Case Diagnosis: 50 year-old male presented to the ED with weakness in the left upper extremity, left lower extremity and left face, found to have right common carotid artery (RCCA) occlusion.
The patient has a history of peripheral arterial disease and throat cancer status post chemoradiation. He had been experiencing intermittent L-sided weakness for a month. Neck CT showed a 3 cm thrombosis involving the proximal RCCA. Carotid duplex demonstrated occluded RCCA with patent retrograde flow in the right external carotid artery and antegrade flow in the right internal carotid artery. He was started on a heparin drip, aspirin, and high-dose statin. While in the ED, his neurological deficits resolved. The initial plan was for medical management however, he experienced intermittent episodes of transient left-sided weakness, left facial droop and slurred speech. He was taken for RCCA exploration, ligation, and division. A chronic appearing thrombus with a friable component was seen in the RCCA. His Postoperative hospital course was complicated by recurrent transient ischemic events (TIAs).
Typically, carotid stump syndrome is caused by an occlusion of the internal carotid artery which leads to periodic cerebral emboli. This is a rare case of common carotid stump syndrome with resultant cerebral ischemia. RCCA ligation was performed in order to prevent further cerebral emboli. Postoperatively the patient continued to have recurrent TIAs in the setting of normotension. At discharge, a systolic blood pressure goal of 170-180 mmHg was recommended in order to maintain adequate perfusion. Rehabilitation in these patients becomes particularly difficult due to recurrent TIAs and strokes. Therefore, it is important to emphasize the need to maintain blood pressure above the guidelines to ensure desired therapeutic outcomes.
Further studies regarding the management of carotid stump syndrome are needed, in order to prevent further neurological damage and maximize the utility of therapeutic rehabilitation
Robert Maldonado– Resident Physician, Medstar Georgetown University Hospital - National Rehabilitation Hospital
Shelly Gulhar– Resident Physician, Medstar Georgetown University Hospital - National Rehabilitation Hospital
Rachna Malhotra– Attending Physician, Medstar Georgetown University Hospital - National Rehabilitation Hospital