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PATIENT STORY

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A 72-year-old Caucasian man presented 1 week after an episode where he spontaneously dropped a cigarette he was holding in his right hand. He had immediately noted an inability to grasp objects and numbness in his right hand. These symptoms lasted for 2 minutes and then spontaneously resolved. After this episode his right hand felt completely normal. He denied other symptoms such as amaurosis, paralysis, paresthesias, speech disturbance, or gait disturbance. His past medical history was significant for hypertension, hypercholesterolemia, and cramping in his calves when he walked long distances. He had a 40 pack-year history of smoking and denied use of alcohol. A carotid duplex ultrasound examination showed a left 70% to 99% internal carotid artery (ICA) stenosis.

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EPIDEMIOLOGY

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  • Stroke ranks third among all causes of death in the United States behind heart disease and cancer, with 795,000 strokes occurring per year.1

  • Annually, 55,000 more women than men are affected, and over 60% of all stroke deaths occur in women. African Americans have twice the stroke risk of Caucasians. Mexican Americans also have an increased incidence of stroke compared to Caucasians.2

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ETIOLOGY AND PATHOPHYSIOLOGY

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  • One-third of all strokes are related to cervical carotid disease.

  • Standard risk factors for coronary and systemic atherosclerosis apply to carotid disease such as age, male sex, family history, smoking, hypertension, hyperlipidemia, sedentary lifestyle, and high dietary saturated fatty acids and cholesterol.

  • The mechanism of cervical carotid stroke is usually embolization from a carotid bifurcation plaque, but hemodynamic compromise from stenosis may also play a role. The risks of embolization and hemodynamic compromise increase with increasing ICA stenosis.3

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DIAGNOSIS

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  • When carotid territory stroke or transient ischemic attack (TIA) is suspected, carotid duplex in an accredited vascular laboratory to define degree of stenosis is mandatory.

  • When carotid duplex is nondiagnostic, computed tomography (CT) or magnetic resonance angiography (MRA) may be used.

  • Catheter angiography is indicated in the setting of conflicting noninvasive studies and when carotid artery stenting (CAS) is planned.4

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CLINICAL FEATURES

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  • Neurologic examination may reveal motor or sensory deficits contralateral to the affected carotid artery. Aphasia, dysphasia, or apraxia may also be reported.

  • Amaurosis fugax, or sudden complete or partial loss of vision in one eye, is a result of embolization from the cervical carotid artery to the ipsilateral central retinal artery.

  • Up to 70% of stroke survivors can regain functional independence; however, 15% to 30% become permanently disabled and 20% will require long-term care.5 In patients over 65 years old, 6 months after stroke 50% have some residual hemiparesis, 30% require some assistance with walking, 26% cannot perform activities of daily living independently, 19% have aphasia, and 26% are institutionalized.6

  • Mean lifetime cost of an ischemic stroke in the United States is $140,048. In 2007, the total cost of stroke exceeded ...

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