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carotid artery stenosis

Pathology: 1) at 70-75% stenosis, lesions become hemodynamically significant 2) low-flow ischemic events may occur - left carotid artery stenosis may be associated with cognitive decline [8] 3) thrombi may form at origin of ICA, which may propagate or embolize 4) coexisting atherosclerosis elsewhere is the rule 5) mortality more frequently due to MI than stroke [3] 6) stroke rarely occurs with asymptomatic carotid stenosis that progresses to total carotid occlusion* * the circle of Willis usually maintains cerebral blood flow despite unilateral, or even bilateral carotid occlusion [25] Clinical manifestations: 1) paresthesias/weakness of hand, arm & face 2) aphasia (dominant hemisphere) 3) dysarthria 4) unilateral neglect 5) carotid bruit 6) 80% of large artery strokes occure without warning Radiology: 1) non-invasive techniques adequate for screening* a) carotid ultrasound (Doppler) 89%/84% b) magnetic resonance angiography (MRA) - contrast-enhanced MRA (CEMRA) 94%/93% c) spiral CT, CT angiography (CTA) 77%/95% 2) angiography a) candidates for carotid endarterectomy b) long-term anticoagulation considered for patient with probable large vessel disease c) recurrent TIAs & inconclusive noninvasive evaluation d) suspected carotid or cerebral dissection 3) progression of carotid artery intimal thickness does not predict cardiovascular risk [20] * sensitivity/specificity [9] Complications: 1) 60% asymptomatic stenosis: 5 year stroke rate reduced from 11% to 5% by carotid endarterectomy 2) 90% stenosis plus ulceration, 73% incidence of stroke 3) 50-99% asymptomatic stenosis: 10 year stroke rate 9% with medical management alone [6] Management: 1) intensified medical management seems to be better choice than carotid endarterectomy for asymptomatic extracranial carotid artery stenosis [3,18,31] - same appears to be true for intracranial atherosclerosis (see cerebrovascular disease) - incidence of ipsilateral carotid-related acute ischemic stroke in patients with severe carotid stenosis is 4.7% over 5 years [3] 2) the Asymptomatic Carotid Atherosclerosis Study demonstrated that asymptomatic individuals with > 60% stenosis of the internal carotid artery stenosis were at low risk for stroke a) 5.1% risk over 5 years with medical management plus carotid endarterectomy (CEA) b) 11% risk over 5 years for medical management alone 3) platelet inhibition: a) aspirin* 75-325 mg PO QD b) clopidogrel c) Aggrenox d) combination of aspirin plus clopidogrel increases risk of hemorragic stroke [16] e) rivaroxaban 2.5 mg BID + aspirin 100 mg/day decreases cardiovascular events (RR=0.72) at the cost of increased risk of bleeding (mostly GI bleeding) (RR=1.6) [30] 4) control of atherosclerotic risk factors (see atherosclerosis) a) aerobic exercise may slow progression of atherosclerosis b) statin therapy may be as effective as aerobic exercise - stroke risk for asymptomatic patients treated with high- intensity statin therapy is < 2%/year [3] - reduce LDL cholesterol to < 100 mg/dL [16] - reduce LDL cholesterol to < 70 mg/dL with diabetes [16] c) niacin more effective as adjunct to statin than ezetimibe 5) tight glycemic control in diabetics (Hgb A1c < 7%) of no proven benefit for stroke prevention [16] 6) carotid endarterectomy: a) symptomatic carotid stenosis [3] b) beneficial for patients with > 70% stenosis [7] - threshold for revascularization may be > 80% stenosis or rapid progression [3] - less benefit in patients with stenosis of 50-69% [24] - no benefit in patients with stenosis of < 50% [24] c) absolute risk reduction = 16% {without near occlusion} d) preferable to stenting in elderly [14, 21] - less risk of stroke e) lower procedural complication rate than angioplasty with carotid stenting in 1st week after ischemic stroke [29] 7) angioplasty with carotid artery stenting a) higher risk for perioperative stroke than with endarterectomy (MKSAP19) b) avoid in patients >= 70 years of age [21,27] c) may be alternative to CEA in younger patients [10,17] d) aggressive medical management better than angioplasty with stenting in patients with intracranial stenosis [3,17] e) medical therapy better than carotid stenting for asymptomatic carotid stenosis [25] 8) carotid endarterectomy equivalent to carotid stenting in younger patients [26] & older ones up to age 80 years [28] 9) combining carotid endarterectomy with cardiac surgery in patients with > 70% but asymptomatic carotid stenosis is associated with more perioperative strokes than cardiac surgery alone [12] 10) no clear benefit of carotid endartectomy or carotid artery stenting vs best medical management for 60-99% asymptomatic carotid artery stenosis [33] 11) carotid atherectomy has not been adequately studied [NEJM knowledge+] 12) USPSTF recommends against screening for carotid artery stenosis [3,23] * No benefit to more than 162 mg QD * No indication to switch from aspirin to clopidogrel [3] Clinical trials: - DNASCO study - Carotid Occlusion Surgery Study randomized trial [19] - extracranial-intracranial bypass for symptomatic carotid artery occlusion of no benefit

Related

atherosclerosis vertebrobasilar disease

General

carotid artery disease arterial stenosis

References

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  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 2338
  3. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021
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  17. The National Institutes of Health. Clinical Alert: Angioplasty combined with stenting plus aggressive medical therapy vs. aggressive medical therapy alone for intracranial arterial stenosis. NINDS stops trial enrollment due to a higher risk of stroke and death in the stented group. Apr 11 , 2011. http://www.nlm.nih.gov/databases/alerts/intracranial_arterial_stenosis.html
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