A 68-year-old man who suffered a right hemispheric transient ischaemic attack two weeks ago has a carotid duplex showing 75% stenosis of the right internal carotid artery. He is on aspirin and a statin with controlled blood pressure. What is the most appropriate management?
- A Carotid endarterectomy performed early, ideally within two weeks of the event ✓
- B Carotid angioplasty with stenting as first choice
- C Continue best medical therapy alone and review in six months
- D Extracranial-intracranial bypass surgery
Correct answer: A. Carotid endarterectomy performed early, ideally within two weeks of the event
Explanation
For symptomatic severe (70 to 99%) internal carotid stenosis, carotid endarterectomy substantially reduces recurrent stroke risk compared with medical therapy alone, and benefit is greatest when surgery is done within two weeks of the index event. Carotid stenting is reserved for patients at high surgical risk or with restenosis after endarterectomy, since peri-procedural stroke rates are higher in standard-risk symptomatic patients. Extracranial-intracranial bypass showed no benefit over medical therapy in trials.
Reference: Schwartz's Principles of Surgery, 11th ed.
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Written and medically reviewed by the StethoPrep medical team.