Carotid Disease Flashcards
(30 cards)
Definition of stroke
Focal neurological deficit lasting >24 hours as result of disease process of vascular origin
Definition of TIA
Focal neurological deficit lasting <24 hours
Percentage of stroke that are
1) Ischemic
2) Hemorrhagic
1) 80%
2) 20%
Percentage of ischemic stroke due to
1) thromboembolic of ICA/Middle cerebral artery
2) Small vessel disease
3) Cardiogenic brain embolism
4) Hematological
5) Other causes
1) 50%
2) 25%
3) 15%
4) 5%
5) 5%
Causes of ischemic stroke
Thromboembolism of ICA/MCA
Small vessels disease
Cardioembolic brain embolism (post MI, AF, vegetation)
Hematological
Others: FMH, arteritis, carotid dissection, carotid tumor, vasculitis
Non-atheromatous carotid diseases
Fibromuscular hyperplasia
Takayasu arteritis
Giant cell arteritis
Carotid aneurysm
Carotid dissection
Carotid body tumor
Carotid body
1) Location
2) Function
1) located within the adventitia of posterior aspect of carotid bifurcation
2) monitor blood gas and pH
Carotid body tumour
1) Pathological origin
2) Percentage malignant
3) Percentage bilateral
1) neural crest ectoderm
2) 5%
3) 5%
Clinical presentation of carotid body tumour
Pulsatile neck mass
Local compression:
-Hoarseness of voice (RLN)
-Horner’s syndrome
-CN palsies
Hormonal mediated:
-Flushing
-Dizziness
-Hypertension
-Arrhythmias
Lyre’s sign
Carotid splaying
Widening of the carotid bifurcation
DDX for carotid body tumor
Glomus vagale
Glomus jugular tumors
Cranial nerves at risk in management of carotid body tumour
Glossopharyngeal
Vagus
Accessory
Hypoglossal
Classic carotid territory symptoms
1) Hemimotor/ sensory signs
2) Transient monocular blindeness
3) Higher cortical dysfunction (dysphasia, visuospatial neglect)
Classic vertebrobasilar territory symptoms
Bilateral blindness
Problems with gait and stance
Hemi- or bilateral motor/sensory signs Dysarthria
Homonymous hemianopia
Diplopia, vertigo and nystagmus (provided it is not the only symptom)
ABCD2 score
Predicts 7-day risk of stroke after TIA
Age >60
SBP >140, DBP >90
Clinical features (unilateral weakness, speech disturbance)
Duration of symptoms
Diabetes
0-3 low risk
4-7 high risk
Total anterior circulation infarct (TACI)
Hemisensory/motor deficit
Higher cortical dysfunction
Homonymous hemianopia
Posterior circulation infarct
Vertebrobasilar infarct
Bilateral blindenss
Gait and stance
Nystagmus
Diplopia
Vertigo
Dysarthria
Management of symptomatic carotid stenosis
Medical treatment
Screen for reversible factors:
-Transcranial color DopplerL: intracerebral arteries
-Duplex USG of neck: carotid arteries
-DSA (gold standard)
Carotid endarterectomy vs endovascular stenting
Evidence in carotid endarterectomy vs medical treatment
ECST (European Carotid Surgery Trial)
NASCET (North American Symptomatic Carotid Endarterectomy Trial)
Conclusion: surgery decreases risk fo stroke significantly in pt with history of TIA/non-disabling stroke in recent 6 months
Evidence for surgical intervention in asymptomatic carotid stenosis
ACAS, ACST: small but significant decrease in stroke risk
Cochrane meta analysis: does not recommend routine surgery
Evidence of CEA vs stenting
Controversial
2005 Cochrane meta-analysis
EVA 2006
SPACE
3 other RCTs ended prematurely
Timing for CEA
1) Immediate
2) Urgent (< 24 hours)
3) Early (within 2 weeks)
- Immediate CEA: Thrombosis secondary to CEA, angiography or angioplasty
- Urgent CEA: Evolving stroke, Crescendo TIA, stuttering hemiplegia particular if an unstable plaque demonstrated
- Early CEA recommended: within 2-4/52 to reduce 20% risk of recurrent stroke within 6 weeks
Criteria for CEA
Symptomatic moderate to severe carotid stenosis should meet the following conditions:
● An ipsilateral TIA or nondisabling ischemic stroke as the symptomatic event
● A surgically accessible carotid artery lesion
● A life expectancy of at least five years
● No prior ipsilateral endarterectomy
● No contraindications to revascularization
Subgroups that would benefit from CEA
Men >50% stenosis
Men and women 70-99% stenosis
