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