From the Guidelines
Carotid stenosis is a condition where the carotid arteries, the major blood vessels in the neck that supply blood to the brain, narrow due to the buildup of fatty deposits called plaque, increasing the risk of stroke. This condition occurs when atherosclerosis, a process of plaque accumulation, takes place inside the artery walls, reducing blood flow to the brain. As the plaque accumulates, it narrows the artery's opening, and if left untreated, carotid stenosis can cause transient ischemic attacks (mini-strokes) or full strokes. According to 1, carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal, but such strokes could be largely prevented through optimal medical therapy and carotid revascularization.
Risk Factors and Treatment
Risk factors for carotid stenosis include smoking, high blood pressure, high cholesterol, diabetes, obesity, and family history of cardiovascular disease. Treatment depends on the severity of narrowing and may include:
- Lifestyle modifications, such as quitting smoking, diet changes, and exercise
- Medications, such as statins, blood thinners like aspirin or clopidogrel
- Surgical procedures, such as carotid endarterectomy or stenting, for severe cases Regular screening with ultrasound is recommended for those at high risk, as early detection and management can significantly reduce stroke risk, as noted in 1.
Management Approach
A unified knowledge foundation and multi-specialty collaborative guidelines are essential for optimal patient care, as proposed in 1. The Neuro-Vascular Team concept, which includes diverse specializations such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery, can provide personalized, stratified medicine approaches to individual patient needs. Patient education regarding current treatment options, their risks and advantages, is also pivotal in promoting patient’s active role in clinical care decisions. Optimal medical therapy and carotid revascularization can significantly reduce the risk of stroke in patients with carotid stenosis, and a multi-disciplinary approach to management is recommended.
From the Research
Definition and Symptoms of Carotid Stenosis
- Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery, leading to a wide range of symptoms, from mild symptoms, such as blurred vision and confusion, to life-threatening presentations, including paralysis due to stroke 2.
- The presentation of carotid stenosis is insidious, with symptoms exhibiting predominantly at severe stenosis, hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications 2.
Pathogenesis and Risk Factors
- Carotid stenosis undergoes almost the same pathogenesis as any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core 2.
- Comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, play a significant role in plaque development 2.
Diagnosis and Treatment
- Duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice for diagnosing carotid stenosis 2.
- Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes 2, 3.
- Medical management alone is also considered a viable option, especially for asymptomatic patients, due to comparable results in recent studies 2, 3.
Complications and Prognosis
- The risk of stroke is strongly related to stenosis severity and symptomatic status (stroke or transient ischemic attack within 6 months) 3.
- Advanced age, stroke, or hemispherical transient ischemic attack (TIA) as presenting symptoms are independent clinical predictors of the combined 30-day outcome measures, including any TIA, stroke, or death 4.
- Patients with crescendo transient ischemic attack have a higher risk of stroke or death after carotid endarterectomy compared to patients with a single transient ischemic attack or stable stroke 5.