Arterial Disease Flashcards
What is carotid artery disease? How will it present?
Build up of atherosclerotic plaques 1+ common & internal carotid arteries -> stenosis/ occlusion
- Mostly asymptomatic
- Causes 10-15% of ischaemic strokes due plaque rupture/ atheroembolism
- TIA (<24hrs)
May Carotid bruit neck auscultation
Pathophysiology of atheromas
Fatty streak -> lipid core -> fibrous cap
Proliferation SM cells, foam cells -> EC lipid -> fibrosis, necrosis, inflammatory cells, cholesterol clefts -> disruption internal lamina then media -> in growth BVs -> plaque fissuring (cracking cap)
How is carotid artery disease classified?
Radiologically - degree of stenosis
Mild - <50% diameter reduction
Moderate - 50-69%
Severe - 70-99%
Total occlusion
Differentials for carotid artery disease
- carotid dissection - <50yrs, CT disorder, precipitated trauma
- thrombotic occlusion CA - imaging different
- fibromuscular dysplasia - stenosis angiopathy hypertrophy vessel wall, <50yrs, females, focal neurological deficit
- vasculitis - giant cell arteritis/ Takayasu’s arteritis, systemic
Hypoglycaemia, Todd’s paresis, subdural haematomma, SOL, VST, MS
How would you investigate someone suspected of carotid artery disease?
Suspected stroke - UrGeNT non-contrast CT head
Also:
- bloods (FBC, U&Es, clotting, lipid profile, glucose)
- ECG (A fib)
Thrombectomy to my considered CT contrast angiography
Post diagnosis I stroke/ TIA:
Duplex USS - degree stenosis
Lesions within CA - Ct angiography
Acute management of carotid artery disease/ suspected stroke
High flow O2
Blood glucose optimised (4-11mmol)
Swallowing screen assessment
- I stroke IV alteplase (admitted <4.5hrs symptoms onset + meet inclusion criteria), 300mg aspirin
✅thrombectomy + consider IV thrombolysis - H stroke correction coagulate the + neurosurgery referral (potential clot evacuation)
Long term management stroke/ TIA
Anti-platelets (aspirin 300mg OD 2 weeks -> clopidogrel 75mg OD)
Statin (atorvastatin)
Management hypertension/ DM/ smoking
Exercise
WL
Speech and language therapy
Physiotherapy
Occupation t
Carotid endarterectomy - all acute non-disabling with symptomatic carotid stenosis 50-99% ~ remove atheroma + damaged intima
Oxford stroke classification
Classification Description Signs and Symptoms
Total Anterior Circulation Stroke (TACS) (20%) Large cortical stroke in middle or anterior cerebral artery areas Must have all of:
Motor weakness or sensory deficit of -¥2/3 areas (face, arm, leg)
Homonymous hemianopia
High cortical dysfunction (dysphasia, dyspraxia, or neglect)
Partial Anterior Circulation Stroke (PACS) (35%) Cortical stroke in middle or anterior cerebral artery areas Will present with either:
2/3 TACS criteria
Limited motor or sensory deficit (1 of leg, arm or face)
High cortical dysfunction alone
Lacunar Stroke (LACS) (20%) Occlusion of the deep penetrating arteries Will present with any of:
Pure motor -¥2/3 areas (face, arm, leg)
Pure sensory -¥2/3 areas (face, arm, leg)
Pure sensorimotor -¥2/3 areas (face, arm, leg)
Ataxic hemiparesis
Posterior Circulation Stroke (POCS) (25%) Occlusion of vertebrobasilar or PCA circulation, affecting brainstem, cerebellum, or occipital lobe Variety of presentations can occur, typically:
Ipsilateral CN palsy with contralateral motor or sensory defects
Bilateral motor or sensory deficits
Isolated homonymous hemianopia
Cerebellar dysfunction
What is an AAA? Risk factors?
Dilation abdominal aorta >3cm
(Aneurysm dilation >50%)
1/70 men >65yrs
RFs: Atherosclerosis Trauma Infection CT disorder Inflammatory disease Smoking Hypertension Hyperlipidemia FH Male Older (DM negative)
Most AAAs are asymptomatic, how are they picked up? If they do have symptoms what would they be?
Incidental finding or screening (NAAASP) abdo USS men 65yrs (>5.5cm -> CT contrast)
Symptomatic: Abdo pain Back/ loin pain Distal embolisation -> limb ischaemia Aortoenteric fistula Pulsatile mass Retroperitoneal haemorrhage signs rare
Rupture - abdo/ back/ lion pain, shock, syncope
Management of AAAs
<5.5cm monitored duplex USS
3-4.4cm yearly scan
4.5-5.4 3 monthly
Reduce cvs factors
Surgery >5.5cm / expanding >1cm yr / symptomatic
- open repair clamping, segment removed, prosthetic graft
- endovascular repair graft via femoral arteries & fixing stent across (higher rates reintervention & rupture)
What is the most important complication of an endovascular repair for AAAs? How can you classify it?
Endovascular leaking
Incomplete seal around aneurysm -> blood leaks around graft
Often asymptomatic - regular surveillance
-> rupture
Type 1 - leak graft end, inadequate seal
Type 2 - sac filling from branch vessel, most resolve
Type 3 - leak through defect in graft, resolves cessation anticoags
Type 5 - continued expansion aneurysm without leak imaging
Complications of AAA
Rupture - pain, syncope, vomiting, pulsatile mass
Retroperitoneal leak
Classic triad (50%): flank/ back pain, hypotension, pulsatile mass
80% rupture posteriorly retroperitoneal space
Embolisation
Aortoduodenal fistula
Management of ruptured AAA
Suspected: High flow O2 IV access Urgent bloods (FBC U&Es clotting crossmatch min 6U) Shock treated carefully (BP <100mmHg) Transferred vascular unit Unstable - open surgical repair Stable - ct angiogram
What does the wall of an artery consist of? Where is the tear in an arterial dissection? How might it spread?
Tunica intima- endothelium, elastic membrane
Tunica media - smooth muscle
Tunica adventitia - external elastic membrane
Tear intima layer -> blood flow between & split intima & media
Can progress distally/ proximal/ both - anterograde -> iliac arteries, retrograde -> aortic valve (cardiac tamponade)
Chronic >14days
