Carotid Stenosis: Etiology, Examination, Diagnosis

by Kevin Pei, MD

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    00:01 Welcome back.

    00:02 Thanks for joining me on this discussion of carotid stenosis in the section of vascular surgery.

    00:10 Carotid stenosis is a very common disease and there are some risk factors, particularly puts you at higher incidence.

    00:17 For example, smoking.

    00:19 In fact, smoking is a high-risk factor for most vascular diseases.

    00:24 There is some association with increased alcohol intake and, of course, like any peripheral vascular disease, when one has one peripheral vascular disease, one is at a higher association for another.

    00:38 In this situation, patients with coronary artery disease also may have carotid disease.

    00:43 This is an important distinction, because when patients have coronary artery disease, also think about working them up for bilateral carotid diseases.

    00:54 Let's discuss the pathophysiology of carotid diseases and atherosclerotic plaques.

    01:01 Here's a depiction of a common carotid bifurcation.

    01:05 It's, of course, situated in your neck.

    01:06 You can feel your own carotid pulses.

    01:09 Atherosclerotic plaques are dense in lipids and they usually occur at the carotid bifurcation.

    01:17 This is particularly because, at the bifurcation, laminar or straight-line flow becomes turbulent.

    01:24 And as turbulent flow occurs at the bifurcation, it perpetuates worsening of the atherosclerotic plaque.

    01:32 At some point, the plaque becomes so thick that it actually narrows the lumen of the vessels.

    01:38 That's when you become symptomatic.

    01:43 What are some common findings of carotid stenosis? One might actually hear a carotid bruit.

    01:48 When you listen to a patient who has a carotid stenosis, the carotid bruit actually sounds like, well, turbulent flow, as I previously described.

    01:57 Some patients will also describe transient ischemic attacks, also known as TIAs.

    02:04 In these select patients, it's a warning sign.

    02:07 Patients may have intermittent stroke symptoms that are self-contained.

    02:12 They may have completely resolved by the time the patient even presents to your office or the emergency room, but don't lose these patients to follow up.

    02:21 They may actually have significant carotid disease.

    02:27 This is a depiction of a curtain drawn down or a shade over a window.

    02:32 And that's a classic description of amaurosis fugax.

    02:36 That's the transient monocular blindness that's associated with plaques.

    02:41 And those plaques may be distributing themselves into the ophthalmic artery.

    02:45 Next.

    02:46 Patients may actually have CVAs or stroke.

    02:49 CVA stands for cerebrovascular accidents.

    02:54 This is most likely due to portions of the atherosclerotic plaque breaking off and being embolic.

    03:01 Also, when the channel is so stenotic that the flow is inadequate, one may actually have a broader distribution ischemic stroke.

    03:10 Labs are unlikely to be helpful to you, but it is very important to screen for carotid disease when you have high suspicions.

    03:18 How do we screen for carotid disease? I’ll give you a second to think about it.

    03:25 That's right.

    03:26 Carotid duplex ultrasonography.

    03:29 As with all ultrasounds, the results and accuracy of these tests are heavily operator dependent.

    03:35 Let's say the clinical scenario is a patient who presents to your office.

    03:39 They describe symptoms consistent with TIAs or amaurosis fugax.

    03:44 The next step of management will be obtain a carotid duplex ultrasound.

    03:50 Duplexes are helpful not only because they give you anatomic information, but more importantly, for stenotic vessels, they give you velocity information.

    04:00 Recall, flow through a smaller diameter is usually at higher velocities.

    04:06 That’s simple physics. A certain velocity, as described as centimeters per second, is indicative of a percentage of carotid stenosis.

    04:16 This is an approximation of course.

    04:19 Angiography.

    04:21 For many years, angiography was the gold standard.

    04:24 I'm talking about the invasive interventional angiography, of course, not the spiral CAT scan angiographies.

    04:32 In this representative invasive angiography, the arrow points at an area that’s most likely representative of a plaque.

    04:39 Note, it's very close to the bifurcation.

    About the Lecture

    The lecture Carotid Stenosis: Etiology, Examination, Diagnosis by Kevin Pei, MD is from the course Special Surgery.

    Included Quiz Questions

    1. Obtain a carotid duplex ultrasound
    2. Perform carotid endarterectomy
    3. Obtain an echocardiogram
    4. Perform carotid stenting
    5. Perform applanation tonometry
    1. Marijuana abuse
    2. Smoking
    3. Coronary artery disease
    4. Alcohol
    5. High cholesterol levels

    Author of lecture Carotid Stenosis: Etiology, Examination, Diagnosis

     Kevin Pei, MD

    Kevin Pei, MD

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