What is the optimal management for a patient with large-artery atherosclerosis causing stroke, given significant carotid stenosis and underlying cardiovascular risk factors, including hypertension, hyperlipidemia, and type 2 diabetes mellitus (T2DM)?

Optimal Management: Carotid Endarterectomy Plus Dual Antiplatelet Therapy

This patient requires right carotid endarterectomy combined with dual antiplatelet therapy for large-artery atherosclerosis causing symptomatic stroke. The clinical presentation—acute stroke with 90% ipsilateral carotid stenosis and luminal irregularities—definitively establishes large-artery atherosclerosis as the stroke mechanism, making revascularization plus antiplatelet therapy the evidence-based standard of care.

Why Carotid Endarterectomy is Indicated

For symptomatic carotid stenosis of 70-99%, carotid endarterectomy reduces absolute stroke risk by 16% at 5 years compared to medical therapy alone (Level A evidence). 1, 2

• This patient has 90% stenosis with recent symptoms (acute stroke), placing him in the highest-benefit category for surgical intervention 1
• The 2024 ESC guidelines recommend CEA for symptomatic patients with 70-99% stenosis, with surgery ideally performed within 14 days of symptom onset to maximize stroke prevention 1
• Surgery should be performed by a surgeon with documented perioperative stroke/death rates <6% for symptomatic patients 1
• The benefit of CEA increases with stenosis severity, and this patient's 90% stenosis with luminal irregularities (suggesting unstable plaque) represents particularly high-risk anatomy 1

Why Dual Antiplatelet Therapy is Required

Dual antiplatelet therapy (aspirin plus clopidogrel) is recommended in the early phase of minor strokes with carotid stenosis for at least 21 days, and may be continued up to 90 days considering bleeding risk. 1

• The 2024 ESC guidelines give this a Class I, Level C recommendation for patients with symptomatic ICA stenosis 1
• DAPT reduces asymptomatic cerebral embolization and stroke recurrence after minor stroke/TIA in patients with carotid stenosis 1
• Following revascularization, long-term single antiplatelet therapy should be continued (Class IIa recommendation) 1

Why the Other Options are Incorrect

Apixaban for cardioembolism is wrong because the patent foramen ovale (PFO) is an incidental finding without supporting evidence of paradoxical embolism (no DVT, normal cardiac telemetry, and the stroke location/mechanism clearly points to large-artery disease) 1

Apixaban for hypercoagulable state is wrong because there is no clinical evidence of hypercoagulability (no family history of thromboembolism, no recurrent events, single vascular territory involvement) and the PFO alone does not constitute an indication for anticoagulation in this context 1

Aspirin for small-artery disease is wrong because the clinical presentation does not match lacunar stroke—the patient has a cortical stroke pattern (face = arm = leg hemiparesis) with a clear large-artery source (90% carotid stenosis), not a small subcortical infarct <15mm that would characterize small-artery disease 1

Clopidogrel for carotid dissection is wrong because there are no clinical or imaging features of dissection—the duplex shows atherosclerotic stenosis with luminal irregularities (plaque), not the typical findings of dissection (intimal flap, double lumen, or long tapering stenosis) 1

Timing Considerations

CEA should be performed within 2 weeks of symptom onset rather than delayed (Class IIa, Level B recommendation) to maximize stroke prevention benefit 1

• Earlier intervention (within 14 days) provides greater absolute risk reduction for recurrent stroke 1
• However, surgery within the first 48 hours remains controversial due to increased risk of hemorrhagic transformation, particularly in patients with large infarcts or impaired consciousness 1
• This patient's small capsular infarct without major neurological deficit makes him a suitable candidate for early intervention 1

Essential Concurrent Medical Management

All patients undergoing carotid revascularization require intensive medical therapy targeting cardiovascular risk factors (the "triple therapy" approach) 1, 3

• Intensive statin therapy with target LDL-C <55 mg/dL, adding ezetimibe or PCSK9 inhibitors if needed 1, 3
• Blood pressure control with antihypertensive therapy 1
• Smoking cessation is mandatory given his active smoking history 1
• Diabetes management to maintain HbA1c <6.5% (his current 6.4% is acceptable) 1

Critical Pitfalls to Avoid

Do not delay revascularization for "optimal medical therapy trial" in symptomatic high-grade stenosis—the evidence clearly shows surgery plus medical therapy is superior to medical therapy alone for 70-99% symptomatic stenosis 1, 2

Do not use anticoagulation instead of antiplatelet therapy for large-artery atherosclerosis—antiplatelet agents are the standard of care for this mechanism, and anticoagulation increases bleeding risk without proven benefit 1

Ensure perioperative stroke/death rates are documented <6% before proceeding, as higher complication rates negate the benefit of surgery 1, 2

Do not overlook the incidental PFO as a distractor—while present, it is not the stroke mechanism given the clear large-artery source and absence of supporting evidence for paradoxical embolism 1