Carotid Artery Disease

Question 1

stroke - defined

Answer 1

*a focal neurological deficit related to neuronal cell death with signs and symptoms lasting GREATER THAN 24 HOURS
*ischemic defects in the brain on imaging

Question 2

transient ischemic attack (TIA) - defined

Answer 2

*a focal neurological deficit with signs and symptoms lasting LESS THAN 24 HOURS
*no ischemic defects in the brain on imaging

Question 3

risk factors for stroke

Answer 3

*HYPERTENSION
*increasing age
*cardiovascular disease (especially ATRIAL FIBRILLATION)
*cigarette smoking
*CAROTID STENOSIS

Question 4

etiologies of strokes

Answer 4

1. hemorrhagic strokes - due to bleeding into the brain by the rupture of a blood vessel (~20% of strokes)
2. ISCHEMIC strokes - due to loss of blood supply to an area of the brain (~80% of strokes)

Question 5

atherothrombotic strokes - causes

Answer 5

*CAROTID DISEASE (accumulation of plaque in the arteries; plaque rupture can lead to a stroke)
*vertebrobasilar disease
*watershed/hypotension
*idiopathic
*iatrogenic

Question 6

carotid artery stenosis - diagnosis

Answer 6

1. CAROTID DUPLEX (ultrasound) = gold standard (non-invasive & safe)
   -severe stenosis considered to be > 80%

*other imaging used to determine whether someone will have surgery:
2. CTA arteriography
3. MR arteriography
4. digital subtraction angiography

Question 7

carotid disease - overview

Answer 7

*disease of the carotid bulb
*rich source of emboli
*embolic risk related to plaque burden
*predominantly atherosclerotic, but can have other causes (fibromuscular dysplasia, arteritis, dissections)

Question 8

carotid disease - risk factors

Answer 8

*hypertension
*cardiovascular disease
*other peripheral vascular disease conditions
*hyperlipidemia

Question 9

carotid disease - clinical presentation

Answer 9

*CAROTID BRUIT is the most common mode of presentation (usually found on evaluation of another problem)
*can also present with:
-TIA
-Amaurosis fugax
-complete stroke
-vertebrobasilar symptoms

Question 10

Amaurosis fugax

Answer 10

*temporary IPSILATERAL monocular VISUAL LOSS due to embolization of retinal artery or branches (retinal artery comes directly off ipsilateral carotid)
*visual field defect
*“like a black shade” pulled over eye
*NOT scotomas or floaters
*may see Hollenhorst plaques on fundoscopic exam

Question 11

carotid disease - when to recommend surgical intervention

Answer 11

*asymptomatic patients with > 70-80% stenosis are treated
*symptomatic patients with any degree of stenosis > 50% are treated

Question 12

carotid disease - treatments

Answer 12

1. secondary prevention / medical management (HTN management, smoking cessation, lipid management with statins, diabetes management, antiplatelet agents)
2. surgery (carotid endarterectomy, carotid stenting)

Question 13

vertebrobasilar disease - overview

Answer 13

*neurological symptoms can occur from embolization or LOW FLOW states associated with lesions supplying the vertebral and/or basilar arteries
*symptoms include: dizziness, vertigo, diplopia, blurred vision, ataxia, drop attacks, bilateral sensory disturbances

Question 14

vertebrobasilar disease - diagnosis

Answer 14

*duplex (ultrasound) assists in defining carotid issues:
-can assess flow in vertebral arteries
-TRANCRANIAL DOPPLER to assess intracranial flow