Carotid artery stenosis

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  • Stroke Risk Population studies<4,5> have reported that patients with asymptomatic neck bruits are at increased risk for stroke: slightly more than 2% per year in the Evans County study (7.5 fold increase for men and 1 .6 fold increase for women) and in the Framingham study the two year incidence of stroke was 3% in men and 4% in women, a 2 to 3 fold increased risk. In these studies, the presence of a bruit did not predict the type (thromboembolic, cardioembolic, lacunar or hemorrhagic) or the hemispheric location of the stroke. Most of the strokes either occurred in a different vascular territory or their presumed cause was unrelated to the carotid stenosis itself. In more recent years, non-invasive imaging (ultrasonography), has shown that the risk of neurological events is directly correlated with the severity of carotid stenosis (Figure 1 ).<6- 1 2> It has also been observed that rapid progression of carotid bifurcation plaque may herald a significant risk of stroke.<6, 1 3> Correlation with plaque morphology such as ulceration or intraplaque hemorrhage as well as correlation with other risk factors is less well defined. In a Canadian prospective referral population study of 696 patients with asymptomatic bruits followed on average for 3.5 years,<7> the annual stroke rate was 1 .3% in patients with equal or less than 50% stenosis and 3.3% in those with greater than 50% stenosis. Ipsilateral stroke rate was 2.5% in patients with >50% stenosis. Other prospective studies of large populations of patients with asymptomatic bruits have shown similar results;<6,8- 1 0, 1 3> the overall risk of stroke is 1 to 2% annually, that is approximately three times the likelihood of having an ischemic stroke in an age- and sex-matched population without bruits.< 11 >
  • Cardiac Risk (Myocardial Infarction and Cardiac Death) In the study by Norris and colleagues,<7> the annual rate of cardiac ischemic events and cardiac death was 9.9% in those with  50% stenosis and 1 4.8% in those with >50% stenosis. Similarly, in most surveys on asymptomatic carotid bruit or stenosis the major risk is cardiac, not cerebrovascular.<4,5,7> However this depends on the type of population studied and their initial cardiac status; in another ongoing prospective study,< 1 0> in which patients with heart conditions requiring the obligatory use of aspirin were excluded, neurological events were more frequent among patients with asymptomatic bruits.
  • Carotid artery stenosis

    1. 1. Carotid Artery Disease Dr P S Deb
    2. 2. How do you define carotid stenosis <ul><li>Degree of stenosis: determined by comparing the most narrow linear diameter of the vessel with the normal internal carotid artery beyond the carotid bulb in American trial and at bulb in European . </li></ul>
    3. 3. What are the risk factors of carotid stenosis? <ul><li>High blood pressure </li></ul><ul><li>High cholesterol </li></ul><ul><li>Lipoprotein (a) </li></ul><ul><li>Low HDL </li></ul><ul><li>Smoking </li></ul><ul><li>Alcohol </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Male Sex (2:1) </li></ul><ul><li>Old age (>50) </li></ul><ul><li>White race (10:1) </li></ul><ul><li>Clamidia, HS, CMV, Helicobactor </li></ul><ul><li>Caoagulation factors VII, VIII, fibrinogen </li></ul><ul><li>Sialic Acid, Feretin </li></ul><ul><li>Homocystine, Uric acid </li></ul>
    4. 4. What is the incidence of carotid stenosis in the population? <ul><li>Asymptomatic </li></ul><ul><li>>50% stenosis by ultrasound </li></ul><ul><li>At 50year 0.5% </li></ul><ul><li>At an above 80years 10% </li></ul><ul><li>Autopsy </li></ul><ul><li>40% had carotid plaque </li></ul><ul><li>10% had carotid block </li></ul><ul><li>Symptomatic </li></ul><ul><li>13% had >70% stenosis </li></ul>
    5. 5. What are the clinical presentation of carotid stenosis? <ul><li>Asymptomatic Carotid bruit </li></ul><ul><li>Silent </li></ul><ul><li>Carotid occlusion </li></ul><ul><li>Cerebral infarction </li></ul><ul><li>(10-40%) Hemispheric/ ocular TIA (10-15%/y) </li></ul><ul><li>Acute cerebral infarction(1-6%/Y) </li></ul>
    6. 6. What is the natural course of carotid disease? <ul><li>Asymptomatic carotid stenosis (Indication of generalized atherosclerosis) </li></ul><ul><li>Stroke 1-6%/year </li></ul><ul><li>TIA 10-15%/year </li></ul><ul><li>Cardiac events: 20-40% </li></ul><ul><li>Proportionate to the severity of stenosis </li></ul>
    7. 7. Symptomatic carotid artery disease <ul><li>Stroke risk </li></ul><ul><li>TIA: approximate 7 % / year </li></ul><ul><ul><li>Hemispheric TIA 12%/year </li></ul></ul><ul><ul><li>Ocular TIA 2%/year </li></ul></ul><ul><li>CVA:  5% to 20% / year </li></ul><ul><li>Ulcerated lesion 2-4times more risk </li></ul><ul><li>Recurrent hemispheric events carry a greater stroke risk than a single event (28% versus 12% at 2 years). </li></ul>
    8. 9. Progression of Carotid stenosis and Event
    9. 17. What is the significance of carotid bruit/ <ul><li>4% of normal population above 40 </li></ul><ul><li>40-70% are haemo dyanamically insignificant </li></ul><ul><li>Sensitivity and specificity of severe stenosis is 60-75% </li></ul><ul><li>Stroke or TIA in asymptomatic carotid bruit is 1-3%/year </li></ul><ul><li>Routine auscultation of carotid artery is not recommended </li></ul>
    10. 25. CE in Asymptomatic carotid stenosis <ul><li>Stroke reduction by surgery is low 2% </li></ul><ul><li>CE if </li></ul><ul><li>Progressive lesion on follow-up </li></ul><ul><li>Ulcerative lesion </li></ul><ul><li>Contralateral carotid occlusion </li></ul><ul><li>Ipsilateral silent infarct </li></ul><ul><li>Severe stenosis </li></ul><ul><li>Associated coronary heart disease </li></ul>

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