Page 10 - Carotid and peripheral vascular interventions textbook
P. 10


                    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.

                       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
                        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
   5   6   7   8   9   10   11