When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Carotid artery stenosis

Last reviewed: 3 Apr 2025
Last updated: 04 Jun 2024

Summary

Definition

History and exam

Key diagnostic factors

  • asymptomatic
  • cervical bruit
  • focal neurologic deficit lasting >24 hours (i.e., stroke)
  • focal neurologic deficit lasting <24 hours (i.e., transient ischemic attack [TIA])
Full details

Other diagnostic factors

  • transient visual symptoms
Full details

Risk factors

  • older age
  • smoking
  • history of cardiovascular disease
  • history of hypertension
  • history of hypercholesterolemia
  • diabetes
Full details

Diagnostic tests

1st tests to order

  • duplex ultrasonography
  • computed tomography angiography (CTA) of head, neck, and chest
Full details

Tests to consider

  • magnetic resonance angiography (MRA) of head, neck, and chest
  • CT brain
  • MRI brain
Full details

Treatment algorithm

ACUTE

asymptomatic carotid stenosis <70%

asymptomatic carotid stenosis ≥70%: good surgical candidate

asymptomatic carotid stenosis ≥70%: poor surgical candidate

symptomatic

ONGOING

bilateral carotid stenosis

carotid restenosis

Contributors

Authors

Brajesh K. Lal, MD, FACS

Professor of Vascular Surgery

University of Maryland School of Medicine

Professor of Neurology

Mayo Clinic

Chief of the Vascular Service

Baltimore VA Medical Center

Baltimore

MD

Disclosures

BKL declares that he has a grant from the National Institutes of Health, Bethesda, MD, USA to conduct a multicenter study comparing revascularization to medical management for asymptomatic carotid stenosis.

​​Richard Bulbulia, MA, MD, FRCS

Associate Professor and Consultant Vascular Surgeon

Clinical Trial Service Unit and MRC Population Health Research Unit

Nuffield Department of Population Health

University of Oxford

Oxford

UK

Disclosures

RB declares that he has no competing interests.

Acknowledgements

Dr Brajesh K Lal and Dr Richard Bulbulia would like to gratefully acknowledge Professor Martin M Brown, a previous contributor to this topic.

Peer reviewers

Tristan RA Lane, ​MBBS, BSc, PhD, FRCS

Consultant Vascular Surgeon

Cambridge Vascular Unit

Addenbrooke's Hospital

Cambridge University Hospital Trust

Cambridge

Honorary Senior Clinical Lecturer, Section of Vascular Surgery

Department of Surgery and Cancer

Imperial College London

UK

Disclosures

TRAL declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Circulation. 2011 Jul 26;124(4):e54-130.Full text  Abstract

Naylor R, Rantner B, Ancetti S, et al. Editor's choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the management of atherosclerotic carotid and vertebral artery disease. Eur J Vasc Endovasc Surg. 2023 Jan;65(1):7-111.Full text  Abstract

AbuRahma AF, Avgerinos ED, Chang RW, et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. J Vasc Surg. 2022 Jan;75(1s):4S-22S. Abstract

North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991 Aug 15;325(7):445-53.Full text  Abstract

Grotta JC. Clinical practice. Carotid stenosis. N Engl J Med. 2013 Sep 19;369(12):1143-50. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Carotid artery stenosis images
  • Differentials

    • Carotid dissection or subintimal hematoma
    • Thrombotic occlusion of the carotid artery resulting from plaque rupture
    • Fibromuscular dysplasia
    More Differentials
  • Guidelines

    • European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease
    • European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease
    More Guidelines
  • Patient information

    Carotid artery stenosis: what is it?

    Carotid artery stenosis: what treatments work?

    More Patient information
  • Videos

    Carotid bruit

    More videos
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer