Carotid artery stenosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Carotid arterial stenosis is a narrowing of the lumen of the carotid artery, usually by atheroma (a fatty lump or plaque causingatherosclerosis). Atheroma’s may cause transient ischemic attacks (TIAs) and cerebrovascular accidents (CVAs) as it obstructs the bloodstream to the brain. It also has the potential to generate emboli (blood clots) that obstruct the cerebral arteries. The narrowing can either be asymptomatic (causing no medical problems) or presents with symptoms such as TIAs and CVAs.
Pathophysiology
Embolism of atherosclerotic lesions in the carotid is the most common mechanism of stroke in patients with carotid artery disease. Thrombosis of the cerebral arteries is also a possible, less common cause of stroke.
Causes
The most common cause of carotid artery stenosis is atherosclerosis. The process of atherosclerotic plaque formation starts in the early adulthood but it takes years for it to cause symptoms. Uncommon causes include Marfan’s syndrome and fibromuscular dysplasia.
Risk Factors
Risk factors for carotid artery stenosis are almost similar to those for cerebrovascular accident (CVA), coronary heart disease (ACS) and peripheral vascular disease (PVD). Common risk factors include hypertension, smoking, advanced age and abnormal cholesterol levels including lowered HDL levels in the blood.
Screening
Screening for carotid disease is done before cardiac surgery.
Diagnosis
Electrocardiogram
The EKG may show evidence of an old infarct or myocardial ischemia. The most common cause of death post-CEA is a myocardial infarction.
CTA
CTA can be used for further imaging to assess whether the artery is still patent, in order to further assess for treatment options.
MRA
If there is doubt whether the narrowing is still patent (open to blood flow) and the patient is to be assessed for treatment, the next imaging option would either be computed tomography angiogram (CTA) or a magnetic resonance imaging angiogram (MRA). MRA tends to over-estimate the stenosis, but can be used in collaboration with duplex to evaluate the carotid stenosis.
Echocardiography or Ultrasound
Carotid stenosis is usually diagnosed by ultrasound scan of the neck arteries. This is the first imaging option and usually used for follow up and observation as it involves no radiation and no contrast agents that may cause allergic reactions.
Treatment
Medical Therapy
Medical therapy for carotid artery stenosis includes; antihypertensives to control blood pressure, antiplatelet agents, management of lipids, and management of diabetes through tight control of blood glucose levels. Management also includes assessment of the global cardiovascular risk, as well as a yearly surveillance ultrasound, and educating the patient about the symptoms of TIA and stroke.
Surgery
Carotid endarterectomy and stenting are two methods of surgical treatment for carotid artery stenosis.
Secondary Prevention
Secondary prevention for carotid artery stenosis include the cessation of smoking. Other preventative methods which can also be treatment measures are tight control of blood pressure, management of diabetes, and management of lipids.
References
Historical Perspective
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References
Classification
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References
Pathophysiology
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]
Overview
Embolism of atherosclerotic lesions in the carotid is the most common mechanism of stroke in patients with carotid artery disease. Thrombosis of the cerebral arteries is also a possible, less common cause of stroke.
Pathophysiology
- Atherosclerotic lesions are commonly located within 2 cm from the bifurcation of the common carotid artery, usually on the posterior wall of the artery. These plaques can extend caudally into the common carotid artery.
- The presence of atherosclerotic plaque is a risk for developing a stroke, regardless of its location.
- In addition to compromising the flow to the brain, the plaque can rupture and a superimposed thrombus can develop on the atheroma further exacerbating the stenosis.
- The emboli then travels upstream until it lodges into a cerebral artery compromising blood supply to the associated territory.
Transient Ischemic Attack
- Low flow: brief, repetitive attacks
- Embolic: single, more prolonged episodes
Total Occlusion
- When the internal carotid artery is totally occluded, it can lead to slow flow or thrombosis. The severity of symptoms depend on the adequacy of the collateral circulation.
Delayed Stroke
- Occurs many months after carotid occlusion
- From propagation of the thrombus or embolization of the clot upstream
References
Causes
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
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Overview
The most common cause of carotid artery stenosis is atherosclerosis. The process of atherosclerotic plaque formation starts in the early adulthood but it takes years for it to cause symptoms. Uncommon causes include Marfan’s syndrome and fibromuscular dysplasia.
References
Differentiating Carotid artery stenosis from other Diseases
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References
Epidemiology and Demographics
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References
Risk Factors
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Overview
Risk factors for carotid artery stenosis are almost similar to those for cerebrovascular accident (CVA), coronary heart disease (ACS) and peripheral vascular disease (PVD). Common risk factors include hypertension, smoking, advanced age and abnormal cholesterol levels including lowered HDL levels in the blood.
Risk Factors
Risk factors for carotid artery stenosis include[1]:
- Age – older age (>65 yrs) is associated with an increased risk
- Male gender
- Hypertension – blood pressure more than 140/90 mm Hg is a risk factor for carotid artery stenosis and should ideally be maintained below 140/90.
- Smoking
- Abnormal cholesterol levels – Low HDL and high LDL cholesterol
- Diabetes
- Obesity – increases the risk of development of atherosclerosis and hypertension
- Insulin resistance
- Alcohol abuse
- Cocaine abuse
- Sedentary lifestyle
- Positive family history for atherosclerosis, coronary heart disease, stroke and carotid artery stenosis
- A diet high in saturated fatty acids
References
Screening
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]
Overview
The U.S. Preventive Services Task Force (USPSTF) advises against screening in the general population for asymptomatic carotid artery stenosis (Grade D).[1] In fact, the evidence in the literature is weak regarding the benefits of treatment of asymptomatic carotid artery stenosis.[2] Screening for carotid disease might be considered before cardiac surgery.[3]
2011 American Heart Association/American Stroke Association Guidelines for the Primary Prevention of Stroke[4]
| Class III (No Benefit) |
| “1. Population screening for asymptomatic carotid artery stenosis is not recommended (Class III; Level of Evidence B). (Level of Evidence: B) ” |
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 (DO NOT EDIT)[3]
Carotid Artery Evaluation and Revascularization Before Cardiac Surgery (DO NOT EDIT)[3]
| Class IIa |
| “1. Carotid duplex ultrasound screening is reasonable before elective coronary artery bypass graft (CABG) surgery in patients older than 65 years of age and in those with left main coronary stenosis, PAD, a history of cigarette smoking, a history of stroke or TIA, or carotid bruit. (Level of Evidence: C)” |
| “2. Carotid revascularization by CEA or CAS with embolic protection before or concurrent with myocardial revascularization surgery is reasonable in patients with greater than 80% carotid stenosis who have experienced ipsilateral retinal or hemispheric cerebral ischemic symptoms within 6 months. (Level of Evidence: C)” |
| Class IIb |
| “1. In patients with asymptomatic carotid stenosis, even if severe, the safety and efficacy of carotid revascularization before or concurrent with myocardial revascularization are not well established. (Level of Evidence: C)” |
References
- ↑ Screening for Asymptomatic Carotid Artery Stenosis. U.S. Preventive Services Task Force Recommendation Statement. 2014 [1]
- ↑ Daniel E. Jonas, Cynthia Feltner, Halle R. Amick,Stacey Sheridan, et al. Screening for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Annals of internal medicine. July 2014.
- ↑ 3.0 3.1 3.2 Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL; et al. (2011). “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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery”. Circulation. 124 (4): 489–532. doi:10.1161/CIR.0b013e31820d8d78. PMID 21282505.
- ↑ Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S; et al. (2011). “Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association”. Stroke. 42 (2): 517–84. doi:10.1161/STR.0b013e3181fcb238. PMID 21127304.
Natural History, Complications and Prognosis
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References
Diagnosis
Diagnosis
Diagnostic Testing Guidelines | History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | CT | MRI | MRA | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies
Treatment
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies
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