Should an elderly male with a 60-year smoking history, presenting with left-sided headache radiating to the neck and arm, and 40% carotid (carotid artery) stenosis on Computed Tomography Angiography (CTA), be referred to a vascular surgeon?

Management of 40% Carotid Stenosis with Focal Neurological Symptoms

This patient should be evaluated by a neurologist or stroke specialist rather than referred directly to a vascular surgeon, as the 40% stenosis does not meet criteria for surgical intervention and the symptoms require comprehensive neurological assessment to determine their etiology. 1

Rationale for This Approach

Why Not Immediate Vascular Surgery Referral

• The American College of Cardiology/American Heart Association guidelines clearly state that carotid revascularization (endarterectomy or stenting) is only considered for severe stenosis ≥70% 2
• At 40% stenosis, this patient falls well below the threshold where surgical intervention provides benefit, even in symptomatic patients 1
• The symptoms described (headache radiating to neck and arm) are atypical for carotid territory ischemia, which typically presents with focal neurological deficits like weakness, numbness in specific distributions, or visual changes—not headache as a primary symptom 1

The Critical Diagnostic Question

The key issue is determining whether these symptoms actually represent carotid territory ischemia or an alternative diagnosis:

• Headache with neck and arm radiation is not a typical presentation of carotid stenosis-related ischemia 1, 3
• The American College of Cardiology recommends that when extracranial carotid disease is not severe enough to account for neurological symptoms of suspected ischemic origin, additional evaluation should be performed to search for alternative causes 1
• Carotid duplex ultrasonography is not recommended for routine evaluation of patients with neurological symptoms unrelated to focal cerebral ischemia (Class III: No Benefit) 1

Appropriate Next Steps

Immediate actions:

1. Neurological evaluation to characterize the symptoms and determine if they represent true cerebral ischemia 1
2. Brain imaging (MRI preferred) to assess for evidence of acute or chronic ischemia 1
3. Evaluation for alternative diagnoses including cervical spine pathology, tension headache, migraine, or other causes of radicular symptoms 1

If symptoms are confirmed to be ischemic in nature:

• The American College of Cardiology recommends that patients with focal ischemic neurological symptoms corresponding to carotid territory should have noninvasive imaging to detect extracranial carotid and vertebral artery disease 1
• When carotid stenosis is insufficient to explain symptoms, echocardiography should be performed to search for cardioembolic sources 1
• Additional intracranial vascular imaging (CTA or MRA) may be needed to identify intracranial disease 1

Aggressive Medical Management is the Primary Treatment

Regardless of symptom etiology, this patient requires intensive medical therapy given the presence of carotid atherosclerosis and extensive smoking history:

Class I Recommendations (Must Do)

• Antiplatelet therapy with aspirin 75-325 mg daily for prevention of myocardial infarction and other ischemic cardiovascular events 1
• Statin therapy to reduce LDL cholesterol below 100 mg/dL (or near/below 70 mg/dL if ischemic stroke is confirmed) 1
• Antihypertensive treatment to maintain blood pressure below 140/90 mm Hg 1
• Smoking cessation interventions are critical given the 60-year smoking history 1

The ESC 2025 Consensus Statement emphasizes:

• Identification of patients with carotid stenosis enables use of triple medical therapy (antiplatelet, statin, antihypertensive) to substantially reduce overall cardiovascular risk 1
• The cardiovascular risk from systemic atherosclerosis far exceeds the stroke risk from 40% carotid stenosis 4

Surveillance Strategy

For this degree of stenosis:

• Annual duplex ultrasonography is reasonable to assess progression or regression of disease 1, 2
• The American College of Cardiology recommends surveillance be performed by a qualified technologist in a certified laboratory 1, 2
• Once stability is established over an extended period, longer intervals or termination of surveillance may be appropriate 1, 2

When to Reconsider Vascular Surgery Referral

Vascular surgery consultation becomes appropriate if:

• Follow-up imaging demonstrates progression to ≥70% stenosis 2
• The patient develops clear focal neurological deficits attributable to carotid territory ischemia with confirmed stenosis ≥50-70% 1
• There is rapid progression of stenosis on serial imaging 1

Critical Pitfalls to Avoid

• Do not refer for carotid revascularization based solely on the presence of stenosis <50%, even with symptoms, as this does not meet evidence-based criteria for intervention 1
• Do not assume headache represents carotid territory ischemia without comprehensive neurological evaluation and brain imaging 1, 5
• Do not neglect the much higher risk of cardiovascular events (myocardial infarction, cardiovascular death) compared to stroke risk in patients with carotid atherosclerosis 4
• Do not fail to implement aggressive medical therapy, which is the cornerstone of treatment for this degree of stenosis 1