CT angiography (CTA), or Doppler ultrasound. Carotid Doppler ultrasound is quick, inexpensive, and portable and thus is performed easily at the bedside; however, it is highly operator dependent. MRA has the advantage of not exposing patients to radiation and has demonstrated greater discriminatory power than ultrasound in assessing high-grade stenosis.1 CTA compares favorably with catheter angiography for the evaluation of carotid stenosis; however, radiation exposure and calcium artifact can be disadvantageous.2

What intervention is most appropriate in this patient?

Carotid endarterectomy (CEA) remains the gold standard intervention for the treatment of high-grade atherosclerotic carotid artery disease. In select patient groups, carotid angioplasty and stenting (CAS) should also be considered. The evidence from randomized clinical trials comparing CEA with best medical management in both symptomatic and asymptomatic patients is substantial. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) found that CEA significantly reduced the risk of any ipsilateral stroke (17% absolute risk reduction) and major or fatal ...

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