Carotid artery disease Flashcards
What is CAD?
- Build up of atherosclerotic plaque in one or both common and internal carotid arteries
- = stenosis/occlusion
Pathophys of CAD
- Same as all atheromas
- Fatty streak
- Accumulate lipid core and fibrous cap
- Turbulent at bifurcation prediposes process to occur here specifically
Classification of CAD
By degree of stenosis:
* Mild - <50% diameter reduction
* Moderate - 50-69% reduction
* Severe - 70-99% reduction
* Total occlusion - 100%
RF for CAD
- Smoking
- Hypertension
- Hypercholestrolaemia
- Obesity
- Diabetes
- CVD
- FH of CVD
Clinica features of CAD presentation
- Often asymptomatic
- But can present with TIA/stroke - focal neurological deficit
Examination finding for CAD
- Carotid bruit - but only associated in less than half of cases
Why is CAD often asympomatic even with complete unilateral occlusion?
- Collateral supply from contralateral internal carotid artery and vertebral arteries via circle of willis
Differentials for other causes of CAD
- Atherosclerosis - most common
- Carotid dissection - CTD, younger, trauma/sudden neck movement
- Thrombotic occlusion of CA - presents same
- Fibromuscular dysplasia
- Vasculitis - GCA or Takayasu
What is fibromuscular dysplasia?
- Non-atheromatous stenotic angiopathy –> hypertrophy of vessel wall
- Young females
- Commonly in renal arteries
- Can present with focal neurological deficit
Non-cerebrovascular conditions that can manifest neurologically
- Hypoglycaemia
- Todds paresis - unilateral motor paralysis following seizure
- Subdural haematoma
- Space occupying lesion
- Venous sinus thrombosis
- MS
Investigations for stroke presentation
- Urgent non-contrast CT head
- Assess for infarction
- Bloods - FBC, clotting, lipids, glucose
- ECG - AF?
Investigations once diagnosed ischaemic stroke
- Image carotids - using duplex USS
- Gives estimate of stenosis
- Can then have CT angiography if needed
Acute management stroke - for all
- High flow O2
- Blood glucose optimised - target 4-11mmol
- Swallowing screen assessment
Ischaemic stroke initial management
- IV alteplase IF patients within 4.5hrs of symptom onset + 300mg aspirin (orally or rectally if swallow problem)
Haemorrhagic stroke management initial
- Correct coagulopathy
- Referral for neurosurgery - clot evacuation?
When can thrombectomy be performed for ischaemic stroke?
- Confirmed acute ischaemic stroke and confirmed occlusion of proximal anterior circulation on angiography
- Considered for IV thrombolysis too
When is neurosurgery often done for haemorrhagic stroke?
- Not often
- Unless superficial lobar or ventricular bleed
Long term stroke management
- Aspirin for 2 weeks (300mg OD) followed by Clopidogrel 75mg OD long term
- Statin - high dose
- Manage HTN and DM
- Smoking cessation
- Exercise, active lifestyle and weight loss
When to refer to SALT for stroke?
- Any dysphagia or dysphasia
When is carotid endarterectomy considered?
Opens up artery and removes plaque
- All patients with acute, non-disabling stroke (or TIA) who have symptomatic cartotid stenosis of 50-99% occlusion
- –> referral for assessment
Carotid endarterectomy surgery
- If eligible, operated on within first 2 weeks following symptoms
- Halves risk of future stroke - can use Oxford vascular carotid stenosis risk score to determine future risk
What does CEA involve?
- Remove atheroma and associated damaged intima
- = reduced risk of strokes and TIA
Risk of CEA
- Ischaemic stroke (2-3%)
- Nerve damage to hypoglossal, glossopharyngeal or vagus nerve
BUT still superior to carotid stenting
Complications of CAD
- Stroke –> dysphagia, incontinence, depression, cognitive decline
- Rehab can improve this with most occuring between 4-6 weeks but 50% will remain dependent at 1 yr.
