Case history
Case history #1
A 72-year-old man presents with sudden onset of left arm weakness and numbness. He is being treated for hypertension and diabetes, and smokes 20 cigarettes per day. He has undergone coronary artery stenting subsequent to a myocardial infarction 2 years ago. He has a regular heart rhythm. Duplex ultrasonography is consistent with a >80% stenosis of the right internal carotid artery. Contrast-enhanced computed tomography demonstrates a right frontoparietal infarction without evidence of intracranial haemorrhage.
Case history #2
A 62-year-old woman presents for a routine annual evaluation to her primary care physician. She is being treated for hypertension and diabetes. She smokes 20 cigarettes per day. She has undergone coronary artery bypass grafting subsequent to unstable angina 2 years ago. She does not recollect an episode of sensory or motor deficit or of monocular blindness. She has a regular heart rhythm with a loud systolic bruit audible over her right neck. She has no demonstrable motor or sensory deficits on physical examination. Duplex ultrasonography is consistent with a 50% stenosis of the right internal carotid artery.
Other presentations
Typically, eye symptoms from carotid atheroembolisation include transient monocular blindness or amaurosis fugax (temporary loss of vision in the ipsilateral eye, typically described as a curtain or shade falling over the eye), central retinal artery occlusion, or branch retinal artery occlusion (which may be asymptomatic and detected during retinal screening). Atypical eye symptoms include: homonymous hemianopia (resulting from emboli to optic radiation), intermittent retinal blindness with loss of vision on exposure to bright light, neovascularisation of iris (resulting from ophthalmic artery ischaemia), and, rarely, complete blindness (resulting from ischaemic optic neuropathy). Transient ischaemic attacks (TIAs) of temporary loss of sensory, motor, or visual function typically last for <60 minutes and always return to baseline within 24 hours. Patients may have recurring attacks of TIA within a few days and the deficit may last longer with each attack. These symptoms are associated with a worse outcome and are referred to as crescendo TIAs. Finally, patients may also present with recurring attacks of focal neurological deficits with progressive deterioration in neurological function. This is termed a stroke in evolution and generally lasts >24 hours.
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