What is the diagnosis?

The symptoms are suggestive of transient ischemic attacks with recurrent amaurosis fugax and hemiparesis.

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What investigation would you arrange?

Transient ischemic attacks should be handled seriously because they can be followed by a major stroke. Causes for thromboembolism should be investigated and they include cardiac causes as well as extracranial and intracranial cerebrovascular diseases. An ECG should be done to note for any arrhythmia such as atrial fibrillation. An echocardiogram would be useful to rule out any intracardiac mass or thrombus, and any valvular or structural heart disease that may predispose to thromboembolism. A CT or MRI brain would be useful to rule out any intracranial lesions and evidence of old or recent strokes. An ultrasound Doppler study of the carotid arteries would be a useful screening test for any extracranial carotid stenosis. If indicated, a contrast enhanced MRI angiography would be useful to delineate the extracranial and intracranial cerebrovascular anatomy. Digital subtraction angiography via catheter technique remains the gold standard for the diagnosis of vascular anatomy.

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Medical therapy includes antiplatelet therapy, lipid lowering therapy with statins, use of angiotensinconverting enzyme inhibitors, and tight control of other atherosclerosis risk factors such as diabetes, hypertension and smoking. Despite a significant reduction of stroke rates with these measures, medical therapy is shown to be inferior to carotid endarterectomy for symptomatic carotid stenosis, which has been the gold standard for revascularization therapy. In recent years, carotid angioplasty and stenting has been emerging as another treatment option for carotid stenosis, especially in those patients with high surgical risk, severe cardiac comorbidities, unfavorable surgical anatomies, previous radiation therapy to the neck and restenosis after prior endarterectomy. The advantages of carotid angioplasty and stenting include minimal invasiveness and early discharge and rehabilitation. In experienced hands, carotid angioplasty and stenting yields a high successful rate and good reduction of stroke rate.

Severe carotid stenosis

Post-carotid angioplasty and stenting

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What is the diagnosis?

The clinical diagnosis is keloids, secondary to acne vulgaris.

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Would you perform a skin biopsy to confirm the diagnosis?

Diagnostic skin biopsy is not warranted unless there is clinical doubt because injury will induce new keloids.

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What are the sites usually being affected?

Keloids may form on any part of the body especially shoulders, upper chest and back, ear lobes and mandibular areas.

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How can one differentiate it from hypertrophic scars?

Hypertrophic scars are confined to the site of the original injury and they tend to regress (becoming flatter and softer). Keloids may extend beyond the site of injury in a clawlike fashion and can be tumour-like.

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What are the treatment options?

Individuals who are prone to keloids should avoid trauma (including cosmetic procedures) to their skin. In patients with acne, more aggressive treatment of acne should be given. Treatment options of keloids include potent topical steroids, intralesional corticosteroids, cryotherapy, surgery with postsurgical radiotherapy, pulsed-dye laser therapy, and silicone gel sheets.

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