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Surgery - Carotid Artery Disease (Atherosclerosis)
Introduction
Atherosclerosis-induced carotid artery narrowing is a common cause of stroke.
Etiology
By causing distal embolization, thrombosis, or poor flow, atheromatous plaque at the common carotid bifurcation or any of the carotid branches might result in stroke or blindness. Atherosclerosis is widespread in the carotid artery bifurcation, a region of the vascular tree. Local hemodynamics, such as low shear stress and "turbulence affecting the outer walls opposite the flow divider," in conjunction with systemic risk factors, predispose to the formation of atheroma, luminal constriction, and the risk of plaque rupture, thrombosis, or embolism.
Epidemiology
frequent, a major contributor to long-term impairment and the third greatest cause of death in the UK, frequency increases with age and is more frequent in men.
History
frequently asymptomatic.
Amaurosis fugax: An embolism into the ophthalmic artery (an internal carotid artery branch) causes a transient unilateral vision loss that is described as "like a curtain coming down."
Temporary ischemic episodes (TIAs): Severe symptoms that persist less than a day could be a sign of an impending stroke. Following a TIA, people with an ABCD2 score of 4 (which requires immediate examination and treatment) are more likely to get a stroke.
Factor ABCD2
Age over 59 years old: 1 point
Presentation BP of 140/90 (1 point)
Clinical Characteristic :
Disturbance in speech but no weakness (1 point)
One-sided vulnerability (2 points)
Duration (minutes): 10–59 (1 point)
>60 (2 points)
Diabetes (1 point)
Crescendo TIAs are TIAs that get longer, more severe, or happen more frequently. This is linked to a significant internal carotid artery stenosis.
Stroke: Long-lasting neurological impairment (based on the infarct-affected region).
Examination
Examined normally shows no abnormalities if asymptomatic.
The degree of stenosis is not indicated by the presence of a carotid bruit.
symptoms of a TIA or CVA, such as limb weakness, dysphasia, or dysarthria.
Investigations
This non-invasive imaging method uses duplex Doppler carotid ultrasound to measure the degree of stenosis.
Brain and carotid imaging using CT, CTA, MRI, and MRA (Fig. 35).
Angiography: Very accurate measurement of the severity of stenosis, invasive (stroke risk ∉1%).
Management
The 90-day risk of recurrent stroke was found to be 80% lower with prompt assessment and treatment, according to the Early Usage of Existing Preventive Strategies for Stroke (EXPRESS) research. A TIA clinic should see everyone who has had a TIA or mild stroke (urgency evaluated by ABCD2 rating).
Medical treatment for: asymptomatic stenosis, <70% internal carotid artery stenosis (ECST criteria), <50% (NASCET criteria), or inoperable illness; low-dose aspirin; cessation of smoking; and treatment of additional risk factors, hypercholesterolemia, hypertension, and diabetes.
Surgical intervention: Carotid endarterectomy, however associated with a high perioperative risk, lowers the risk of further stroke in ECST and NASCET trials when performed within two weeks following a stroke or TIA.
May be taken into consideration in cases of crescendo TIAs that do not respond to therapy, symptomatic stenosis of 70–99% (ECST criteria), or 50–99% (NASCET criteria).
It is debatable whether surgery should be used to treat a disease that shows no symptoms.
Angioplasty, with or without stenting: A comparison with carotid endarterectomy for symptomatic illness is now being conducted.
Complications
Disease-related complications: thromboembolic or watershed stroke.
Surgical complications: Cardiac ischaemia or infarction (3%), nerve injury (2–7%, mandibular branch of facial nerve, recurrent laryngeal or hypoglossal nerves), haematoma, hypertension, hypotension, perioperative stroke (1–5%). There is a 0.5-2.8% perioperative mortality rate.
Prognosis
The annual stroke rate is 10–20% with carotid artery stenosis greater than 70%.
In patients with severe stenosis, surgical correction can result in a six- to eight-fold reduction in stroke risk when compared to the best medical therapy alone.
Introduction
Atherosclerosis-induced carotid artery narrowing is a common cause of stroke.
Etiology
By causing distal embolization, thrombosis, or poor flow, atheromatous plaque at the common carotid bifurcation or any of the carotid branches might result in stroke or blindness. Atherosclerosis is widespread in the carotid artery bifurcation, a region of the vascular tree. Local hemodynamics, such as low shear stress and "turbulence affecting the outer walls opposite the flow divider," in conjunction with systemic risk factors, predispose to the formation of atheroma, luminal constriction, and the risk of plaque rupture, thrombosis, or embolism.
Epidemiology
frequent, a major contributor to long-term impairment and the third greatest cause of death in the UK, frequency increases with age and is more frequent in men.
History
frequently asymptomatic.
Amaurosis fugax: An embolism into the ophthalmic artery (an internal carotid artery branch) causes a transient unilateral vision loss that is described as "like a curtain coming down."
Temporary ischemic episodes (TIAs): Severe symptoms that persist less than a day could be a sign of an impending stroke. Following a TIA, people with an ABCD2 score of 4 (which requires immediate examination and treatment) are more likely to get a stroke.
Factor ABCD2
Age over 59 years old: 1 point
Presentation BP of 140/90 (1 point)
Clinical Characteristic :
Disturbance in speech but no weakness (1 point)
One-sided vulnerability (2 points)
Duration (minutes): 10–59 (1 point)
>60 (2 points)
Diabetes (1 point)
Crescendo TIAs are TIAs that get longer, more severe, or happen more frequently. This is linked to a significant internal carotid artery stenosis.
Stroke: Long-lasting neurological impairment (based on the infarct-affected region).
Examination
Examined normally shows no abnormalities if asymptomatic.
The degree of stenosis is not indicated by the presence of a carotid bruit.
symptoms of a TIA or CVA, such as limb weakness, dysphasia, or dysarthria.
Investigations
This non-invasive imaging method uses duplex Doppler carotid ultrasound to measure the degree of stenosis.
Brain and carotid imaging using CT, CTA, MRI, and MRA (Fig. 35).
Angiography: Very accurate measurement of the severity of stenosis, invasive (stroke risk ∉1%).
Management
The 90-day risk of recurrent stroke was found to be 80% lower with prompt assessment and treatment, according to the Early Usage of Existing Preventive Strategies for Stroke (EXPRESS) research. A TIA clinic should see everyone who has had a TIA or mild stroke (urgency evaluated by ABCD2 rating).
Medical treatment for: asymptomatic stenosis, <70% internal carotid artery stenosis (ECST criteria), <50% (NASCET criteria), or inoperable illness; low-dose aspirin; cessation of smoking; and treatment of additional risk factors, hypercholesterolemia, hypertension, and diabetes.
Surgical intervention: Carotid endarterectomy, however associated with a high perioperative risk, lowers the risk of further stroke in ECST and NASCET trials when performed within two weeks following a stroke or TIA.
May be taken into consideration in cases of crescendo TIAs that do not respond to therapy, symptomatic stenosis of 70–99% (ECST criteria), or 50–99% (NASCET criteria).
It is debatable whether surgery should be used to treat a disease that shows no symptoms.
Angioplasty, with or without stenting: A comparison with carotid endarterectomy for symptomatic illness is now being conducted.
Complications
Disease-related complications: thromboembolic or watershed stroke.
Surgical complications: Cardiac ischaemia or infarction (3%), nerve injury (2–7%, mandibular branch of facial nerve, recurrent laryngeal or hypoglossal nerves), haematoma, hypertension, hypotension, perioperative stroke (1–5%). There is a 0.5-2.8% perioperative mortality rate.
Prognosis
The annual stroke rate is 10–20% with carotid artery stenosis greater than 70%.
In patients with severe stenosis, surgical correction can result in a six- to eight-fold reduction in stroke risk when compared to the best medical therapy alone.
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