Asymptomatic carotid stenosis.

A 78-year-old woman, a retired primary school principal, was referred for a second opinion regarding a recommendation that she undergo stenting of a severe carotid stenosis. A bruit in the right carotid had led to a carotid ultrasound study and a diagnosis of 80% stenosis of the right internal carotid artery. This was confirmed by computed tomogra-phy angiography, which also showed moderate stenosis of the right vertebral origin. Her only symptoms were verte-brobasilar: She recently had an episode of vertigo accompanied by numbness in the left side of her tongue, which lasted 10 minutes. Her only past history was of a partial hysterectomy at 54 years of age. Her only medications were atorv-astatin 10 mg daily and amlodipine 5 mg daily. Her father died at 62 years of age of a myocardial infarction; her mother died at 88 years of age with Alzheimer disease, and a brother was alive and well at 74 years of age. Her height was 5′7″, weight 150 pounds. Her blood pressure was 137/78 mm Hg; her general physical examination was unremarkable except for the right carotid bruit and diagonal ear lobe creases. Her neurological examination was normal except for reduced nasal tickle and reduced corneal sensation on the left; there was no indication of cognitive decline. Her serum lipids (in mg/dL) were total cholesterol 164, tri-glycerides 125, high-density lipoprotein 1.2, and low-density lipoprotein 2.56. Her cardiologist told her that she was a walking time bomb and offered to stent her right internal carotid artery, but she subsequently read a column by Jane Brody in The New York Times on August 16, 2012, 1 and wanted more information about the potential risks and benefits of stenting. Because her symptoms were in the vertebrobasilar territory, her carotid stenosis was asymptomatic. To determine whether she might be a candidate for carotid endarterectomy (or stenting, which is less desirable because it carries twice the risk of stroke), a 1-hour transcranial Doppler embolus detection study was performed. This showed that she did not have microemboli from the asymptomatic carotid stenosis. The patient was therefore advised that she would be better treated with intensive medical therapy than with endarterec-tomy or stenting. She was advised to follow a Cretan Mediterranean diet, exercise for a half hour daily, add aspirin 81 mg daily and perindopril 4 mg daily, increase the dose of atorvastatin to 40 mg daily, and add ezetimibe 10 mg daily. …