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Abstract: Carotid atherosclerosis is a relatively common disease in clinical practice and requires vigilance. In this case, the patient was found to have carotid plaque formation on physical examination and had recently developed symptoms such as dizziness and head confusion, so she was seen in our hospital. Ultrasound examination revealed carotid artery sclerosis with plaque formation (single), and the patient was diagnosed with carotid artery sclerosis. The patient was given antiplatelet therapy, plaque stabilization therapy and treatment to improve cerebral blood supply.
Basic information】Female, 57 years old
Disease Type】Carotid Atherosclerosis with Plaque
Hospital】Liaoning Provincial People’s Hospital
Date of consultation】February 2022
Treatment plan】Medication (aspirin enteric solution tablets, atorvastatin calcium tablets, betahistine hydrochloride tablets)
Treatment period】Inpatient treatment for 1 week, monthly outpatient review
Treatment effect] The patient’s dizziness improved significantly, and there was no significant discomfort in the outpatient review after 3 months.
I. Initial consultation
The patient came to our department with the chief complaint of “carotid plaque found during physical examination”. Patient’s description: In the past 10 days, he had occasional dizziness, but no symptoms such as blurred vision, nausea and vomiting, weakness of limbs and unstable walking. During the outpatient physical examination, ultrasound findings suggested plaque formation (single) at the bifurcation of the carotid arteries bilaterally and plaque formation (single) at the right carotid bulb. The patient had a previous history of hyperlipidemia for 3 years, during which he was treated with oral atorvastatin calcium tablets for lipid lowering. There was no hypertension, diabetes mellitus, heart disease, lung or kidney disease.
Physical examination: clear consciousness, accurate replies, normal orientation, calculation and memory, GCS score of 15. The sense of smell and vision were normal in rough measurements, and there was no choking and coughing, hoarseness and swallowing difficulties. The muscle strength of the extremities was normal, the sensorimotor was possible, and the bilateral Bartholomew’s sign was negative.
In order to further clarify the results, the patient was admitted to the hospital for the next examination.
II. Treatment history
After admission, the patient was further examined and a cerebral hemogram was performed. The results showed that the local blood flow was increased, so it was considered that the patient’s current dizziness might be related to carotid arteriosclerosis combined with plaque formation, and a follow-up CT examination of the cervical spine was performed to rule out the possibility that it was caused by cervical spondylosis.
Since the patient’s condition is mild, surgical treatment is not required for the time being. Conservative treatment was recommended and the patient was given oral aspirin enteric tablets for antiplatelet therapy, oral atorvastatin calcium tablets to stabilize the plaque and achieve lipid-lowering therapy, and betahistine hydrochloride tablets to improve the cerebral blood supply deficiency. After 1 week of hospitalization, the patient’s symptoms of dizziness and head confusion were significantly relieved, so he was discharged from the hospital for recuperation, and was instructed to visit the outpatient clinic for monthly review after discharge.
III. Treatment effect
After regular symptomatic treatment of antiplatelet, plaque stabilization and improvement of intracranial circulation, the patient’s symptoms of dizziness and lightheadedness improved after 3 days of medication, and the patient’s symptoms of discomfort were significantly relieved after 1 week. During hospitalization, the patient did not experience acute cerebral ischemia and other plaque dislodgement, and the intracranial blood flow improved significantly. One month after discharge, during the outpatient review, the patient indicated that he did not have any cerebral ischemic symptoms such as significant dizziness, head confusion, transient black clouding, and no obvious complaints of discomfort from the time of discharge to the outpatient follow-up. Three months after discharge, the patient’s outpatient follow-up ultrasound showed no significant progression of carotid plaque and good disease control.
IV. Notes
We are glad that after active symptomatic treatment such as antiplatelet, plaque stabilization and improvement of intracranial circulation, the patient’s symptoms of dizziness and head confusion were relieved and no significant progress of carotid plaque was seen, but this does not mean that the disease has been completely cured, and the patient and his family still cannot take it lightly.
1. Once carotid artery sclerosis with plaque formation occurs, patients need long-term drug treatment and regular review in hospital to assess the nature and stability of plaque, if there are sudden choking and coughing with water, speech difficulty, and partial sensory movement disorder, they should seek timely medical treatment.
2. In daily life, patients should quit smoking and alcohol, recommend low-salt, low-fat and low-sugar food, eat more fresh fruits and vegetables, and exercise appropriately to prevent further aggravation of the disease.
V. Personal insight
Carotid atherosclerosis is a manifestation of vascular aging, often accompanied by intimal thickening and plaque formation clinically, and the majority of patients are asymptomatic and are often detected during physical examination. However, this does not mean that there is no need for intervention. The continuous development of carotid plaque will not only cause insufficient blood supply to the intracranial arteries, but also induce acute cerebral infarction if the plaque is unstable and falls off. Early intervention, diet and exercise control, and regular review are of great importance for such patients.
In this case, the patient’s condition was stabilized within a relatively short period of time due to timely detection and good compliance during treatment, which shows that active cooperation with the doctor’s treatment has a high correlation with the speed of recovery, which also indicates that it is equally important to take medication as prescribed by the doctor and to have regular checkups during the treatment of the disease.