What is the recommended management for a 78-year-old man with a left cerebral vascular accident (CVA) and internal carotid artery (ICA) stenosis of 50-69%?

Management of Left CVA in a 78-Year-Old Man with 50-69% ICA Stenosis

For a 78-year-old man with a left cerebral vascular accident (CVA) and internal carotid artery (ICA) stenosis of 50-69%, carotid endarterectomy (CEA) should be considered depending on individual characteristics including age, comorbidities, and surgical risk, alongside optimal medical therapy. 1

Immediate Evaluation and Management

• The patient should be urgently evaluated by a vascular team that includes a neurologist to determine the optimal management strategy 1
• Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel should be initiated for at least 21 days following the CVA if revascularization is not immediately performed 1
• DAPT may be continued for up to 90 days in some cases, depending on bleeding risk 1

Revascularization Decision

Indications for Carotid Endarterectomy (CEA)

• For symptomatic 50-69% ICA stenosis (as in this case), CEA should be considered based on:

  • Age (78 years is a consideration but not an absolute contraindication) 1
  • Expected life expectancy (should exceed 5 years) 1
  • Comorbidities and surgical risk 1
  • Male sex (men derive greater benefit from CEA in moderate stenosis) 1

• If CEA is indicated, it should be performed within 14 days of symptom onset for maximum benefit 1

• The surgical team should have a documented perioperative stroke/death rate of <6% 1

Carotid Stenting Considerations

• Carotid artery stenting (CAS) may be considered as an alternative to CEA if the patient has high surgical risk factors 1
• However, CEA is generally preferred over CAS for symptomatic stenosis 1

Medical Management

Antiplatelet Therapy

• If not undergoing immediate revascularization, DAPT with aspirin and clopidogrel (75 mg) is recommended for at least 21 days 1
• Following this period, long-term single antiplatelet therapy with either aspirin (75-325 mg daily) or clopidogrel (75 mg daily) should be continued 1
• After CEA, long-term aspirin (75-325 mg daily) or clopidogrel (75 mg daily) is recommended 1
• If CAS is performed, DAPT with aspirin and clopidogrel is recommended for at least 1 month, followed by long-term single antiplatelet therapy 1

Risk Factor Management

• Intensive medical therapy is essential regardless of whether revascularization is performed 1
• This includes:
  • Lipid management with high-potency statins 2, 3
  • Blood pressure control with goal <140/90 mmHg 3
  • Diabetes management if applicable 1
  • Smoking cessation 2
  • Mediterranean-style diet and regular exercise 2, 3

Follow-up Care

• After revascularization, duplex ultrasound surveillance is recommended within the first month 1
• Annual follow-up to assess neurological symptoms, cardiovascular risk factors, and treatment adherence 1
• Ongoing monitoring for recurrent stroke symptoms and progression of carotid stenosis 4

Important Considerations and Caveats

• The benefit of CEA in 50-69% stenosis is substantially lower than in those with ≥70% stenosis 1
• In the 50-69% stenosis range, CEA is associated with a higher risk of poor outcomes in the first 2 post-procedural years, but shows benefit at 5 years 1
• Revascularization is not recommended for patients with <50% stenosis 1
• The patient's age (78) requires careful consideration of life expectancy and surgical risk, but age alone should not exclude appropriate candidates from revascularization 1