A four-vessel cervical and cerebral angiogram is ordered. The angiogram shows bilateral 70% ICA stenosis with a 50% siphon stenosis of the left ICA (Fig. 42.1). The left A-1 segment is not well visualized.

• Initial management of the patient should include
  
  
  
  • Admission to hospital for control of blood pressure, glucose, arrhythmias
    
  • Consider heparin if no intracranial bleeding
    
  • Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA)1
    
  • Cardiac echography

• Hospital admission should be considered for patients with first TIA within 24–48 hours and with:
  
  
  
  • Crescendo TIAs
    
  • Duration of symptoms >1 hour

• Direct hospital admission
  
• Repeat CT/MRI
  
• Repeat duplex scan
  
• Transcranial Doppler

• Risk factors for IAD²
  
  
  
  • Race: African American or Asian³
    
  • Gender: risk of 28.4% in females versus 16.6% in males⁴
    
  • Hypertension
    
  • Hyperlipidemia
    
  • Diabetes mellitus
  
  
• Risk factors for combined EAD and IAD^2,5
  
  
  
  • Diabetes mellitus
    
  • Coronary artery disease

• Etiology of symptoms in patients with tandem disease
  
  
  
  • Embolism from carotid bifurcation
    
  • Hypoperfusion—IAD > EAD

• Distribution of IAD
  
  
  
  • ICA 49%
    
  • Middle cerebral artery (MCA) 20%
    
  • Posterior cerebral artery (PCA) 11%
    
  • Vertebrobasilar artery (V-B)11%
    
  • Anterior communicating artery (ACOM) 9%

• Deficits persist longer
  
• Plaques more fibrotic⁶
  
• Independent risk factor for stroke^3,7
  
• Risk of stroke is greater in IAD as compared with MCA lesions alone (36% vs. 24%).

• Treatment of combined EAD and IAD stenosis
  
  
  
  • Carotid endarterectomy (CEA) in cases of 70–90% stenosis⁸
    
  • CEA if 50–79% EAD stenosis and 70% IAD stenosis^3,7
    
  • Other options include
    
    
    
    • CEA and IAD angioplasty (Angioplasty and stenting are increasingly being used for intracranial disease. Long-term results and large population studies are not yet available.)
      
    • Carotid stenting (CAS)⁹ and IAD angioplasty (32% restenosis in 6 months)
      
    • CEA is not beneficial if the IAD is worse than the EAD.

• See Table 42.1^8,10,11 and Table 42.2^12–14 for a summary.
  
• In symptomatic cases⁸:
  
  
  
  • CEA is of benefit if there is 70–99% stenosis as long as surgical morbidity and mortality (M&M) is 6% or less. The stroke risk is overall decreased by Ã8% per year.
    
  • CEA is of marginal benefit in cases of 50–69% stenosis. Consider this procedure if there are associated risk factors such as
    
    
    
    • Associated ulcerated lesion⁷ (as in this case)
      
    • Contralateral ICA occlusion
      
    • Male gender
      
    • Intraluminal thrombus
      
    • Stroke more than transient (not TIA)
      
    • Younger age at presentation
  
  
• In asymptomatic cases¹²:
  
  
  
  • CEA is of marginal benefit in cases of 60–99% carotid stenosis.
    
  • Consider performing this procedure if
    
    
    
    • The overall operative risk (M&M) is Ã3% or less
      
    • There are associated risk factors such as the ones described above.

• Surgery is delayed until the symptoms resolve and the deficits have plateaued.

• Medical therapy for patients with inoperable disease
  
• Control: blood pressure, blood sugar, lipids
  
• Warfarin (Coumadin; Bristol-Myers Squibb, New York, NY)