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Updated: Dec 8 2021

Carotid Stenosis

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  • Snapshot
    • A 60-year-old man presents with a visual disturbance that occurred one day ago. He reports that he experienced a “curtain coming down” over his left eye that lasted a few minutes. His past medical history includes long-standing type 2 diabetes mellitus, hypertension, coronary artery disease, and a 20 pack-year smoking history. On physical exam, he has bilateral carotid bruits. An ultrasound duplex of his carotids shows bilateral stenosis with 40% on the right and 75% on the left.
  • Introduction
    • Clinical definition
      • carotid artery narrowing, or stenosis, caused by atherosclerotic plaques
    • Associated conditions
      • peripheral artery disease
      • coronary artery disease
  • Epidemiology
    • Demographics
      • male > female
    • Risk factors
      • family history
      • hyperlipidemia
      • smoking
      • hypertension
      • diabetes
      • older age
  • Etiology
    • Atherosclerosis
    • Pathogenesis
      • build up of atherosclerotic plaques in the carotid arteries causes narrowing of the lumen
        • free cholesterol creates a necrotic core, contained by a weak fibrous cap
        • enlargement of the necrotic core can disrupt the fibrous cap and cause thrombosis or embolization
  • Presentation
    • Symptoms
      • may be asymptomatic
      • if symptomatic, usually presents as transient ischemic attack or stroke
        • transient visual disturbance (amaurosis fugax)
        • unilateral muscle weakness or paresthesia
        • dizziness
        • tinnitus
        • aphasia
    • Physical exam
      • carotid bruit (typically present if there’s 60-70% stenosis)
      • motor or sensory deficits
  • Imaging
    • Duplex Doppler ultrasound
      • indications
        • best initial test
      • findings
        • level of stenosis
        • > 50% is moderate
        • > 70% is severe
    • Angiography (magnetic resonance or computed tomography)
      • indications
        • ultrasound unavailable or findings are unclear
  • DIAGNOSIS
    • Making the diagnosis
      • based on clinical presentation and imaging
  • Differential
    • Temporal arteritis
      • distinguishing factors
        • may also present with amaurosis fugax and carotid bruit
        • however, may present with other symptoms such as headache or jaw claudication
        • ↑ inflammatory markers
        • no carotid stenosis is seen on ultrasound
  • Treatment
    • Management approach
      • screening for asymptomatic patients is not recommended
      • all patients should receive optimal therapy for the underlying cardiovascular disease, such as hypertension or hyperlipidemia
    • Conservative
      • smoking cessation
        • indication
          • for all patients
    • Medical
      • anti-platelet therapy
        • indication
          • symptomatic patients
        • drugs
          • clopidogrel
          • aspirin plus dipyridamole
      • statins
        • indication
          • for all patients
    • Operative
      • carotid artery revascularization
        • indication
          • stenosis > 70%
          • post-transient ischemic attack or stroke
        • surgeries
          • carotid endarterectomy (CEA)
            • first-line for patients who can tolerate surgery
          • carotid artery stenting
            • for patients unable to tolerate CEA
  • Complications
    • Neurological sequelae
      • central retinal artery occlusion
      • transient ischemic attack
      • stroke
      • nerve injury
        • facial nerve
          • specifically the marginal mandibular branch
        • hyopglossal nerve
        • recurrent laryngeal nerve
        • glossopharyngeal nerve
          • specifically nerve of Herin branch
        • sympathetic nerve
  • Prognosis
    • ↑ Survival with appropriate treatment
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