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Abstract: An elderly female patient presented to our outpatient clinic with the chief complaint of “double vision for more than 10 days”. Ultrasound of carotid artery showed that the left carotid artery was occluded and the right carotid artery was severely stenosed. After further improvement of relevant examinations and assessment of surgical risks, the patient underwent right carotid endarterectomy under general anesthesia, and combined with pharmacological treatment.
Basic information】Female, 72 years old
Disease Type】Carotid artery stenosis
Hospital】Liaoning Provincial People’s Hospital
Date of consultation】May 2022
Treatment plan】Surgical treatment (carotid endarterectomy) + medication (aspirin enteric capsules, atorvastatin calcium tablets, clindamycin hydrochloride capsules)
Treatment period】Inpatient treatment for 10 days, outpatient follow-up after 1 month
Treatment effect] The incision healed well after surgery, symptoms improved significantly, and CTA indicated blood flow was smooth.
I. Initial consultation
In May 2022, a 72-year-old woman came to our department with the chief complaint of “double vision for more than 10 days”. The patient developed double vision 10 days ago without any obvious cause, and was clear, cooperative in physical examination, and could move her limbs. Recently, the patient’s symptoms worsened and he came to our clinic. Ultrasound showed plaque formation at the bifurcation of the right carotid artery (multiple) with 70-99% stenosis, and 70-99% stenosis at the beginning of the left internal carotid artery, with low flow rate and high resistance flow signal change. On examination, he was clear, with accurate replies, normal orientation, calculation and memory, normal speech, normal sensorimotor function, and normal deep and superficial reflexes.
II. Treatment history
After further assessment of the vascular condition, intracranial Doppler ultrasound and CTA of the head and neck were performed, suggesting severe bilateral carotid stenosis or occlusion, and open collateral circulation of the right external carotid artery- internal carotid artery. The patient had a past history of hypertension for many years, and his blood pressure was reasonably well controlled. The patient’s overall status was assessed to be tolerant of the procedure. After assessing the risks of the procedure, the patient was advised to open the right internal carotid artery first and the left internal carotid artery in the second stage. After the patient and his family agreed, the right carotid endarterectomy was performed under general anesthesia. After the operation, the patient had no symptoms such as dizziness and disorientation, transient blackness, normal speech, and the movement of the limbs, and the visualization of the right eye was significantly improved. After the operation, the patient was given aspirin enteric capsule for antiplatelet, atorvastatin calcium tablet for lipid lowering, and clindamycin hydrochloride capsule for anti-inflammatory treatment, and the patient recovered well after 1 week and was discharged successfully.
III. Treatment effect
The patient’s postoperative effect was remarkable. The patient had no obvious complications during the perioperative period, no dizziness, no nausea and vomiting, no impaired consciousness, significant improvement in the symptoms of left-sided visualization, and no acute intracranial ischemia. The patient’s symptoms almost disappeared 1 week after the operation, and the incision healed well. 10 days later, the patient had no obvious complaints of discomfort, and the preoperative symptoms completely disappeared, and the CTA of the head and carotid artery before discharge indicated that the right internal carotid artery stenosis was released and the blood flow was smooth.
IV. Notes
I was very happy to see that the patient was discharged in good spirits. The long-term effect of carotid artery stenosis endarterectomy is good, but after the operation, the patient needs to take oral aspirin and antiplatelet for a long time, and statin to lower lipid therapy to avoid recurrence of the disease, therefore, it is necessary to review the carotid ultrasound regularly and CTA if necessary. Regular medication, otherwise the time of recurrence will be very short.
V. Personal insight
Carotid stenosis is one of the common clinical causes of intracranial blood supply deficiency, most patients have chronic onset and prolonged course, most patients have no obvious symptoms, some patients may have dizziness and confusion, transient blackout, transient ischemic attack, etc., but it does not mean that surgical intervention is not needed. It is clinically recommended to consider surgery for patients with no obvious symptoms and carotid stenosis >75%; if there are ischemic symptoms, consider surgery for stenosis >50%. Surgery not only relieves stenosis, but most of all greatly reduces the risk of acute cerebral infarction due to plaque dislodgement.