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Answer 1
  1. Initiate aspirin. The best treatment for this patient at this time is optimal medical therapy with an antiplatelet medication such as aspirin. Antiplatelet agents (eg, aspirin, aspirin-dipyridamole, clopidogrel) are recommended as initial therapy for reducing the risk of ischemic stroke after a transient ischemic attack.1 Selection of an appropriate agent is based on the patient’s risk factors, tolerance, and other clinical features. Warfarin, an anticoagulant, is not preferred for the treatment of intracranial stenosis and is associated with higher rates of death and major hemorrhage when compared with antiplatelet agents such as aspirin.2 Patients with severe carotid artery stenosis (70%–90%) should undergo CEA.1 In patients with moderate carotid artery stenosis (50%–69%), CEA is considered based on the patient’s age, gender, and comorbidities and the severity of initial symptoms.1 The patient’s symptoms (ie, language and right body motor function) are localized within the territory of the left middle cerebral artery. This patient’s right internal carotid artery lesion is considered asymptomatic, the degree of stenosis is moderate, and he has not been on optimal medical therapy, so CEA is not recommended. In general, interventions such as endarterectomy or angioplasty and stenting are indicated when a patient has symptoms while on optimal medical therapy that correlate with the vascular lesion in question.1

    1. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006;37:577–617.

    2. Chimowitz MI, Lynn MJ, Howlett-Smith H, et al; Warfarin-Aspirin Symptomatic Intracranial Disease Trial Investigators. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 2005;352:1305–16.

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