Page 10 - Carotid and peripheral vascular interventions textbook

CAROTID AND PERIPHERAL VASCULAR INTERVENTIONS: STEP-BY-STEP

CLINICAL PRESENTATION Patients that have both hemispheric and retinal symptoms
often suffer severe extracranial carotid disease. The clinical
A careful consideration of patient history is important manifestations associated with ICA branch stenosia or
in determining whether symptoms are attributable occlusions are summarized in Table 6-1.
to carotid stenosis. Most patients that have carotid Amaurosis fugax or transient monocular blindness
artery stenosis are asymptomatic and only diagnosed is traditionally expressed as, ‘a shade coming down over
following auscultation of a carotid bruit or routine carotid one’s eye’. Hemispheric symptoms comprise sensory loss,
ultrasound screening. In symptomatic patients, the clinical unilateral motor weakness, language or speech disruptions,
presentation is either TIA or ischemic stroke. TIA is def ned and visual f eld disruptions. It is important to discriminate
as a brief neurological dysfunction episode arising from between vertebrobasilar and hemispheric symptoms,
focal temporary cerebral ischemia, which is not linked with because patients may have asymptomatic carotid stenosis
an acute cerebral infarction and resolves within 24 hours. and/or vertebrobasilar insuff ciency. Signs and symptoms
If not treated, 11% of TIA patients develop a stroke within which are caused by infarction or ischemia in the
90 days, with about one-half occurring within the f rst vertebrobasilar system include cranial nerve def cits
2 days (24). Ischemic stroke is designated as a neurological (dysarthria, diplopia, dysphagia), ataxia, imbalance,
dysfunction episode resulting from retinal or focal cerebral dizziness, visual f eld loss, and incoordination, which
infarction that persists longer than 24 hours. are atypical for the circulation of the carotid artery.
The typical symptoms of extracranial carotid stenosis The accurate designation of symptoms will greatly
are transient monocular blindness (amaurosis fugax), help with clinical management and appropriate
hemiparesis, hemiplegia, and speech disorders (aphasia). revascularization timing.

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Table 6-1. Clinical manifestations associated with ICA branch stenosia or occlusion (37).

Occluded artery Clinical manifestation
Ophthalmic artery • Transient monocular blindness (amaurosis fugax)
Anterior choroidal artery • Contralateral dense hemiparesis: face, arm, leg
• Contralateral hemisensory loss (if lateral geniculate is involved, a contralateral
hemianopsia)
Recurrent artery of heubner • Mild weakness in the contralateral limb with dysarthria
• Abulia with apathy and inertia of movement
Anterior cerebral artery • Contralateral weakness of the legs and shoulder
• Cortical sensory def cit with poor touch localization and extinction with bilateral
stimuli (left arm apraxia only)
Middle cerebral artery (MCA)
- M1 Segment • Contralateral spastic hemiplegia, visual def cit
- M2 Segment • Hemiparesis affecting the face and arm more than the legs
• Visual def cits
Left hemisphere MCA (superior branch) • Motor aphasia (Broca’s aphasia)
• Apraxia-both upper extremities
• Oral buccal apraxia

Left hemisphere MCA (inferior branch) • Receptive aphasia (Wernicke’s)
Nondominant hemisphere MCA (superior branch) • Neglect—left side of space
• Apraxia in left upper extremity only
Nondominant hemisphere MCA (inferior branch) • Constructional apraxia and diff culty with shape
• Confusion and delirium
MCA, middle cerebral artery; ICA, internal carotid artery