Carotid Artery Stenosis


Article Author:
Erion Qaja
Prasanna Tadi


Article Editor:
Pramod Theetha Kariyanna


Editors In Chief:
Melissa Max
Danyae Lee
Manouchkathe Cassagnol


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
3/22/2019 12:59:08 AM

Introduction

The distinction between hemodynamic and embolic stroke in the setting of chronic internal carotid artery occlusion is important. Embolic symptoms are those of classic stroke or transient ischemic attack (TIA) and typically are focal. Symptoms may include a contralateral motor or sensory deficits or amaurosis. Hemodynamic symptoms may be similar to those of classic stroke or TIA, but may also be less predictable and atypical. Patients have reported symptoms such as limb shaking, retinal claudication, headache from large pulsatile external carotid artery collaterals, syncope, and generalized fatigue. One-third of all strokes are related to a cervical carotid disease. Standard risk factors for coronary and systemic atherosclerosis such as age, male sex, family history, smoking, hypertension, hyperlipidemia, sedentary lifestyle, and high dietary fat apply to this patient population. The mechanism of cervical carotid stroke is usually embolization from the carotid bifurcation plaque, but hemodynamic compromise from stenosis may also play a role. The risks of embolization and hemodynamic compromise increase with increasing carotid artery stenosis.[1][2][2][3]

Etiology

Carotid artery stenosis is a consequence of systemic atherosclerotic disease. Thus, any risk factor predisposing a patient to progressive atherosclerosis can potentially manifest itself as stenosis of the carotid artery with resultant ischemic stroke and or TIA like symptoms. Risks include smoking, hyperlipidemia, male gender, and age.[4][5][6][7]

In a minority of patients, especially young females with stenosis of the carotid artery, fibromuscular dysplasia (FMD) plays a much more significant role. Fibromuscular dysplasia is a noninflammatory, nonatherosclerotic process that most commonly affects the carotid and renal arteries, although it can occur elsewhere in medium-sized vessels. Fibromuscular dysplasia usually occurs in the mid and distal internal carotid artery, sometimes extending into the intracranial region. Aneurysms may be a component of the disease process as well.

Epidemiology

Symptomatic internal carotid artery occlusion has an incidence of six per 100,000, though the rate of asymptomatic chronic occlusion is unknown and may be higher. Internal carotid artery occlusion is a known risk factor for stroke in the United States. In fact, one-third of all the strokes are related to carotid occlusive disease. Stroke ranks third among all causes of death in the United States, behind heart disease and cancer. Annually about 55,000 more women are affected compared with men, and approximately 60% of all stroke deaths occur in females. African Americans and Mexican Americans have a higher risk of stroke compared with Caucasians. Thus diagnosis, prevention, and treatment of the carotid artery stenosis play a pivotal role in stroke prevention.

Pathophysiology

Total internal carotid artery occlusion results from thrombosis in the setting of chronic stenosis. Cardiogenic embolization to a normal carotid bifurcation or carotid dissection may also cause total occlusion of the internal carotid artery occlusion. Acute occlusion may result in a carotid territory stroke. A previously asymptomatic chronic internal carotid artery occlusion may become symptomatic if related to embolic or hemodynamic issues. Embolism may occur from the ipsilateral external carotid artery via collaterals to the cerebral circulation. It may also occur when there is occult patency of the occluded internal carotid artery occlusion, which then serves as the source of embolic material. Hemodynamic insufficiency may occur when any condition that interferes with cerebral perfusions such as orthostasis, hypotension, volume depletion, or cardiac failure is superimposed on the carotid occlusion, especially when the contralateral carotid disease is significant.

History and Physical

Usually, patients will present with recent stroke (slurred speech, cranial nerve deficits, limb weakness, or visual disturbances) which either have resolved or should be expected to improve within 48 hours otherwise known as transient ischemic attack. Typically, history and physical are notable for a patient in their 70s and 80s because they may have a history of smoking, high lipid profile, sedentary lifestyle. It is imperative to realize that carotid artery atherosclerotic disease is not a segmental disease, rather it has the propensity to involve other arteries in the human body. Of concern are the coronary arteries. Hence, it is prudent for this patient to undergo a cardiac evaluation should surgical intervention be contemplated in treating the degree of stenosis. 

Evaluation

Evaluation should include but not be limited to a thorough physical exam. The physical should be coupled with diagnostic imaging (CT head), followed by telemetry floor admission, as only third of ischemic strokes are due to carotid artery disease, the remaining is due to the cardiac embolic phenomenon. Thus, consultation with a stroke specialist like a neurologist, as well as a cardiologist is of paramount importance.

Regarding diagnosing carotid artery stenosis, one usually starts with a least invasive inexpensive test such as Carotid Duplex. This examination typically shows a high-resistance signal in the carotid bulb and the very proximal internal carotid artery. Distally, there are no Doppler signals audible in the carotid artery. As a confirmatory test, some form of contrast examination such as digital subtraction arteriography, magnetic resonance arteriography (MRA), or computed tomographic (CT) arteriography is required to confirm the diagnosis and plan a surgical approach. Gadolinium-enhanced MRA is better for differentiating high-grade stenosis than the time of flight which overestimates the stenosis in some times. Conventional angiography is the gold standard for the diagnosis. 

Treatment / Management

Acute symptomatic carotid occlusion should be treated with urgent revascularization in select cases with immediate presentation. This can be accomplished with carotid endarterectomy (CEA) or interventional techniques including thrombolysis. In the setting of chronic total internal carotid artery occlusion (ICA) occlusion, medical management is preferred over revascularization. However, several special clinical indications exist for procedural intervention. Ipsilateral hemodynamic symptoms in the setting of ipsilateral ICA occlusion and contralateral ICA stenosis may benefit from contralateral ICA revascularization to ameliorate hemodynamic insufficiency. Ipsilateral embolic symptoms in the setting of ipsilateral ICA occlusion and ipsilateral external carotid occlusion (ECA) stenosis may be treated with ipsilateral ECA revascularization to eliminate the source of embolization, which occurs via enlarged ECA collaterals; ligation of the ipsilateral ICA also eliminates a source for embolization. Finally, ipsilateral hemodynamic symptoms in the setting of a patent contralateral carotid system, ipsilateral ICA occlusion, and ipsilateral ECA stenosis indicate ipsilateral ECA revascularization to improve ipsilateral hemodynamic flow.[8][9][10][11]

For patients with symptomatic carotid occlusion (50-99%), if carotid endarterectomy was done within 2 weeks of symptoms, the number needed to treat for preventing one stroke is 5. The number needed to treat increases to 125 if it has done more than 2 weeks of symptoms or stroke onset. CEA is beneficial if the symptoms are non-disabling, no tandem stenoses, high-grade stenosis. CEA can be deferred if the stroke is too big, contralateral carotid occlusion, hemodynamic instability, and contralateral laryngeal palsy is a relative contraindication. There is more myocardial infarction associated with CEA. 

Carotid artery stenting (CAS) is preferred in symptomatic carotid occlusion (50-99%) with multiple comorbidities, tracheostomy, patients with prior neck radiation or dissection. Usually, there is an increased risk of stroke after the CAS. Due to the advancement of the stents and technique, CAS is comparable to CEA in most instances. CREST-2 study is ongoing and will shed more light in this important area. 

Pearls and Other Issues

There are no specific criteria for surveillance of patients with chronically occluded ICA, nor are there criteria to specify the degree of ECA stenosis by duplex ultrasound. A reasonable regimen is to follow the patient clinically every six months to a year, with or without duplex study. The development of symptoms indicates investigation with imaging of some kind to see if cerebrovascular revascularization is indicated.

Enhancing Healthcare Team Outcomes

The management of patients with carotid artery stenosis is with a multidisciplinary team that consists of a nurse practitioner, primary care provider, internist, vascular surgeon, an interventional radiologist, and a neurologist. When a patient is discovered to have carotid stenosis, a referral should be made to the neurologist who can determine if treatment is required. Today, the carotid stenosis can be managed via surgery or stenting; both have similar outcomes in the short term. The treatment also greatly reduces the risk of a future stroke. [12]


  • Image 1653 Not availableImage 1653 Not available
    Contributed by Scott Dulebohn, MD
Attributed To: Contributed by Scott Dulebohn, MD

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Carotid Artery Stenosis - Questions

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Which of the following cranial nerves is most commonly affected during carotid endarterectomy?



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A 65-year-old male with hypertension, diabetes mellitus, and a prior myocardial infarction is found to have profound weakness in his left arm. Examination of his eyes reveals that he has Hollenhorst plaques. What is the most likely diagnosis?



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A 68-year-old female who has a long history of smoking and hypertension presents for a routine follow-up for her hypertension. She takes lisinopril/hydrochlorothiazide and aspirin daily. An exam reveals a blood pressure at goal and a left-sided carotid bruits. She denies a history of amaurosis fugax, transient ischemic attack, or stroke. An ultrasound is done the following week and reveals that she has 50% stenosis of her left internal carotid artery. What is the best next step in management?



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A 71-year-old male presents with a 1-hour history of slurred speech and confusion. Emergency MRA reveals 95% carotid artery stenosis. Which of the following is most appropriate for the management of this patient?



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A 59-year-old with moderate hypertension and emphysema presents with transient ischemic attacks. Ultrasound of the carotids reveals 75% narrowing at the bifurcation. Which of the following is the most appropriate treatment recommendation?



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Aspirin is sufficient in which of the following patients with left carotid artery stenosis?



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A patient with stable angina and three vessel coronary artery disease also has a 80 percent lesion of his right internal carotid artery. What is the best method to manage this patient?



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A patient with a previous transient ischemic attack (TIA) has a significant carotid lesion. Cardiac catheterization reveals critical triple coronary vessel disease. What should be done?



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A 75-year-old male is relatively healthy with hypertension and diabetes mellitus well controlled with medications. He has a bruit of the left carotid artery during his physical. There is no history of prior transient ischemic attack (TIA) or stroke. A carotid ultrasound shows 85% stenosis on the left side and 60% on the right. Which of the following statements is not correct concerning the decision to perform a carotid endarterectomy (CEA)?



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A 65-year-old asymptomatic female presents after having a screening carotid duplex showing 60% stenosis on the right. Her past medical history is remarkable for hypertension well-controlled on hydrochlorothiazide. Her exam is normal except for a right carotid bruit. She has never smoked, and her lipid profile is normal. What is the appropriate next step?



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What statement is true concerning atherosclerotic vascular disease of the head and neck?



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Ipsilateral filling of a proximally occluded internal carotid artery (ICA) is most commonly accomplished by which collateral arteries?



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Which of the following statements with regards to carotid artery disease is not true?



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Carotid Artery Stenosis - References

References

Doonan RJ,Abdullah A,Steinmetz-Wood S,Mekhaiel S,Steinmetz OK,Obrand DI,Corriveau MM,Mackenzie KS,Gill HL, Carotid Endarterectomy Outcomes in the Elderly: A Canadian Institutional Experience. Annals of vascular surgery. 2019 Feb 22;     [PubMed]
Morales MM,Anacleto A,Filho CM,Ledesma S,Aldrovani M,Wolosker N, Peak systolic velocity for calcified plaques fails to estimate carotid stenosis degree. Annals of vascular surgery. 2019 Feb 22;     [PubMed]
Savardekar AR,Narayan V,Patra DP,Spetzler RF,Sun H, Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery. Neurosurgery. 2019 Feb 25;     [PubMed]
Coelho AP,Lobo M,Nogueira C,Gouveia R,Campos J,Augusto R,Coelho N,Semião AC,Canedo A, Overview of evidence on risk factors and early management of acute carotid stent thrombosis during the last two decades. Journal of vascular surgery. 2019 Mar;     [PubMed]
Texakalidis P,Chaitidis N,Giannopoulos S,Giannopoulos S,Machinis T,Jabbour P,Rivet D,Reavey-Cantwell J,Rangel-Castilla L, Carotid Revascularization in the Elderly: a Systematic Review and Meta-analysis. World neurosurgery. 2019 Feb 21;     [PubMed]
Tokugawa J,Kudo K,Mitsuhashi T,Yanagisawa N,Nojiri S,Hishii M, Surgical Results of Carotid Endarterectomy for Twisted Carotid Bifurcation. World neurosurgery. 2019 Feb 19;     [PubMed]
Wangqin R,Krafft PR,Piper K,Kumar J,Xu K,Mokin M,Ren Z, Management of De Novo Carotid Stenosis and Postintervention Restenosis-Carotid Endarterectomy Versus Carotid Artery Stenting-a Review of Literature. Translational stroke research. 2019 Feb 22;     [PubMed]
Gaba K,Bulbulia R, Identifying asymptomatic patients at high-risk for stroke. The Journal of cardiovascular surgery. 2019 Feb 20;     [PubMed]
Lamanna A,Maingard J,Barras CD,Kok HK,Handelman G,Chandra RV,Thijs V,Brooks DM,Asadi H, Carotid artery stenting: Current state of evidence and future directions. Acta neurologica Scandinavica. 2019 Jan 4;     [PubMed]
Ong CT,Wong YS,Sung SF,Wu CS,Hsu YC,Su YH,Hung LC, Progression of Mild to Moderate Stenosis in the Internal Carotid Arteries of Patients With Ischemic Stroke. Frontiers in neurology. 2018;     [PubMed]
Li Y,Zhu G,Ding V,Huang Y,Jiang B,Ball RL,Rodriguez F,Fleischmann D,Desai M,Saloner D,Saba L,Hom J,Wintermark M, Assessing the Relationship between Atherosclerotic Cardiovascular Disease Risk Score and Carotid Artery Imaging Findings. Journal of neuroimaging : official journal of the American Society of Neuroimaging. 2019 Jan;     [PubMed]
Brott TG,Calvet D,Howard G,Gregson J,Algra A,Becquemin JP,de Borst GJ,Bulbulia R,Eckstein HH,Fraedrich G,Greving JP,Halliday A,Hendrikse J,Jansen O,Voeks JH,Ringleb PA,Mas JL,Brown MM,Bonati LH, Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data. The Lancet. Neurology. 2019 Feb 6;     [PubMed]

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