Crescendo TIAs With an Occluded Contralateral Carotid and a Radiated Neck

Timing. He has a symptomatic 80–99% stenosis with a small, non-space-occupying infarct and a second event 12 hours ago. The benefit of carotid endarterectomy is greatest in the first 2 weeks and largely lost by 12 weeks; current guidance is to operate within 14 days and ideally within 7, with the steepest benefit in the first 48–72 hours. There is no physiological reason to wait for the infarct to 'mature' - the only legitimate reasons to delay are a large infarct with mass effect, hemorrhagic transformation, or uncontrolled medical instability, none of which apply. A second event within hours makes this effectively urgent: book the next available slot, ideally within 24–72 hours, and do not let a cardiac workup push it back.

Blood pressure. Both hemispheres are at risk. The left internal carotid is occluded and the left hemisphere depends on cross-flow through the anterior communicating artery; the right hemisphere is critically stenotic and its perfusion pressure depends on systemic pressure. Autoregulation is shifted rightward after a recent ischemic event. Lowering him to 120/80 would risk watershed infarction on either side. Aim for permissive hypertension - roughly his baseline, systolic 140–180 mmHg - and specifically instruct anesthesia to keep intraoperative mean pressure within about 20% of baseline, since the dangerous period for a clamp-related stroke in a patient with contralateral occlusion is intraoperative hypotension. If blood pressure exceeds about 200/110 with symptoms of hypertensive encephalopathy, lower it slowly and partially.

Also: continue aspirin, confirm high-intensity statin therapy, and address smoking if applicable.

Carotid endarterectomy. The reference standard with the most durable result and the lowest stroke rate in experienced hands, and it is not excluded by contralateral occlusion. The problem is the field: a radiated, fibrosed neck with a sacrificed hypoglossal nerve makes dissection planes absent, raises the risk to the vagus and marginal mandibular nerve, and increases wound-healing complications. It remains entirely feasible with a generous incision, identification of the vagus low in the neck in unscarred tissue, and a shunt. It requires general or regional anesthesia and a patient who can tolerate temporary occlusion.

Transfemoral carotid stenting. Avoids the neck entirely, which is attractive, but in symptomatic patients over 70 the periprocedural stroke risk is consistently higher than with endarterectomy in randomized data and pooled analyses. It also requires navigating a potentially hostile arch and a stenotic, possibly tortuous right internal carotid, and it commits him to dual antiplatelet therapy.

Transcarotid artery revascularization with flow reversal. Direct common carotid access avoids the arch and avoids dissection across the bifurcation and the radiated field. Flow reversal provides cerebral protection. Large registry experience suggests stroke rates comparable to endarterectomy, including in patients over 70 and in hostile necks. The requirements are a common carotid with enough length and calibre to accommodate the sheath (roughly 6 cm of accessible neck and a 6-mm artery) and no overlying tracheostomy.

Recommendation: transcarotid artery revascularization with flow reversal, performed urgently, provided the common carotid is accessible on duplex and CT. If it is not, I would do carotid endarterectomy with a shunt and meticulous nerve identification, with the patient counselled about cranial nerve and wound risk. Transfemoral stenting is my third choice here, not my first.

This is a crescendo transient ischemic attack, which signals an unstable plaque with active embolization and a very high risk of completed stroke within days. The management changes from 'urgent' to 'today'.

• Escalate the operation. Move him to the next available emergency or add-on slot, within 24 hours if at all possible. Do not complete an exhaustive workup first. Repeat imaging only if the clinical picture suggests a new infarct that would change the risk balance (for example a large new territory or hemorrhagic transformation).
• Avoid hypotension even more rigorously; keep him with permissive hypertension and on continuous monitoring.
• Medical bridging: continue aspirin and consider adding clopidogrel for short-term dual therapy until surgery, accepting a modest increase in bleeding. Continue high-intensity statin. Some clinicians use intravenous heparin, but evidence is weak; if used, it is to prevent further thrombus propagation, not as a substitute for revascularization.
• Reassess the plaque and anatomy with CT angiography if not already done, to confirm the stenosis has not progressed to near-occlusion and to plan access.
• Do not thrombolyse - the events are transient with no fixed deficit, and lytic therapy would delay and complicate surgery.
• Involve the patient and family in an explicit conversation: the risk of stroke with continued waiting now exceeds the perioperative risk, and surgery during a crescendo pattern is higher risk than elective surgery but less risky than doing nothing.

If he develops a fixed deficit instead, the same principle holds: operate within 2 weeks, and within days if the infarct is small and he is stable, since the risk of recurrence dominates.