Carotid Artery Surgery - Presentation, Investigation & Therapy

Question 1

What is often the cause of transient ischaemic attacks and ischaemic stroke.?

Answer 1

Carotid artery artherosclerosis

Question 2

What is the definition of a TIA?

Answer 2

Focal CNS disturbance caused by vascular events

Symptoms less than 24 hours

No permanent neurological sequelae

(vascular events = such as microemboli and occlusion, leading to cerebral ischaemia)

Question 3

What are the causes of stroke (TIA)

Answer 3

Cerebral infarction (84%)

Primary intracerebral haemorrhage (10%)

—Subarachnoid haemorrhage (6%)

Question 4

What are the causes of cerebral infarction?

Answer 4

AF

Carotid atherosclerotic plaque rupture/thrombus (15%)

Endocarditis

MI (clot arises from here)

Carotid artery trauma/dissection

Drug abuse

Haematological disorder e.g. sickle cell disease

Question 5

What are the risk factors for carotid atherosclerosis?

Answer 5

Smoking

Diabetes

Family history

Male sex

Hypertension

Hyperlipidaemia/hypercholesterolaemia

Obesity

Age

(NOT: DVT 2° to flight – venous disease is different from arterial disease)

Question 6

How is diagnosis of carotid artery atherosclerosis achieved?

Answer 6

History

Examination

CT

Carotid USS

Question 7

How can you examine for atherosclerotic carotid artery?

Answer 7

Cardiac

Auscultate carotids

Neurological: remember contralateral symptoms of paralysis, paresis (partial paralysis) /visuospatial neglect, dysphasia (deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage.); ipsilateral amaurosis fugax symptoms (this is when the embolus is in the retinal artery – only circumstance it is ipsilateral)

Question 8

How does the velocity of blood change as it passes through an occluded coaritf artery?

Answer 8

Velocity increases - diagnosis via carotid imaging is achieved this way

Question 9

What is the best management for Stroke and TIA?

Answer 9

—Smoking cessation

—Control of hypertension

—Antiplatelet (aspirin or clopidogrel)

—Statin

—Diabetic control

Question 10

What are the names of these arteries?

Answer 10

Question 11

What is carotid endarterectomy?

Answer 11

1. Artery clamped above and below plaque
2. Incision opens carotid artery
3. Plaque removed
4. Repaired artery is closed

Can prevent stroke in the case of a severely narrowed carotid artery

Question 12

What does the external carotid give supply to?

Answer 12

Supplies thyroid, tongue, facial artery

Internal carries onto the next territory

Question 13

What are the complications of an endarterectomy?

Answer 13

Wound infection

Bleeding

Scar

Anaesthetic risks

Nerve damage

Perioperative stroke:

• Plaque rupture
• Hypoperfusion (clamping carotid)

Virchow’s triad – raw intimal surface and thrombosis – (change to vessel wall can cause thrombus formation)

Question 14

What are the possible nerves that you may damage during a carotid endarterectomy?

Answer 14

Hypoglossal nerve - controls the tongue

Glossopharyngeal nerve

Question 15

What is another means of reducing restriction of blood flow through the carotids?

Answer 15

Stenting

Question 16

What is the difference in treatment between non-significant carotid stenosis and significant stenosis?

Answer 16

Non-significant - Best medical treatment

Significant - BMT, imaging, carotid endarterectomy and carotid stenting

Question 17

What is the surgery described as?

Answer 17

PROPHYLACTIC

Question 18

When should we offer carotid surgery to women?

Answer 18

Higher stenosis value:

NNT (number needed to treat) to prevent one stroke at five years - 9 for men, 36 for women.

Clear benefit in women with 70-99% stenosis but not 50-69% stenosis

Women have higher operative risk and respond better to BMT

Question 19

What are the rules for when you should start suregry?

Answer 19

Offer carotid surgery for all symptomatic patients with >70% stenosis (except occluded)

Consider surgery in men with 50-69% stenosis

Consider surgery in asymptomatic stenosis >70%