Carotid stenosis

Background

• Narrowing of internal carotid artery, usually from atherosclerotic plaque
• Responsible for 10-20% of ischemic strokes and TIAs
• Risk factors: hypertension, diabetes, smoking, hyperlipidemia, age >65

Clinical Features

• Often asymptomatic until stroke or TIA occurs
• Symptomatic carotid stenosis:
  • Anterior circulation TIA or stroke (ipsilateral to stenosis)
  • Amaurosis fugax (transient monocular vision loss) — classic for carotid disease
  • Hemispheric symptoms: contralateral weakness, numbness, aphasia
• Carotid bruit on exam (low sensitivity and specificity — absence does NOT rule out stenosis)

Evaluation

• Carotid duplex ultrasound — first-line screening study
• CT angiography (CTA) or MR angiography (MRA) for definitive assessment
• Standard stroke workup if presenting with TIA/stroke: CT head, ECG, labs
• Screen for concurrent coronary artery disease (high comorbidity)

Management

Medical Therapy (All Patients)

• Antiplatelet therapy: aspirin or clopidogrel
• Statin therapy (high-intensity)
• Blood pressure control, diabetes management, smoking cessation

Surgical/Interventional

• Carotid endarterectomy (CEA):
  • Symptomatic stenosis ≥50-70%: Strong benefit from CEA (NNT ~6 for 70-99%)
  • Asymptomatic stenosis ≥60-80%: Modest benefit in select patients with good surgical risk
  • Should be performed within 2 weeks of index event for maximal benefit
• Carotid artery stenting (CAS): Alternative for high surgical risk patients
• Near-occlusion or complete occlusion: Medical management preferred (surgery not beneficial)

Disposition

• New symptomatic carotid stenosis (TIA/stroke) — admit for stroke workup, expedited surgical evaluation
• Incidental asymptomatic stenosis — outpatient vascular surgery referral

See Also

• Stroke
• TIA
• Amaurosis fugax
• Carotid artery dissection