A 63-Year-Old Man Comes to the Emergency Department Due to Sudden-Onset

question 1465

Multiple Choice

A 63-year-old man comes to the emergency department due to sudden-onset right-sided weakness that resolved spontaneously within 30 minutes.  Medical history includes hypertension and an early-stage sigmoid colon cancer that was resected 5 years ago; follow-up colonoscopy showed no recurrence.  The patient takes lisinopril.  He has a 20-pack-year history and quit smoking 10 years ago.  Blood pressure is 130/80 mm Hg and pulse is 74/min.  Examination shows a left carotid bruit.  Neurologic examination is normal.  ECG shows normal sinus rhythm.  CT scan of the head is normal.  Lipid panel results are as follows: Echocardiography is unremarkable.  Carotid duplex ultrasonography and follow-up CT angiography show 80% stenosis in the left internal carotid and 40% stenosis in the right internal carotid artery.  Which of the following is the most appropriate next step in preventing a further stroke in this patient?

• A)Bilateral carotid artery revascularization
• B)Left carotid artery revascularization
• C)Medical therapy with an oral anticoagulant only
• D)Medical therapy with heparin and a high-intensity statin
• E)Right carotid artery revascularization

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Definitions:

Larva

The immature, wingless, and often worm-like stage in the life cycle of insects, before they transform into adults.

Pupa

A transitional stage of a developing insect, after larva and before adulthood, during which it undergoes transformation.

Cocoon

A protective casing spun by the larvae of many insects, inside which they undergo metamorphosis into their adult form.

Caterpillar

The larval stage of butterflies and moths, often recognized by its elongated body, multiple legs, and the ability to transform into a butterfly or moth.