Stroke is the fifth leading cause of death, and the leading cause of disability in the US. Carotid artery stenosis causes approximately 10% to 15% of all ischemic strokes.
Atherosclerotic plaque in the cervical carotid artery is the most common cause. Plaque disruption and atheroembolization 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 revascularization of moderate- or high-grade recently symptomatic carotid artery stenosis prevents future stroke.
The benefit of revascularization 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 hemodynamics 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 embolize to occlude intracranial arteries, causing a transient ischemic attack or stroke, or occlude retinal arteries to cause transient monocular blindness (amaurosis fugax) or retinal strokes.
History and exam
Key diagnostic factors
- cervical bruit
- focal neurologic deficit lasting >24 hours (i.e., stroke)
- focal neurologic deficit lasting <24 hours (i.e., transient ischemic attack [TIA])
Other diagnostic factors
- transient visual symptoms
- older age
- history of hypertension
- history of cardiovascular disease
- history of hypercholesterolemia
1st investigations to order
- duplex ultrasonography
- computed tomography angiography (CTA) of head, neck, and chest
Investigations to consider
- magnetic resonance angiography (MRA) of head, neck, and chest
- cervical angiography
- CT brain
- MRI brain
asymptomatic carotid stenosis <70%
asymptomatic carotid stenosis ≥70%: good surgical candidate
asymptomatic carotid stenosis ≥70%: poor surgical candidate
bilateral carotid stenosis
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.
- Carotid dissection or subintimal hematoma
- Thrombotic occlusion of the carotid artery resulting from plaque rupture
- Fibromuscular dysplasia
- Screening for asymptomatic carotid artery stenosis
- Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack
Carotid artery stenosis: what is it?
Carotid artery stenosis: what treatments work?More Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer