Stuttering cerebrovascular accident and a rare intervention: A case report

B. Mahendrasamy1, Jos Jasper2

1Physician Assistant, Department of Neurosurgery, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

2Head of Brain & Spine Surgery, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Abstract

Stuttering stroke is defined as waxing and waning focal neurological deficits with or without return to a normal baseline. We report a case of a 47-year-old female with diabetes mellitus and systemic hypertension who presented with recurrent cerebrovascular symptoms secondary to severe left common carotid artery stenosis. The patient underwent successful left carotid endarterectomy with favourable postoperative recovery.

Key words: Stuttering stroke; Diabetes Mellitus; Recurrent cerebrovascular symptoms; Arteriotomy; Carotid endarterectomy

Introduction

Cerebrovascular accidents (strokes) are a leading cause of morbidity and mortality worldwide. Carotid artery stenosis, often secondary to atherosclerosis, is among the most common aetiologies. Early diagnosis and appropriate intervention are crucial to prevent recurrent ischemic events. This report highlights a case of left common carotid artery stenosis presenting with a relatively rare “Stuttering” cerebrovascular events, managed surgically with carotid endarterectomy.

Case Presentation

A 47-year-old female, known case of diabetes mellitus and systemic hypertension (on regular medication), presented to the emergency department on 06/09/2025 with complaints of slurring of speech, inability to move the right upper and lower limbs, giddiness, fall, headache, and decreased activity lasting for more than 8 hr.

She had a previous history of two episodes of speech disturbance and subtle right sided limbs weakness, which had resolved spontaneously a weeks ago.

Clinical Examination

Vitals: Stable, BP 160/100

Neurological Status

  • GCS: E4V4M6
  • Pupils: Bilateral 2.5 mm, reactive to light
  • Right hemiplegia – at admission
  • Dysphasia – Broca’s present
  • Headache present

Investigations

Blood Investigations

  • Routine blood investigations: Within normal limits
  • Lipid profile: Cholesterol 350
  • Homocysteine normal

Imaging

CT Brain

Fig 1 (a) & (b): Hypodensity appearance present in left parietal region

MRI Brain (06/09/2025)

Fig 2 (a) & (b): Acute disseminated infarct in the left parieto-occipital cortex

CT Cerebral and Carotid Angiography (06/09/2025)

  • Hypo dense plaque/thrombus involving the distal arch of the aorta.
  • Focal hypo dense plaque in mid-left common carotid artery causing 80–90% luminal narrowing
  • Hypo plastic left vertebral artery. Fig (3)

Fig (3)

Fig (5): At the level of plaque -Left CCA more than 70 % of stenosis seen (green arrow)

Fig (6): Above the plaque level

Management

Initial Treatment

Admitted to Neuro ICU for close monitoring (GCS, HR, and new deficits)

Dual antiplatelet therapy (DAPT):

  • Aspirin 150 mg OD
  • Clopilet 75 mg OD

Further Evaluation

  • Echocardiography: Normal LV function
  • Additional blood tests: APLA profile, homocysteine, Vitamin B12 levels – all normal

The patient showed good clinical improvement with motor power improving to 4/5 and speech becoming normal. But she had frequent waxing and waning episodes of motor weakness and frequent transient speech deficits.

Fig (7) (a) & (b): Multiple small new infarct in left side of the brain and mild mass effect

Indications for surgery

  • Initially, the patient presented with motor dysphasia and right sided hemiplegia This showed improvement after observation and initiation of medical treatment.
  • However, after 24 hr, her speech disturbance worsened again and improved within a short time. Her motor power also improved to 4/5.
  • She developed another episode of worsening speech deficit. Repeat MRI brain revealed multiple new small lacunar infarcts on the left side.
  • This waxing and waning happened in spite of best medical practices.
  • Hence, a decision was made to proceed with left carotid endarterectomy to preserve remaining neurological functions (mainly speech) and prevent further clinical deterioration or plaque dislodgement.

Surgical Intervention

Procedure: Left Carotid Endarterectomy (11/09/2025)

Anaesthesia: General anaesthesia

Operative Steps

  • Patient in supine position with head tilted to the right
  • Incision made along the anterior border of the left sternocleidomastoid muscle
  • Carotid sheath opened and carotid artery carefully delineated (noted to be thickened and severe adhesions present)
  • Distal and proximal clamps applied
  • Arteriotomy performed; good backflow noted
  • Whitish plaque (~1.5–2 cm) excised and sent for histopathological examination
  • Arteriotomy closed with 6-0 Prolene suture
  • Haemostasis achieved and wound closed in layers with non-suction drain.

Postoperative Course

  • Shifted to Neuro HDU for close monitoring of BP and sensorium
  • Blood sugar: >200 mg/dL; physician initiated insulin infusion, later tapered and stopped after achieving control
  • Physiotherapy: Initiated (limb and spirometry exercises)
  • Gradual clinical improvement with stable vitals and improving right hemiplegia, so patient was shifted to ward.

Ward stay

The patient was managed in the ward with aggressive physiotherapy, speech and swallow follow up. She made good recovery.

Biopsy report: Histology features consistent with fibrin clot

She was discharged on the fifth post op day with following status,

  • Conscious and oriented
  • Right hemiplegia improving (Power 4+/5), ambulant with minimal support,
  • Speech improving – coherent appropriate slowed speech
  • Swallowing well
  • Ambulated with minimal support
  • No new neurological deficits

Discussion

Carotid artery stenosis contributes significantly to ischemic stroke, particularly in patients with vascular risk factors such as diabetes and hypertension. Early recognition and imaging using carotid Doppler or angiography are vital. Medical management with dual antiplatelet and anticoagulation is first-line treatment.

Guidelines for Carotid endarterectomy suggest the following criteria:

  1. Symptomatic patients with 50–60% carotid artery stenosis – usually within 2 weeks.
  2. Asymptomatic patients with more than 70% carotid artery stenosis.

If either of these criteria are present, immediate surgical management is recommended.

However, there is no clear-cut guidelines for stuttering stroke. Most guidelines suggest thrombolysis, dual anti platelet therapy, anticoagulation or even BP modifications for managing stuttering stroke.

Conclusion

Although most of the treatment protocols suggest medical management for stuttering strokes, in our patient as there was progressive newer clinical worsening the decision to do a Carotid Endarterectomy was taken. The patient made good recovery thus justifying the procedure.

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