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Transient ischemic attack with symptomatic carotid stenosis — ABIM Board MCQ

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HardNeurologyTransient ischemic attack with symptomatic carotid stenosisABIM Board

A 69-year-old independent man has a left-hemispheric TIA with complete recovery. CT excludes hemorrhage, and vascular imaging shows 82% stenosis of the ipsilateral internal carotid artery. He has no prohibitive surgical comorbidity and the center has a low perioperative complication rate. What is the best secondary-prevention plan?

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Correct answer: B — Begin medical therapy and schedule carotid endarterectomy within two weeks

The best answer is “Begin medical therapy and schedule carotid endarterectomy within two weeks”. A recent ipsilateral TIA makes this severe carotid stenosis symptomatic. In a suitable surgical candidate, carotid endarterectomy should be performed promptly—generally within two weeks—alongside intensive medical prevention. A negative brain MRI does not negate a clinical TIA. Stenting is reserved for selected anatomy or surgical risk and has relatively more peri-procedural stroke in older patients.

Reference: AHA/ASA Guideline for Prevention of Stroke After Stroke or TIA: https://professional.heart.org/en/science-news/2021-guideline-for-the-prevention-of-stroke-in-patients-with-stroke-and-transient-ischemic-attack