Stroke is the fourth and fifth leading cause of death in the UK and US, respectively, and the leading cause of disability in both countries. Carotid artery stenosis causes approximately 10% to 15% of all ischaemic strokes.
Atherosclerotic plaque in the cervical carotid artery is the most common cause. Plaque disruption and atheroembolisation into the intracranial circulation is the most common mechanism for stroke.
The majority of carotid artery stenoses are mild or moderate, and asymptomatic.
Duplex ultrasonography is a commonly used mode of diagnosis; computed tomography angiography or magnetic resonance angiography are alternatives that also help to define the anatomy if intervention is indicated.
Most patients with carotid artery stenosis should receive antiplatelet therapy, and all should receive risk factor modification.
Carotid revascularisation of moderate- or high-grade recently symptomatic carotid artery stenosis prevents future stroke.
The benefit of revascularisation for asymptomatic stenosis is less certain.
Carotid artery stenosis is a narrowing of the lumen of the carotid artery. Atherosclerotic plaque in the cervical carotid artery is the most common cause. The unique haemodynamics at the carotid bifurcation predisposes this area to atherosclerosis. The majority of patients have mild- or moderate-sized plaques, while some develop high-grade stenoses. A small percentage of plaques may rupture and embolise to occlude intracranial arteries, causing a transient ischaemic attack or stroke, or occlude retinal arteries to cause transient monocular blindness (amaurosis fugax) or retinal strokes.
History and exam
Martin M. Brown, MA, MD, FRCP
Professor of Stroke Medicine
UCL Stroke Research Centre
Department of Brain Repair and Rehabilitation
UCL Queen Square Institute of Neurology
University College London
MMB received a project grant from the Stroke Association to support the European Carotid Surgery Trial-2; he is also an author of references cited in this topic.
Professor Martin M. Brown would like to gratefully acknowledge Dr Brajesh K. Lal, the previous contributor to this topic.
BKL is an author of references cited in this topic.
Seemant Chaturvedi, MD, FAAN, FAHA, FANA, FESO
Stewart J. Greenebaum Endowed Professor of Stroke Neurology
Director, Comprehensive Stroke Program
Vice-Chair for Strategic Operations
Department of Neurology
University of Maryland School of Medicine
SC declares that he is an executive committee member of the CREST-2 study.
Mark A. Adelman, MD
Professor and Chief
Vascular and Endovascular Surgery
NYU Langone Medical Center
MAA declares that he has no competing interests.
Jeffrey E. Indes, MD, FACS
Assistant Professor of Surgery and Radiology
Yale University School of Medicine
JEI declares that he has no competing interests.
Jonathan D. Beard, ChM, Med, FRCS
Professor of Surgical Education
Consultant Vascular Surgeon
Sheffield Vascular Institute
JDB declares that he is on the Steering Committee of ICSS and ECST-2 Trials.
Ross Naylor, MBBS
Professor of Vascular Surgery
Vascular Surgery Group
Division of Cardiovascular Sciences
Leicester Royal Infirmary
RN declares that he has no competing interests.
Christos D. Liapis, MD, PhD, FACS, FRCS, FEBVS
Professor of Vascular Surgery
Head, Department of Vascular Surgery
Athens Medical Center
CDL declares that he has no competing interests.
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