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Sixty-year-old woman presents with episode of weakness and numbness in right arm. Episode lasted 15 minutes and resolved in one hour. Risk of repeated neurological event? Evaluation?

40% chance of TIA or stroke within two years

1. Examine for carotid bruits, residual neurologic deficit, cardiac disease (murmurs)
2. If murmur, get an ECHO
3. Duplex ultrasound carotid vessels to look for stenosis or plaques

1

Sixty-year-old woman presents with episode of weakness and numbness in right arm. Episode lasted 15 minutes and resolved in one hour. Duplex exam shows 80% stenosis of left internal carotid artery – treatment options?

1. If stenosis 70% or more in carotid artery with ipsilateral symptoms or asymptomatic carotid bruit, carotid endarterectomy
2. Otherwise medical treatment with aspirin

2

Complications of carotid endarterectomy?

Nerve Injuries – hypoglossal nerve, Vegas nerve, marginal branch of facial nerve

3

Patient with a TIA. What condition is most likely to cause patient's death?

MI

4

Patient experiences an episode of blindness in the left eye is cleared rapidly, with no other neurologic events. Artery affected? Episode called? Examination of the Fundus may reveal? Management?

Ophthalmic artery (first branch of internal carotid artery)

Amaurosis fugax

Hollenhorst plaque (portion of the thrombus)

Duplex scanning of the carotids and carotid endarterectomy if appropriate

5

Right-handed patient relates an episode of aphasia with no other neurologic symptoms – Where is the lesion? Management?

Left hemisphere. Duplex study of left carotid and carotid endarterectomy if appropriate

6

Patient experiences marked weakness and numbness in the right arm that is not transient. Condition does not improve in one week. Suspected diagnosis? Management?

Stroke.

1. Carotid duplex study and observation for improvement (no endarterectomy at this time)
2. If after observation, recovery is favorable and neurologic function improves, consider endarterectomy (if appropriate) 2-4 weeks after diagnosis or when neurologic status stabilizes

7

Patient presents with asymptomatic carotid bruit - evaluation?

evaluation shows 65% stenosis – next step?

Carotid duplex study

Probably endarterectomy but still controversial

9

Patient with compartment syndrome – management?

1. Fasciotomy
2. After episode is resolved, close with split-thickness graft
3. Chronic anticoagulation therapy (warfarin)
4. ECHO, CT to search for embolic source

10

Signs of chronic ischemia to a limb?

1. Claudication
2. Rest pain
3. Ischemic ulceration (Up to gangrene)
4. Skin findings - Hair loss, dependent rubor, loss of sensation, thin/shiny skin

11

Patient with intermittent claudication and absent popliteal and pedal pulses – where is the occlusion?

If femoral pulse is absent?

Superficial femoral artery typically at adductor hiatus

Aortoiliac disease

12

Ankle-brachial index?

Notable values?

Comparison of systolic arterial pressure in ankle versus brachial artery with Doppler

Normal over 1
.6-.8 – Mild claudication
<.3 – rest pain or tissue loss

13

Normal Doppler waveform? Change in ischemic disease?

Triphasic – systolic flow, reverse flow from elastic recoil, diastolic flow

In ischemic disease, vessel becomes less compliant and waveform may become monophasic

14

Doppler blood pressure measurements may be incorrect in these patients? Why?

Diabetics – calcified vessels prevent arterial occlusion with a blood pressure cuff (blood pressure is as high as the cuff is inflated)

15

Treatment for patients with claudication?

Typically nonsurgical

1. Exercise
2. Smoking cessation, lipid lowering agents, weight loss
3. Control hypertension and diabetes

23

Patient undergoes embolectomy. After surgery, improved perfusion but inability to dorsiflex the foot and tenderness in the calf – likely cause? Mechanism? Irreversible injury if?

Compartment syndrome – ischemia-reperfusion injury that results in edema of the muscle. Edema increases pressure within fascial compartments

Irreversible injury it pressure approaches 20-40 mm Hg

24

Patient with intermittent claudication and absent femoral pulse – suggests? Difference from more peripheral occlusive disease? Important symptoms? If disease progresses, treatment?

Aortoiliac occlusive disease

More progressive than peripheral disease. Treatment is more aggressive – ie surgery

Impotence in males, claudication's in five or but

Aortoiliac reconstruction with either 1. balloon dilation and/or stent placement
2. Surgical revascularization

25

Patient with claudication is lost to follow-up. Returns one year later complaining of ulcer on big toe. ABI is 0.3. Next step? Likely to heal if?

Measure ankle systolic blood pressure to determine whether blood supply is sufficient for ulcer to heal

Nondiabetic – likely to heal if ankle systolic blood pressure is over 65 (unlikely if less than 55)

Diabetic – likely to heal if ankle systolic blood pressure is over 90 (unlikely if less than 80)

26

Patient with vascular disease comes in with ulceration on toe. ABI is 0.3. Ankle systolic blood pressure is 50. Next steps?

1. Determine whether patient would benefit from revascularization or just an amputation (Cardiovascular condition, limited mobility, short life span)
2. If revascularization, get arteriogram to assess arterial occlusion
3. Determine whether occlusions can be bypassed successfully to improve blood supply to ulcer

27

Patient undergoes arteriogram – two types of vascular disease found?

1. Inflow disease – inadequate blood flow into femoral artery (iliac artery occlusion)
2. Outflow disease – occlusions of the leg arteries (superficial femoral artery, popliteal artery)

28

When would a patient he better off with an amputation over revascularization?

Cardiovascular condition, limited mobility, short life span