CCS Interactive Case 14

Question 1

65 y/o M presents to ED w/R hand weakness, difficulty speaking lasting a few hours, resolved entirely before arrival in the ED. Active smoker w/30 pack-year history, on enalapril, simvastatin, metformin for HTN, HLD, DMII.

Exam?

Answer 1

Focused physical w/thorough neurologic exam to look for neuro deficits and potential sources of emboli

Question 2

Exam reveals no residual neuro deficits, but a loud bruit over the L carotid artery

Next steps?

Answer 2

All patients w/suspected TIA require urgent evaluation due to the high risk of subsequent stroke. Dx evaluation and stroke prevention treatment should be implemented without delay.

Hospitalization is considered in patients presenting w/first TIA within the past 24-48 hours, crescendo TIA, duration of symptoms >1 hour symptomatic ICA stenosis >50%, hx AFib, hypercoagulable state

Labs: CBC, BMP, glucose, EKG, non-contrast head CT, carotid Dopplers, echocardiogram

IV access, cardiac monitoring

Question 3

Work-up confirms stenosis of >70% in the L carotid artery. Otherwise normal.

Next steps?

Answer 3

Consult vascular surgery for carotid endarterectomy

Question 4

Rx TIA - antiplatelet agents?

Answer 4

ASA, ASA + extended-release dipyridamole, or clopidogrel recommended for non-cardioembolic TIA

ASA + extended-release dipyraidamole or clopidogrel preferred for TIA of atherothrombotic, lacunar, or cryptogenic types

Do not give until CT head r/o hemorrhagic stroke

Question 5

Rx - carotid stenosis

Answer 5

CEA
- Indications: proven benefit for symptomatic patients with 70-99% stenosis, greatest benefit if done w/in 14 days of last symptomatic event
- Contraindications: 100% stenosis, previous stroke w/persistent neuro symptoms, poor surgical candidate
- ASA prior to procedure, continue indefinitely. Clopidogrel is acceptable alternative if unable to tolerate ASA
Wafarin and heparin NOT indicated unless AFib
Pre-op ABX (Cefazolin 1g IV) due to frequent use of prosthetic material
Risk factor management - HTN, DM, smoking, dyslipidemia

Question 6

Rx - cardioembolic stroke

Answer 6

Antithrombotic therapy for AFib - heparin for acute TIA is controversial. AC w/warfarin, dabigatran, apixaban, rivaroxaban used for all who can tolerate AC
Direct thrombin or factor Xa inhibitor preferred to warfarn

Question 7

Sequence

Answer 7

Exam: focused (general, HEENT/neck, chest/lung, CV, abdominal, extremities/spine, neuro/psych)
Order: IV access, CBC w/diff, BMP, EKG, Head CT without contrast (all stat)
Clock: advance to obtain above results - head CT is negative
Order: Aspirin, continuous
Location: transfer to ward
Order: diabetic diet, ambulate at will, glucometer gluocse Q8hrs, carotid Doppler, cardiac monitor, IV access, echocardiography, MRI head, MRA head, HBA1C, lipid profile (all stat)
Advance to get carotid Doppler results. Note >70% L ICA stenosis. No echo shows no thrombus
Order: vascular surgery consult (CEA for >70% L carotid artery stenosis and TIA)
Advance clock to get consult recommendation
Order: cancel diabetic diet, order PT/INR, pTT, NPO, cefazolin, CEA
Clock: advance to obtain CEA result
Case ends
Final orders: counseling (no smoking, no alcohol, regular exercise, diabetic diet, med compliance, better BP control, DM control)
Primary Dx: TIA