Carotid artery stenosis

D: Narrowing of the carotid artery by atherosclerosis, a common cause of stroke. ^^

A: Atheromatous plaque development in the region of the common carotid bifurcation.

A/R: Hypercholesterolemia, hypertension, DM and smoking are all strong risk ^^ factors for carotid artery disease.

E: Common, affecting men more than women with increasing incidence with age.

H: May be asymptomatic.

TIAs or CVAs (responsible for 25-30%).

Amaurosis fugax (temporary unilateral vision loss - 'like a curtain coming down' caused by embolism into the ophthalmic artery, the first branch off the internal carotid artery).

E: Often normal. There may be a carotid bruit heard; however, this often does not reflect the degree of stenosis.

Signs of CVA (e.g. dysarthria, dysphasia, weakness in limbs). Signs of systemic vascular disease.

P: The carotid artery bifurcation is an area of the vascular tree where atherosclerosis is common. In combination with systemic risk factors, local haemo-dynamics, including low shear stress and " turbulence affecting the outer walls opposite the flow divider predispose to atheroma development, luminal narrowing and risk of plaque rupture, thrombosis or embolism (see Fig. 6).

_I: Duplex Doppler ultrasound: Non-invasive imaging to assess degree of stenosis.

Angiography: Invasive procedure carrying a risk of precipitating a stroke (1% CVA, 4% TIA), but allows more accurate assessment of stenosis severity. MRA: Also non-invasive.

M: Medical: For asymptomatic or < 70% internal carotid artery stenosis; at present, recommended treatment is medical, i.e. low-dose aspirin, stopping smoking and treatment of other risk factors, hypercholesterolaemia, hypertension and diabetes.

Surgical: For symptomatic (within last 6 months) internal carotid artery stenosis > 70-99% or if the plaque is ulcerated, carotid endarterectomy has been shown to reduce risk of stroke (ECST and NASCET). Trials are underway to ascertain if asymptomatic stenosis should be surgically treated and also comparing local and general anaesthesia.

Angioplasty +/— stenting: The CAVATAS trial shows endovascular treatment has similar major risks and effectiveness at preventing stroke over 3 years but a greater rate of re-stenosis and immediate post-op stroke. The CREST and ICSS trial are underway, comparing endarterectomy and endovascular stenting.

_C Complications of disease: Cerebrovascular attacks.

Complications from surgery: Cardiac ischaemia or infarction (3%), cranial nerve injury (2-7%, usually recurrent laryngeal nerve or hypoglossal nerves), haematoma with or without airway compromise, hypertension, hypotension, peri-operative stroke (1-5%). The peri-operative mortality rate is 0.5-1.8%.

P: For carotid artery stenosis of > 70%, annual stroke rate is 10-20%. If untreated, asymptomatic stenosis of 50% has an annual stroke risk of 1%. If surgically corrected: Results in a six- to eightfold reduction in risk of stroke compared to best medical therapy alone in patients with severe stenosis.

Carotid Artery Stenosis
Fig. 6 Arteriogram showing atheromatous carotid arteries and right carotid stenosis.
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