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Angiogram before carotid endartectomy; yes or no??
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Angiogram before carotid endartectomy; yes or no??

by jamie, for marcus, Dec 27, 2000 12:00AM
My mother is 84; active, normal EKG, normal BP.  She had a mild stroke on 11/28; woke up with a "dead" left arm; arm feels fine now; residual stuff in her left hand; slowly improving.  She had MRI/MRA/Carotid US/and Circle of Willis tests.



I have copies of her test results.  \



Carotid US impression: "finding of a high grade (90% or greater) stenosis involving right internal carotid artery.  Correlation with carotid MRA performed same day confirms this finding.  No evidence of hemodynamically significant stenosis with the left internal carotid artery.  An area of reported stenosis on MRA within the left internal carotid artery is likely artifactual in nature.  Mild to moderate stenosis right external carotid artery."



MR Brain w/wo cont. impression: "Single focus of intensely increased activity on diffusion sequences with the right parietal lobe deep white matter, consistent with an area of acute/subacute ischemia.  Extensive chronic small-vessel ischemic disease with brain volume loss commensurate with age.  No mass or other area of pathologic contrast enhancement is evident."



MR Carotid: Two-D time of flight imaging was performed.  Both vertebral arteries are patent.  The left vertebral artery is dominant.  Carotid imaging is somewhat limited by patient motion related artifact.  Unfortunately, the patient moved during a critical portion of the exam.  There is extensive signal drop out within the proximal 4cm of the right internal carotid artery.  There does appear to be stenosis within this region on source images and this is felt to be a real finding suggsting significant stenosis of the proximal right internal carotid artery.  There appears to be moderate stenosis involving the proximal right external carotid artery as well.  There is evidence of a least moderate stenosis involving the proximal left internal carotid artery which appears to be focal in nature.  Mild to moderate stenosis involves the proximal left external carotid artery.  Visualized portions of both common carotid arteries appear unremarkable.  Impression:  Somewhat technically limitd study.  However, the findings are suggestive of high grade stenosis involving the proximal right internal carotid artery and moderate stenosis within the proximal left internal ca as detailed above.  There are also apparent stenoses within both proximal external carotid arteries.  Depending on the patient's clinical status and if she is a surgical candidate, consider better anatomic delineation with eith CR angiography of the carotid arteries or catheter angiography."



Circle of Willis: unremarkable.



Now, for my dilemma.  Take a deep breath, this will take a minute!  On 11/28, the day of waking up with this "dead arm" episode, my mom had a previously scheduled appt. with her primary care doc.  She had been to him a week previous, complaining of "gait" problems; did some muscle testing (push, pull, etc.) and told me to take her to a neurologist.  On 11/28, he did NO muscle testing, did not look at her arm/hand in any manner.  She was very explicit about her symptoms.  He handed me a referral for cervical spine x-rays, saying "I think your mother's problem is tied up with some nerve compression."



Cervical spine xray impreessions: 1)Spondylosis w/ degenerative disc change @ C5-6 and C6-7.  2)Extennsive facet arthopathy.  3)  Poitential spinal stenosis @ C5-6.



First appt with neuro doc was 12/11.  He looked at the films, dismissed them as "lousy film."   He did muscle testing on mother and said "I am 100% positive that she's had a mild stroke, but will have to do testing to prove this."  My mom said

"I was hoping to go to Cailf for Christmas to be with my son; can I still go?"  He told her to make her reservations and go, but to take an aspirin every day.  So, she did; departure date; 12/20; his office was informed of this.



Testing was done on 11/15.  The day of the tests, we ran into him as we were leaving Outpatient testing.  He said "If there is a problem, I will call you this weekend.  If not, I will call you on Monday."  We heard nothing.  Numerous, numerous calls were placed to obtain results; days were spent going nowhere in order to be home to receive calls; calls promised by nurse and office manager during specific times.  With each call I placed, I reminded them that she was departing and when.



We never heard a word.  I had my mom sign a release so I could obtain her test results, which I did after I put her on the plane.  I went to her primary care docs office; he was out of the country; I just wanted a doctor, ANY DOCTOR, to help me with the test results.  She got on the phone and after almost 2 hours, the neuro doc phoned her.  She put me on the phone with him and he said to me "I have read your mother's test results.  I don't have them in front of me right now, but I don't recall any abnormalities; nothing of signifcance.  Call me in the morning at the office."  When I left the primary doc's office, his office manager apparently called him back; he phoned his office, had the test results faxed to his house and called me in 15 minutes.  "Your mother needs to come home; we need to act on this fairly quickly; she needs surgery."



I faxed the test results to my brother.  When mom found out, she was extremely upset; they took her to the ER for observation, with test results in hand.  Her BP was all over the place; 205/55, then down, then up.  They attributed it to severe anxiety.  They discharged her with normal BP and told my brother to take her to a doc in the AM.



He took her to a Vascular Surgeon; test results in hand.  "Yes, she needs surgery, but not yet; brain needs time to cool off. (neuro doc here told me that enough time has passed for cooling off; the need for action is fairly urgent.) He scheduled surgery for 1/4.  



When neuro doc called, he had all the time in the world for me at that point.  One of the things he said is "We need to do a formal cerebral angiogram on your mother before we do surgery; the testing to date is fine for an initial study, but if we are to proceed with surgery