Second Opinion

[Lawrence W. Olenginski]

This question is in regard to my father-in-law (78 yr. old male).Last week experienced TIA, immediately hospitalized. CT scan-no masses, no bleed, minimal cerebral atrophy. Heparinized and next day second TIA. Cerebral angio-Approx.50 % stenosis bilaterally, plaque seen on left, symptoms of TIA were right sided. Vascular consult-no immediate surgery,(small vessel disease??), Plavix,ASA, Lipitor, followup in 6 months. Should embolic phenom. recur carotid exploration necessary. Neurologist suggested ASA,Coumadin, Lipitor. No permanent neuro deficit from TIA's.                                                           Past medical history: COPD (coal miner 25 yrs.), A-fib. approx. 1 year ago (acute onset), normal sinus rhythm for past year.  Lumbar disc approx. 4 years ago. Recent echo- essent. normal     My dilema are the statistics for a future stroke and possible permanent neuro deficit with this wait and see approach. My father-in-law is active in his gardening and lives with my wife and I. Do you feel second opinion warranted? If so neurologist or vascular? Immediacy of second opinion? Please suggest someone at Cleveland Clinic if warranted. My daughter is a senior at Case so second opinion in Cleveland wouldn't be a problem. Thank you!    Trying to get my father-in-law the best possible medical care in regard to this recent problem.   Sincerly,                                                        Lawrence W. Olenginski,C.R.N.A.

[CCF Neuro[P] MD, RPS]

Dear Lawrence:

Sorry to hear about your father-in-law.  I am assuming that the stenosis your talking about is internal carotid, and a 50% stenosis is not too worrisome at present.  Some prognostic factors such as HDL level have been recently published but need to be repeated in other centers.  The etiology therefore becomes important.  I am not hearing that they did an MRI with diffusion weighted scan nor did I hear what symptoms your father-in-law had, that would tell me what sort of TIA he had.  The recent a-fib is worrisome and hopefully they ruled out an intermittent a-fib event as the cause of his TIA (if so, then coumadin would likely be the best choice).  If his vasculature shows stenoic lesions in the major vessels of the head then again likely coumadin would be best.  If there is history of athrosclerosis then maybe ASA with or without pyrimadine or plavix might be the best.  Liptor (liptor) might help if there is a high cholesterol level.  If no etiology is known, then ASA alone is likely good enough.  A lifestyle change will also be important as diet, excercise, etc become important.  Find out the cause or etiology of the TIA and begin working on correcting that problem.

If you decide to come to the Cleveland Clinic for a second opinion, I would suggest Dr. Cathy Sila or Anthony Furlan (if it was my father, I would have them see him).

Sincerely,

CCF Neuro MD

[Lawrence W. Olenginski]

Please note my mistake in posting this question(TIA symptoms were left sided not right)  My apology.