carotid artery disease Flashcards
what is carotid artery disease?
refers to the build up of atherosclerotic plaque in one or both common and internal carotid arteries, resulting in stenosis or occlusion
what can the consequences of carotid artery disease be?
ischaemic strokes due to plaque rupture
atheroembolism
what is the pathophysiology for carotid artery disease?
same as for atheromas elsewhere
starting with a fatty streak, accumulating a lipid core and formation of a fibrous cap. The turbulent flow at the bifurcation of the carotid artery predisposes to this process specifically at this region.
what are the risk factors for carotid artery disease?
- age (65+)
- smoking
- hypertension
- hypercholesterolaemia
- obesity
- DM
- history of CV disease
- FH
what are the clinical features of carotid artery disease?
generally asymptomatic
may present as a focal neurological deficit. Can take 1 of two forms
- TIA. Lasts less than 24hrs before full resolution
- stroke. lasts for more than 24 hours without full resolution.
- on examination, carotid bruit may be heard as a result of carotid stenosis
carotid stenosis, even with complete occlusion, may be asymptomatic due to collateral supply from contralateral internal carotid artery and the vertebral arteries via the circle of willis
what is used to classify stroke symptoms in relation to arterial regions involved?
the Oxford stroke classification
what are the differentials for carotid artery disease?
- carotid dissection
- thrombotic occlusion of carotid artery
- fibromuscular dysplasia
- vasculitis
- non cerebrovascular conditions that manifest neurologically should be considered e.g hypoglycaemia, subdural haematoma, space occupying lesion, venous sinus thrombus, MS.
what investigations should be done into carotid artery disease?
suspected ischaemic or haemorrhage stroke = urgent non contrast CT head for evidence of infarction
- first line is via carotid US doppler, with confirmed cases being further investigated with CT angiography
- Bloods, FBC, U&E, clotting, lipping profile, glucose
- ECG for AF
- if considering thrombectomy in patients with evidence of ischaemia, image via CT head contrast angiography is required
once a diagnosis for ischaemic stroke/TIA is made, what follow up investigations are requested?
screen carotid arteries for disease precipitating presentation with duplex ultrasound scan
it will show degree of stenosis and exclude any differentials
lesions within carotid artery may be characterised via CT angiography
what is the acute management of a patient admitted with a suspected stroke?
- high flow oxygen
- blood glucose optimised (4-11 mmol)
- swallowing screen assessment
- ischaemic stroke needs IV alteplase for thrombolysis and aspirin
- thromboectomy in acute ischaemic strokes and confirmed occlusion of proximal anterior circulation on angiography, as well as consideration for IV thrombolysis to
- haemorrhage stroke needs correction of coagulopathy and referral to neurosurgeon for potential clot evacuation
what is the longterm management for strokes/TIA?
CV risk fact management
- anti platelet therapy e.g aspirin for 2 weeks then clopidogrel
- statin high dose
- manage hypertension and DM
- smoking cessation
- regular CV exercise and active lifestyle with weight loss
- refer to speech and language therapy for any dysphagia or dysphasia
- physiotherapy and occupational therapy for motility issues
what is a carotid endarterectomy?
for patients with acute non disabling stroke or TIA who have symptomatic carotid stenosis should be referred for assessment for a carotid endarterectomy
involves removing atheroma and the associated intima, therefore reducing risk of future strokes or TIA
main risks are stroke, nerve damage to hypoglossal, glossopharyngeal or vagus nerve, MI, local bleeding and infection.
seen as the superior option to carotid stenting
what are the complications of strokes?
- dehabilitation
- dysphagia
- seizures
- spasticity
- bladder/bowel incontinence
- anxiety
- depression
- cognitive decline
