Carotid artery disease

Question 1

What is CAD?

Answer 1

• Build up of atherosclerotic plaque in one or both common and internal carotid arteries
• = stenosis/occlusion

Question 2

Pathophys of CAD

Answer 2

• Same as all atheromas
• Fatty streak
• Accumulate lipid core and fibrous cap
• Turbulent at bifurcation prediposes process to occur here specifically

Question 3

Classification of CAD

Answer 3

By degree of stenosis:
* Mild - <50% diameter reduction
* Moderate - 50-69% reduction
* Severe - 70-99% reduction
* Total occlusion - 100%

Question 4

RF for CAD

Answer 4

• Smoking
• Hypertension
• Hypercholestrolaemia
• Obesity
• Diabetes
• CVD
• FH of CVD

Question 5

Clinica features of CAD presentation

Answer 5

• Often asymptomatic
• But can present with TIA/stroke - focal neurological deficit

Question 6

Examination finding for CAD

Answer 6

• Carotid bruit - but only associated in less than half of cases

Question 7

Why is CAD often asympomatic even with complete unilateral occlusion?

Answer 7

• Collateral supply from contralateral internal carotid artery and vertebral arteries via circle of willis

Question 8

Differentials for other causes of CAD

Answer 8

• Atherosclerosis - most common
• Carotid dissection - CTD, younger, trauma/sudden neck movement
• Thrombotic occlusion of CA - presents same
• Fibromuscular dysplasia
• Vasculitis - GCA or Takayasu

Question 9

What is fibromuscular dysplasia?

Answer 9

• Non-atheromatous stenotic angiopathy –> hypertrophy of vessel wall
• Young females
• Commonly in renal arteries
• Can present with focal neurological deficit

Question 10

Non-cerebrovascular conditions that can manifest neurologically

Answer 10

• Hypoglycaemia
• Todds paresis - unilateral motor paralysis following seizure
• Subdural haematoma
• Space occupying lesion
• Venous sinus thrombosis
• MS

Question 11

Investigations for stroke presentation

Answer 11

• Urgent non-contrast CT head
• Assess for infarction
• Bloods - FBC, clotting, lipids, glucose
• ECG - AF?

Question 12

Investigations once diagnosed ischaemic stroke

Answer 12

• Image carotids - using duplex USS
• Gives estimate of stenosis
• Can then have CT angiography if needed

Question 13

Acute management stroke - for all

Answer 13

• High flow O2
• Blood glucose optimised - target 4-11mmol
• Swallowing screen assessment

Question 14

Ischaemic stroke initial management

Answer 14

• IV alteplase IF patients within 4.5hrs of symptom onset + 300mg aspirin (orally or rectally if swallow problem)

Question 15

Haemorrhagic stroke management initial

Answer 15

• Correct coagulopathy
• Referral for neurosurgery - clot evacuation?

Question 16

When can thrombectomy be performed for ischaemic stroke?

Answer 16

• Confirmed acute ischaemic stroke and confirmed occlusion of proximal anterior circulation on angiography
• Considered for IV thrombolysis too

Question 17

When is neurosurgery often done for haemorrhagic stroke?

Answer 17

• Not often
• Unless superficial lobar or ventricular bleed

Question 18

Long term stroke management

Answer 18

• 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

Question 19

When to refer to SALT for stroke?

Answer 19

• Any dysphagia or dysphasia

Question 20

When is carotid endarterectomy considered?

Opens up artery and removes plaque

Answer 20

• All patients with acute, non-disabling stroke (or TIA) who have symptomatic cartotid stenosis of 50-99% occlusion
• –> referral for assessment

Question 21

Carotid endarterectomy surgery

Answer 21

• 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

Question 22

What does CEA involve?

Answer 22

• Remove atheroma and associated damaged intima
• = reduced risk of strokes and TIA

Question 23

Risk of CEA

Answer 23

• Ischaemic stroke (2-3%)
• Nerve damage to hypoglossal, glossopharyngeal or vagus nerve

BUT still superior to carotid stenting

Question 24

Complications of CAD

Answer 24

• 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.