Case Sharing(2022.11.20): Dizziness only thinks of high blood pressure? Don't miss this disease!

Case Sharing:

Preface: Since the beginning of my public account, it has basically revolved around lung nodules and lung cancer, and some articles in the early days also involved breast, thyroid or other surgical diseases, but the proportion is really small
.
Why do you want to talk about dizziness that has nothing to do with lung nodules today? Because a few days ago, an elder and a friend who had forgotten the year called and said that he suddenly became dizzy and had difficulty
walking and standing.
But without a history of high blood pressure, his blood vessels had a systolic blood pressure of 180 mm Hg
.
But later ambulatory blood pressure was okay, as if high blood pressure could not be used to explain his symptoms
.
Because the carotid ultrasound was also checked in the nearby hospital, it was found that the left internal carotid artery was narrowed, and the narrowest remaining diameter was only 0.
18 cm, that is, less than 2 mm! And plaque in the internal carotid artery is an important cause of stroke! My family also has a family history, grandpa, grandmother, and aunt all have a history of cerebrovascular accidents, and I am also taking high blood pressure medicine
.
In the past, I did not pay attention to the examination of neck blood vessels, but this time the old friend's symptoms were serious and severe internal carotid artery stenosis, I think it is necessary to learn to sort it out, which is not only good for myself, but also hopes to be beneficial
to the friends who follow my public account.

(1) Friend's situation:

Symptoms: Dizziness symptoms are episodic, strong when they are sent, but stop when they say
.
The volume of blood vessels is sometimes elevated during the attack, and the systolic blood pressure is about 160 to 180 mm Hg
.

Color ultrasound: plaque in the carotid artery causes stenosis of the lumen of the internal carotid artery, with a residual diameter of only 0.
18 cm and a diameter stenosis rate of 80%.

CTA results: mixed plaque at the beginning of the left internal carotid artery, severe stenosis of the lumen, and the degree of stenosis is about 75-90%

Arteriography before surgery: The image is as follows, I marked the segment of the blood vessel at the stenosis, but the specifics need to be cleared by a specialist
.

Surgery: Below are some pictures of the procedure

Surgery result: Recently, my friend has gone home to recuperate, and there is no dizziness after the operation, and the recovery is good
.

(2) Those things that cause carotid artery stenosis

Stroke is the "number one killer" endangering the health of Chinese residents, and carotid artery stenosis is an important cause of ischemic stroke, accounting for up to 20%.

What are the symptoms of carotid artery stenosis?

1.
Transient monocular darkness or visual field loss
.

2.
One side limb sensory disorder, limb numbness, clumsy movement, hemiplegia, aphasia, cranial nerve injury, coma, etc
.

3.
Symptoms such as blurred thinking, memory loss, postural vertigo (refers to vertigo related to body posture), dizziness, and double vision may occur
.

Carotid plaque rupture and acute thrombosis, or plaque debris, appendage thrombus detachment into cerebral blood vessels, or even secondary vascular occlusion, resulting in decreased cerebral blood flow, transient black blindness, transient ischemic attack, stroke
.
Some may have atypical symptoms such as memory loss, less active thinking, severe carotid artery stenosis can lead to loss of consciousness, affect language, cognitive ability, but also cause ocular ischemic lesions, transient vision loss, visual field defects, cerebral infarction, local paralysis and even death
.

Treatment of carotid artery stenosis aims to improve the blood supply to the brain, correct or relieve the symptoms of cerebral ischemia, and prevent TIA and ischemic stroke
.
Treatment is based on the degree of carotid artery stenosis and the patient's symptoms, including medical medications, carotid endarterectomy, and carotid stenting.

Less than 50% carotid artery stenosis, medical therapy can be selected, and regular follow-up is available; For severe symptomatic carotid artery stenosis, early surgery is recommended
.
Among them, carotid endarterectomy is the preferred surgical method for the treatment of carotid artery stenosis, which has the advantages
of complete plaque removal, no need to take antithrombotic drugs for a long time, and low cost.

(III) What does the guide say?

According to the European Stroke Organization Guidelines for Endometrial Acorticectomy and Stent for the Treatment of Carotid Artery Stenosis:

1.
Overview: Carotid atherosclerotic disease is one of the main causes of ischemic stroke and transient ischemic attack (TIA), accounting for about 10-15%
of cases according to the etiological classification method and the study patient population.
Carotid atherosclerotic stenosis occurs at the bifurcation of the carotid artery, involving the distal common carotid artery and the proximal internal carotid artery
.
Other sites prone to atherosclerotic stenosis are the beginning of the common carotid artery and the cavernous sinus segment
of the internal carotid artery.
The prevalence of atherosclerotic carotid artery disease increases with age, with men being higher than females
.

2.
Endometrial peeling or drug treatment for asymptomatic carotid artery stenosis: For patients with ≥60% asymptomatic carotid artery stenosis, the best drug treatment alone still believes that the risk of stroke increases, and carotid endarterectomy
is recommended.

3.
Stent implantation or drug therapy for patients with asymptomatic carotid artery stenosis: For patients with asymptomatic carotid artery stenosis, carotid artery stenting is not recommended as a routine alternative
to the best drug treatment alone.

4.
Stent placement or endarterectomy for patients with asymptomatic carotid artery stenosis: For patients with asymptomatic carotid artery stenosis, we believe that revascularization is appropriate, and it is recommended that carotid endarterectomy be preferred as a treatment option
.
If carotid endarterectomy surgery is less suitable, stenting
is recommended.

5.
Carotid endarterectomy or drug therapy in patients with symptomatic carotid stenosis: For 50-99% of patients with symptomatic carotid artery stenosis, if surgery is considered appropriate, we recommend early carotid endarterectomy, preferably within two weeks after the first neurological event
.

6.
Stent implantation or carotid endarterectomy for symptomatic carotid artery stenosis: For patients with symptomatic carotid artery stenosis who require vascular reconstruction, carotid endarterectomy
is recommended.
For patients under 70 years of age with symptomatic carotid stenosis requiring revascularization, stenting is recommended as an alternative
to carotid endarterectomy.

Brief Summary: Carotid artery stenosis refers to the narrowing of the main blood vessels in the neck (carotid artery), which is caused
by the deposition of fat and calcium (atherosclerotic plaque) in the walls of blood vessels.
Carotid artery stenosis may lead to transient ischaemic attack (TIA or "warning stroke") or stroke
.
Stenosis can be treated with a surgical procedure called carotid endarterectomy, in which the surgeon opens the carotid artery and removes carotid plaque
.
Another treatment called "carotid stenting" involves passing a thin wire and tube through the skin into a narrowed artery
in the neck.
Stent support is placed within the carotid artery to prevent further stenosis
.
Carotid endarterectomy
is recommended for patients with asymptomatic carotid stenosis who are still considered to be at risk of stroke with medical therapy alone.
In patients with recent symptomatic carotid artery stenosis, we suggest carotid endarterectomy if stenosis is severe, and carotid endarterectomy
if moderate stenosis is moderate.
Carotid artery stenting may be used as an alternative treatment
for carotid endarterectomy in patients with symptomatic carotid stenosis, particularly those younger than 70 years of age.

(4) Carotid endarterectomy (CEA) introduction

1.
What is CEA?

Carotid endarterectomy is a procedure
to treat pre-arterial stenosis.
It works by removing carotid plaque, which relieves carotid artery stenosis, thereby increasing the blood
supply to the brain distal to its end.

2.
Indications for surgery

3.
Simplified judgment principle of surgical indications

The indications for surgery of carotid artery stenosis have been reached worldwide consensus, in order to be concise and convenient for clinical use, Professor Qian Hai proposed 3 values: 50, 70, 100
.
Stenosis above 50% can be operated, more than 70% must be operated, and 100% (occlusion) is inoperable
.
For some patients with obvious symptoms and positive willingness to treat, as long as the symptom side does not anastomosis, 50% of the stenosis is completely capable of surgery
.
At the same time, even if the symptoms are not obvious, if the stenosis is more than 70%, excluding the risk factors for surgery, surgery must be performed as soon as possible, otherwise the probability of infarction in the next few years will increase
significantly.

4.
MR manifestations and timing of surgery

In patients with ischaemic symptoms, MR
is clinically investigated.
If the patient has abnormal MR or has an old cerebral infarction, there is no need to wait and surgery can be performed
as soon as possible.
If the patient has a hyperintense DWI sequence and is considered to have acute or subacute cerebral infarction, case-specific analysis
is required.
In general, CEA in the early stage or emergency department (infarction 0~7 days) is considered to be high risk, and after 7 days, it is basically considered safer
.
In terms of clinical application, the physician must control the risks of surgery as much as possible, so if the patient is generally well and does not have severe neurological impairment, surgery can be performed
after 10 days of infarction.
Surgery
is not recommended if the patient has a massive cerebral infarction, coma, or severe neurological deficit.

5.
CTA, DSA and ultrasound Doppler examination

Preoperative DSA is considered the gold standard
for diagnosing carotid artery stenosis.
However, clinically, it is common to encounter situations in which some patients cannot undergo DSA testing for some reason, or patients are reluctant to undergo invasive DSA testing due to fear of risk
.
In such patients, CEA can also be performed if CTA is only available
.
That is, a DSA is not a requirement for
CEA.
However, DSA still has unique advantages over CTA
.
Advantage 1: Other intracranial lesions may be found, especially smaller vascular lesions such as aneurysms and smokey blood vessels, and DSA is clearer and clearer
than CTA diagnosis.
Advantage 2: It is possible to fully observe the blood flow compensation and assess the risk of
surgery.
Of course, as an important means of outpatient screening, ultrasound Doppler examination can also detect carotid artery stenosis, and preliminarily determine the location and degree of
stenosis.

(5) Examples of actual combat cases

Surgical case display of Professor Fang Xin's team of the Department of Vascular Surgery, Hangzhou First People's Hospital:

Case 1:

Case 2:

Case 3: Restenosis CEA after stent implantation

(6) Peel or stent

According to the European Society for Vascular Surgery (ESVS):

1.
Secondary prevention of asymptomatic patients

In asymptomatic patients with carotid artery stenosis requiring further surgery, randomized trials have shown that carotid endarterectomy (CEA) has a better prognosis than carotid artery stenting (CAS), with a higher rate of stroke/death from CAS than CEA
.
Therefore, ESVS guidelines suggest that for asymptomatic patients with carotid artery stenosis between 60%~99% and at average surgical risk, CEA should be considered when the patient has one or more imaging features that may be associated with an increased risk of late ipsilateral stroke, which is recommended
as IIa B.
In the same case, CAS is also possible, which is recommended
as IIb B.
Among them, asymptomatic patients who are considered to be "high surgical risk" by a multidisciplinary team can undergo CAS, which is recommended
as IIb B.

2.
Tertiary prevention in recent symptomatic patients

In patients older than 70 years, CEA is superior to CAS
.
Recommendation: CEA
is recommended for patients with carotid artery supply area symptoms in the past 6 months and carotid artery stenosis of 70%~99%.
This is recommended
as an I-A grade.
For patients with the same condition, patients with a stenosis rate of 50%~69% are also recommended CEA as IIa grade A recommendations
.
If you are older than 70 years old, you will be more inclined to recommend CEA, which is recommended as an I A grade
.
Based on a previous multicentre RCT, treatment with CEA was safer
than CAS.
Therefore, ESVS recommends that when 50%~99% of patients with symptomatic carotid artery stenosis have indications for revascularization, it is recommended to perform CEA as soon as possible, preferably within 14 days after the onset of symptoms, which is recommended as level I
.

My summary: In fact, the above basically means that exfoliation is recommended for those who require surgical intervention, and if there is a high surgical risk, stent implantation
is possible.