Flashcards in Chap 97 Carotid Disease Deck (80):
what are RF for stroke
Age >55 risk doubles
Sex men >women
Race blacks hispanice higher risk
HTN lifetime risk if BP <120 is half
Alcohol if heavy
What is risk of stroke after TIA?
What is risk of recurrence after stroke?
What is risk of death after stroke?
10% in 90d
2% at 7 days
4% at 30d
12% at 1 yr
29% at 5 yr
7% at 7d
14% at 30d
27% at 1 year
53% at 5 years
What are high risk features on duplex for plaque rupture?
What are non atherosclerotic causes of stroke?
Carotid kinking or coiling
Radiation induced arteritis
Giant cell arteritis
What are symptoms of stroke from hypo perfusion?
bright light amaurosis
lightheadedness or presyncopy with any preceding focal deficits
also bilat UE weakness, cognitive difficulties, decreased visual acuity
what is wallenbergs syndrome?
intracranial vert artery lesion or PICA lesion
ipsi facial pain, numbness, sensory loss,
ipsi ptosis, meiosis
contra loss of temp and sensation
loss of balance
What is a hollenhorst plaque?
retinal infarct seen on fundoscopic exam suggest cholesterol emboli
What are the NNT for ICA stenosis of 70-99 for
NNT 3 to prevent 1 stroke at 5 yr
NNT 6 to prevent 1 stroke in 5 year
NNT 9 to prevent one stroke in 5 year
What is sense and spec for US, CTA, MRA, contrast enhanced MRA for carotid lesions?
What is the gray-weale classification?
duplex plaque characterization
Type 1 echolucent
type 2 predominantly echolucent
Type 3 predom echogenic
Type 4 echogenic
What were the results of NASCET for >70%?
sympto patient >70%
BMT 26% CEA 9%
BMT28% CEA 13%
What are the results for NASCET 50-69%?
BMT 15% CEA 9%
BMT282% CEA 16%
What were the results for ECST 80-99?
sympto 80-99 (60-99 by NASCET criteria)
BMT 20% CEA 7%
What were the results for ACAS
BMT 11% CEA 5%
What were the results for ACST?
Asympto stenosis >60%
BMT 12% CEA 6%
What are caveats to CEA in asympto patients?
should have life expectancy of 3-5yr
women no benefit
likely no benefit if high co-morbid burden
What is the evidence for CTO?
MA no diff, 2.4 vs 3.7
What is the risk of contra CTO?
increase peri-op risk of stroke for CEA
What is the risk of protamine use in CEA?
decreased in postop bleeding, hematoma
no difference in stroke
What is the risk of dextran use in CEA?
not associated with stroke periop
CI with cardiac dz
What is difference of GA, local or block in stroke death or MI for CEA?
all the same
Describe incision for CEA.
parallel to SCM
posterior to earlobe
What are different shunts for CEa?
What is the difference?
pruitt less cerebral embolism but less physiologic flow
What were the results of Everest?
compared eversion to patch
no difference in restenosis 4 yr
What is the evidence for patch, no patch or eversion in CEA?
patch or eversion better then no patch
primary closure increase stroke and restenosis
What are the SVS recommendations for peri-op management of anti-plt for CAS?
plavix 3 days before and 1 month after
What are techniques to get surgical access to high ICA lesions.
division of digastric muscle
resection of styloid process
anterior subluxation of the mandible
describe division of the digastric.
what are the relationships of the nerves to the muscle?
divide posterior belly of digastric
same course as hypoglossal but sits anterior so protect the nerve
spinal accessory nerve is in upper 1/3 of muscle
glosspahryngeal lies deep
describe resection of the styli process
After digastric divided, remove insertion of styloglossus, stylopharyngeus and stylohyoid
Identify occipital artery as it runs on inferior border of digastric and don’t injure
Resect process with rongeur
What is the difference b/w shunting and non-shunting?
What are different ways to protect the brain during CEA?
no diff in routine shunting and routine non-shunting
none completely accurate
What are the criteria for stump pressures?
<50mmhg then 50% neuro rate if not shunted vs 10% if shunt
What re criteria for shunting with EEG?
50% decrease in fast background activity
increase in delta wave activity
complete loss of reg signal
stroke rate 10% in patient with abnormal reg who did not have shunts
Is there a benefit to awake CEA?
shunt use 5-15%
lower rate of MI
What are the risks of using vein patch?
GSV <3.5 mm prone to rupture
What are RF for stroke with CAS?
angle ICA-CCA >60
What situations are better suited for CAS?
prior nerve palsy
What is a consequence of balloon and stent deployment in CAS?
bradycardia and hypotension
What are the recommendations for filter devices?
What are different kind of filter devices?
SVS recommends use although evidence not robust
Distal occlusion devices
cross lesion, apply suction before removing. smaller diameter sheath
proximal occlusion devices
placement of two occlusion balloons CCA and ECA with flow reversal. large death size
distal fileters. cross lesion. small sheath size. ante grade flow
What is most common complication after CAS?
Name RCT that compare CAS vs CEA
SPACE stroke/death CAS 7% CEA 6.5% non-inf not reached
CAS10% CEA 4% stopped early
CAS 6% CEA 3% periop
no diff of ipso stroke at 4 yrs
CAS higher risk then CEA 30d stroke or death
CAS lower for MI
What are the restenosis rates for CAS?
30% at 10yrs in CAVATAS vs 10% for CEA
What feature should consider protection device during CAS?
Bovine or type 3 arch
incomplete circle of willis
What is most common cause of death after CEA?
Name different nerves that can be injured in CEA and what their injury is.
hypoglossal, ipsi tongue weakness and difficulty masticating
recurrent laryngeal, ipsi vocal cord--hoarseness and inefffective cough
superior laryngeal, voice fatiug and difficulty with voice modulation at high registers
facial nerve, marginal mandibular branch, drooping of ipso lower lip
Glosspharygeal, mild dysphagia, recurr aspiration
Spinal accessory, shoulder drop and pain, scapular winging, weak abd
greater auricular nerve, numbness of angle of mandible and lower part of ear lobe
transverse cervical nerves, anesthesia of anterior neck skin
ansa, innervates the hyoid muscles
describe course of hypoglossal
descend medial to ICA then courses lateral to ECA usually above bifurcation, may cross at bifurcation
if need to mobilize may need to divide tethering branches of the ECA
describe course of vagus
Usually posteoti to CCA can be variable
Can lie anterior
Recurrent laryngeal usually originates in mediastium
Can arise at level of bifurcation (nonrecurrent recurrent laryngeal) and enters larynx posterior to CCA
Describe course of SLN
Originates from vagus near jugular foramen and passes obliquely to the laryns posterior to ECA and ICA
describe course of marginal mandibular branch
Anterior border of parotid b/w platysma and deep cervical fasci
What is cerebral hypo perfusion syndrome?
increased regional blood flow secondary to disordered intracerebral autoregulation and relief of high grade stenosis in setting of severe contra lesion
What symptoms can occur with CHS?
ipsi H/A, seizure, focal neuro
HA frontal, pounding, face/eye pain
focal neuro--hemiplegia, aphasia, vomitting
What are RF for CHS?
–Poor collateral blood flow
–Increased peak flow velocity
–Contralateral carotid occlusion
–Recent contralateral CEA
distal carotid pressure <40mmhg
What are the branches of the ECA?
Some American Ladies Found Our Pyramids Most Satisfactory
S: superior thyroid artery
A: ascending pharyngeal artery
L: lingual artery
F: facial artery
O: occipital artery
P: posterior auricular artery
M: maxillary artery
S: superficial temporal artery
What are causes of carotid aneurysm?
at hero degeneration
What are symptoms of carotid aneurysm?
tender or asympto
What are different treatments for carotid aneurysm?
ligation (neuro 50%)
can do balloon occlusion test frist
What are outcomes to open vs endo for carotid aneurysm?
reconstruction stroke and mortality 10%
nerve dysfunction 20%
lower stroke rate
What is the carotid body?
What does it respond to?
neural crest cell derived chemoreceptor located in the medial portion of the carotid bifurcation
changes in O2, CO2, pH
How common are carotid body tumours?
most common H&N paraganglioma
60% right side
What are RF for CBT?
high altitudes, smoking, COPD
von hippel lindau;s disease
MEN type 2
What is carney's triad?
gastric stromal sarcoma, pulmonary chondroma, paraganglioma
What are anatomical features of CBT?
splay the bifurcation
can encapsulate the adjacent arteries
most of it located deep to bifurcation
What are microscopic features?
Granular epitheloid chief cells and sustentacular supporting cells
These cells form clusters called zellballen or cell balls
This grows into the tumor
What is fontaines sign?
fixed vertically but mobile horizontally
What other test should be done for CBT?
octreotide scan to rule out other paragangliomas. measures uptake of a somatostatin analogue
What tx options for CBT?
What is the grading for CBT?
Type I tumor
Small lesion nested in the bifurcation
Type II larger, splay the bifurcation but to not encase
Type III large ancapsulate the int/ext arteries and often adhere to adjacent nerves
What are other vascular tumours of the H&N?
What is the carotid sinus?
Carotid sinus is a sensory branch (nerve of Hering) of the glossopharyngeal nerve that terminates in carotid bifurc in a baroreceptor complex
Response to stretch
Activation of parasympathetic and inhib of sympathetic
What is carotid sinus syndrome?
Sinus hypersensitivity, Severe light headedness, syncope or drop attacks
Diagnosed by reproducing the symptom with carotid massage
Excessive brady, hypotension, (50 reduction in SBP), combination
Movement can precipitate symptoms
What are RF for CSS?
elderly, vascular dz, HTN, CADm atherosclerosis, DM
What are tx for CSS
Divide nerve of hering
Strip carotid bulb or periadventitia to distance of 3cm from bifurc
93% symptoms free at 30d
What are the SVS guidelines for intervention on carotid stenosis (6)?
1. sympto angio >50% or duplex >70%
2. asympto >80% consider if stroke risk CAS unless decamp CHF or scarring
4. CAS>BMT if high risk for CEA
5. intervention within 2 weeks
6. BMT for CTO
What are causes of carotid dissection?
Cystic medial necrosis
Autosomal dominant polycystic kidney disease
Osteogenesis imperfecta type I
What vascular anomalies are implicated in carotid dissection?
Aortic root dilation
Increased arterial distensibility
What is the triad of cervical dissection?
Horners syndrome (21%)
Neck or head pain (70%)—ipsi frontotemporal
Cerebral ischemia 30%
What causes hornets syndrome?
Sympathetic fibers involved in the dissection which run along the carotid
usually without anhidrosis
What other symptoms of carotid dissection?
Unilat weakness (55%)
May also get neck pain
Cranial nerve palsy (CN IX-XII) particularly the hypoglossal
What is natural hx of carotid dissection?
60% persistent neuro
50% luminal recovery
2% annual risk of recurrent stroke
What is risk benefit of treatment?
ICH rate with AC is 0.5%, 0 without
But recurrent TIA 5% with anti plt alone whereas 0 with AC