Faculty Bibliography

Patients or Programs: An 82-year-old woman with supraventricular tachycardia managed with carotid sinus massage. Program Description: The patient is an 82-year-old woman with medical history of hypertension, coronary artery disease, abdominal aortic aneurysm, and carotid artery stenosis after right carotid artery endarterectomy and who developed supraventricular tachycardia and presented to her outpatient clinic. Carotid sinus massage was implemented with termination of the arrhythmia. The patient subsequently began to complain of weakness in her left upper and lower extremity. The patient was transferred to an emergency department where examination revealed dysarthria, left lower facial palsy, and left hemiparesis. Setting: Acute rehabilitation hospital. Results: Magnetic resonance imaging revealed multiple rightsided acute infarctions of embolic etiology and subtle atherosclerosis of the right common carotid artery. The patient was stabilized on the neurology service and subsequently was admitted to a rehabilitation program where her dysarthria resolved and she regained strength in her left upper extremity. The patient was discharged with a mild residual weakness of her left hand, and functionally she was ambulating 300 ft with modified independence. Discussion: There have been few case reports that note neurologic complications after carotid sinus massage. Two large prospective studies that review complications after carotid sinus massage report neurologic rates from 0.1%-0.17%. To our knowledge, this is the first reported case of an embolic stroke after carotid sinus massage on a surgically treated carotid artery. In a background that included prior carotid artery endarterectomy and lack of bruits on carotid auscultation, there remains sufficient risk to embolize atherosclerotic disease and the potential exists for iatrogenic cerebral infarction. Conclusions: Physicians should only use vagal maneuvers in patients whose comorbidities permit. In an elderly population, especially those who have undergone carotid artery endarterectomies or other surgical procedures that indicate the severity of their atherosclerosis, carotid sinus massage should be implemented sparingly to terminate supraventricular tachycardia