Introduction Up to 9% of patients with stroke or transient ischemic attacks (TIA) studied in hospital-based series will have a symptomatic internal carotid artery (ICA) occlusion . These patients will have a long-term risk of stroke of approximately 4%–6% per year. Clinical features In terms of clinical features, the initial symptoms at the time of ICA occlusion can be due to watershed (WS) areas of infarction or territorial infarcts. In many patients, the first sign of carotid artery occlusive disease is an embolus to the middle cerebral artery (MCA) that causes a small or substantial MCA territory infarct. Evaluation of patients with MCA territory infarction reveals a very significant number with carotid artery occlusive disease and carotid artery dissection. Common symptoms of carotid territory ischemia are motor and sensory involvement of the contralateral extremities, isolated motor dysfunction, isolated sensory loss, and least commonly, isolated dysphasia. Fractional arm weakness, such as greater involvement of the hand and arm compared to the proximal upper extremity, is common. This is presumably due to the portion of the homunculus representing the hand and arm being in the distal portion of the carotid circulation. Hand weakness and dysphasia is a common pattern seen in TIAs due to left ICA disease. With internal WS infarction, a different pattern with greater proximal extremity weakness compared to distal extremity weakness is observed.
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