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
- 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
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