Review Question - QID 109593

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Transient Ischemic Attack Imaging Intracranial non-invasive vessel imaging QID: 109593 (M2.NE.17.4867)

QID 109593 (Type "109593" in App Search)

A 65-year-old man presents to the emergency department for a loss of vision. He was outside gardening when he suddenly lost vision in his right eye. He then immediately called emergency medical services, but by the time they arrived, the episode had resolved. Currently, he states that he feels fine. The patient has a past medical history of diabetes and hypertension. His current medications include lisinopril, atorvastatin, metformin, and insulin. His temperature is 99.5°F (37.5°C), blood pressure is 140/95 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% on room air. Cardiac exam is notable for a systolic murmur along the right sternal border that radiates to the carotids. Pulmonary exam reveals mild bibasilar crackles. Neurological exam reveals cranial nerves II-XII as grossly intact with 5/5 strength and normal sensation in the upper and lower extremities. The patient has a negative Romberg's maneuver, and his gait is stable. A CT scan of the head demonstrates mild cerebral atrophy but no other findings. Which of the following is the next best step in management?

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Tissue plasminogen activator

2/50

MRV

0/50

Heparin bridge to warfarin

10%

5/50

Ultrasound of the carotids

86%

43/50

No further management necessary

0/50

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This patient is presenting with a transient ischemic attack (TIA) that has resolved. After the acute episode, the best next step in management is an ultrasound of the carotids.

Amaurosis fugax (a type of transient ischemic attack) presents with a sudden, painless loss of vision from dislodged emboli. By the time these patients present, they often are asymptomatic and the episode has resolved. These patients should still receive a head CT/MRI to rule out any other abnormalities. After the acute episode, the next step in management is to perform ultrasound of the carotids (or CTA/MRA) to search for plaques, since many emboli can originate at the bifurcation of the carotid.

Incorrect Answers:
Answer 1: Tissue plasminogen activator is appropriate management for an acute ischemic (nonhemorrhagic) stroke in a patient without any contraindications. It is not indicated for a patient who presents with a resolved TIA.

Answer 2: MRV of the head is not the appropriate study as it is indicated for imaging the veins of the brain. An MRI of the brain and an MRA neck would be preferred imaging for this patient.

Answer 3: Heparin does not have strong evidence that it is helpful for acute episodes of stroke/TIA. Aspirin could be given as a prophylactic measure.

Answer 5: No further management necessary is inappropriate, as a potential source for this patient's presentation should be investigated.

Bullet Summary:
The next step in management of amaurosis fugax (after the acute episode) is ultrasound of the neck to search for carotid plaques.

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