Carotid Artery Disease

Question 1

What is Carotid artery disease?

Answer 1

• build up of atherosclerotic plaque in one or both common and internal carotid arteries, resulting in stenosis or occlusion.

Question 2

What is the Px of CAD?

Answer 2

1. fatty streak, accumulating a lipid core
2. formation of a fibrous cap

Question 3

Why is the birufication of the carotid aretry prone of getting atherosclerotic plaque build p?

Answer 3

• turbulent flow

Question 4

How would you classify CAD?

Answer 4

• radiologically by degree of stenosis

Question 5

Describe the classification of CAD

Answer 5

• Mild <50%
• Moderate 50-69%
• Severe 70-99%
• Total Occlusion 100%

Question 6

What are the RF for CAD

Answer 6

• age (≥65years)
• smoking
• hypertension
• hypercholesterolaemia
• obesity
• diabetes mellitus
• history of cardiovascular disease
• family history of cardiovascular disease.

Question 7

What are the clinical features of CAD?

Answer 7

• Asymptomatic (mostly)
• Focal neurological deficit
• Carotid bruit

Question 8

Why does unilateral CAD present asymptomatically and not have focal neurological deficit?

Answer 8

• collateral supply from the contralateral internal carotid artery and the vertebral arteries, via the Circle of Willis.

Question 9

What are the differential diagnosis for CAD?

Answer 9

• Carotid dissection
• thrombotic occlusion of carotid artery
• fibromuscular dysplasia
• vasculitis

Question 10

What Ix would you order for CAD?

Answer 10

If suspect stroke do

• urgent non contrast CT head

Other Ix

• Bloods
  
  • FBC, U&E, Clotting, lipid profile, glucose
• ECG
  
  • check AF

After stroke is diagnosed

• DUS - estimate degree of stenosis
• CT angiogram - assess disease portion of vessel prior to surgery

Question 11

How would you acutely mx CAD?

Answer 11

• high flow oxygen
• blood glucose optimised (target 4-11mmol)
• swallowing screen assessment

If ischaemic stroke

• IV alteplase (r-tPA) - if patients are admitted within 4.5hrs of symptom onset and meet inclusion criteria
• 300mg aspirin - if dysphasic
• Thrombectomy

If haemorrhagic stroke

• correction of any coagulopathy and referral to neurosurgery

Question 12

What is the long term mx of CAD?

Answer 12

• CV RF mx
  
  • aspirin 300mg OD for two weeks, then clopidogrel 75mg OD
  • aspirin and dipyradimole (if clopidogrel not tolerable)
  • atorvastatin 80mg
  • aggressive mx of DM and HTN
  • Smoking cessation
  • Exercise and weight loss
• Cartoid endarectomy

Question 13

What are the criterias for carotid endarectomy?

Answer 13

• acute non-disabling stroke
• symptomatic carotid stenosis between 50 – 99%

Question 14

What are the cx of CAD?

Answer 14

• death 19% at 30 days
• rehabilitation and dependancy
• dysphagia, seizures, ongoing spasticity, bladder or bowel incontinence, depression, anxiety, or cognitive decline.