A 60-year old advertising executive presented with the following history. One month earlier, while viewing television commercials, he noted a greying-out of the vision in his left eye, as though it was being obscured by a cloud. This lasted for fifteen minutes and subsided within one half hour. Two weeks later, a spell identical to the first occurred, also subsiding without residual symptoms. Three days later, while conversing with his family at the dinner table, his speech suddenly slowed and he appeared to be unable to produce the words he wanted to say. He was able only to repeat the phrase, “I’m, ugh,.. .ugh. ..". Twenty minutes later, he regained the use of a limited number of words, and three hours later, his speech appeared normal. During this episode, there was no paralysis, sensory abnormality, headache, or visual disturbance. His past medical history was remarkable for moderate hypertension, treated sporadically.

 On examination, the patient appeared alert, with fluent speech and no evidence of disturbed higher cortical function. The blood pressure was 150/95 in each arm. The carotid artery pulsation in the neck was graded as 2+ (normal) on the right and 1+ (slightly reduced) on the left. The temporal arteries were non tender, but the pulsation on the left side appeared accentuated compared to the right. The preauricular pulse on the left side was also of greater intensity than on the right. A moderately loud bruit was heard over the left carotid artery at the level of thyroid cartilage. Cardiac examination was normal. The optic fundi displayed irregular narrowing of the arterioles of mild degree. The remainder of the cranial nerve examination was normal. Muscle strength, reflexes, coordination, sensation, and gait were likewise normal. 

Doppler Ultrasound test suggested at least a 60% occlusion of the left internal carotid artery. An aortic arch study (arteriogram of the major arteries of the neck and head) was performed via the transfemoral route. The right common, internal, and external carotid arteries appeared normal. On the left, the initial 1.5 cm of the internal carotid artery was narrowed by 75%. The findings were consistent with atheromatous plaque, a portion of which appeared to be ulcerated. Following arteriography, the patient was anticoagulated with heparin intravenously, and a vascular surgeon was consulted. He recommended that left carotid endarterectomy be performed. This was carried out uneventfully, and the patient was discharge eight days thereafter.