Updated: 2/6/2020

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
  • 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
  • Associated conditions
    • peripheral artery disease
    • coronary artery disease
  • Prognosis
    • ↑ survival with appropriate treatment
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
Studies
  • 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
 

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(M3.CV.15.56) A 71-year-old woman presents with a transient episode of right arm and hand weakness that resolved in approximately one hour. Her symptoms started while she was gardening. Her past medical history is notable for hypertension, diabetes, anxiety, and dyslipidemia. Her current medications include insulin, metformin, and fluoxetine. Examination reveals a left carotid bruit. Ultrasound duplex of her carotid arteries demonstrates right and left carotid stenosis of 35% and 50%, respectively. Which of the following is the best next step in management? Tested Concept

QID: 103347
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Aspirin

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Bilateral carotid endarterectomy

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Left carotid endarterectomy only

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Observation

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Warfarin

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