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Issue: Issue 4 (2017) – Supplement 1


Debate

Challenging clinical case—unstable carotid plaque

Author(s):
Eduardo Freitas, Célia Machado, José Amorim, João Pinho, Jaime Rocha, and Carla Ferreira
Abstract:
We present a 79-year-old man with a previous history of hypertension, dyslipidemia and ischemic stroke of the left middle cerebral artery caused by severe atherosclerotic stenosis of the left internal carotid artery (treated with carotid artery stenting) in 2011. He was medicated with clopidogrel 75mg/day, ramipril 2.5mg/day and atorvastatin 20mg/day. He was admitted for a left-hand motor deficit after he woke up. Vital signs were normal and there was a mild motor deficit of the left upper limb, with apraxia of the left hand. Electrocardiography showed sinus rhythm, and there were no signs of acute ischemia or hemorrhage in brain CT. Carotid ultrasound showed a normal position of the left stent with no residual stenosis and, additionally, an irregular hypoechoic atherosclerotic plaque in the proximal right internal carotid artery without significant stenosis. He was treated with a loading dose of acetylsalicylic acid and maintained double antiplatelet therapy and atorvastatin 80mg/day. On the third day after admission, the left motor deficit worsened. The brain MRI revealed multiple acute hyperintense ischemic lesions in the right hemisphere (cortical and subcortical) with varying intensities suggesting different timings of the ischemic lesions. At this point we would like to discuss with the experts the best management in this case, namely among the following options: maintain double antiplatelet therapy and close monitoring; start anticoagulation; or proceed to endovascular or surgical treatment of the unstable plaque.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D1
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