Question 25#

A 73-year-old man has had three episodes of visual loss in the right eye. The episodes last 20 to 30 minutes and resolve completely. He describes the sensation as like a window shade being pulled down in front of the eye. He has a history of hypertension and tobacco use. He denies dyspnea, chest pain, palpitations, or unilateral weakness or numbness. On examination the patient appears healthy; his vital signs are normal and the neurological examination is unremarkable. An ECG shows normal sinus rhythm without evidence of ischemia or hypertrophy. Initial laboratory studies are normal. Both noncontrast CT scan of the head and MR scan of the brain are normal.

What is the best next step in this patient’s management? 

a. Begin anticoagulation with low-molecular-weight heparin and warfarin
b. Obtain an echocardiogram
c. Check for antiphospholipid antibodies and homocysteine levels
d. Order a carotid duplex ultrasonogram and begin antiplatelet therapy
e. Begin lamotrigine for probable nonconvulsive seizure

Correct Answer is D


This patient has suffered several transient ischemic attacks with the classic description of amaurosis fugax. Although the traditional symptom duration of less than 24 hours is often cited, most TIAs last less than 1 hour, usually 15 or 20 minutes. Many patients whose symptoms last for several hours are found to have ischemic strokes on MRI imaging. TIAs carry a high risk of neurological morbidity and should be promptly evaluated and treated. Five percent of patients will have a full-blown stroke within the next 2 weeks. Assessing the extracranial carotid arteries for evidence of atherosclerosis is crucial in patients with anterior circulation TIAs. If a common or internal carotid stenosis of 70% or greater is found, carotid endarterectomy has been proven to decrease the risk of subsequent stroke. Carotid angioplasty with stenting is used in some centers, but has not been studied as rigorously as carotid endarterectomy. Lesions of the external carotid artery do not cause CNS symptoms. Cardiogenic sources of clots (ie, atrial fibrillation, mitral valve disease, intracardiac tumors) usually cause large vessel ischemic strokes rather than TIAs, so echocardiography would be less important in this patient. The use of anticoagulants in acute stroke has diminished greatly and is primarily used in cases of demonstrated cardiogenic emboli. For the typical atherosclerotic process, antiplatelet therapy is preferred. Testing for thrombophilia is rarely helpful in patients with TIA. These tests may be helpful in patients with large-vessel strokes and no identifiable source of the stroke. Amaurosis fugax would not be a manifestation of seizure disorder.