Extracranial Carotid

Artery Disease
Dr Qusai Al-Jarrah

Jordan University of Science &

Technology

11/22/16

Anatomy
Brain supplied by 2 internals and 2 vertebrals. The

internal supply 80-90% of total blood flow.

The common carotids bifurcate at angle of mandible

into external and internal.

Branches of external are lingual, ascending pharyngeal,

superior thyroid, occipital, posterior auricular. The

terminal branches are int. maxillary and superficial
temporal a
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Epidemiology
ICA stenosis causes majority of all territorial TIAs/
strokes
Prevalence of asymptomatic ICA stenosis in
arteriopaths(2540%)
3rd LEADING CAUSE OF DEATH IN THE UK.
LARGEST CAUSE OF DISABILITY IN THE UK.
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Definitions
TIA: Transient hemispheric neurological deficits that may last
from several seconds to hours, but no longer than 24hrs.

Crescendo TIAs: TIAs in rapid succession interspersed with

complete recovery but with progressively smaller intervals
between attacks.

Amaurosis Fugax : Temporary monocular Blindness

(Hollenhorst plaques)
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Etiology
80% of Strokes are Ischemic.
Thromboembolism of the ICA or MCA 50%
Small Vessel Intracranial Disease 25%
Cardiac Embolism 15%
Haematological Disorders 5%
Non Atheromatous disease 5% (FMD, Arteritis)

20% of Strokes are Haemorrhagic.

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Jordan University of Science &

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Pathophysiology
Atherosclerotic CAD can cause stroke or TIA by 3
mechanisms:
1. By plaque or clot breaking off (debris) from the
carotid arteries and blocking a smaller artery in
the brain
2. Thrombotic occlusion of a severe stenosis
3. Hemodynamic failure. <2% of stokes
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Jordan University of Science &

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At bifurcation you get separation of flow, disruption of laminar flow, flow

stasis, prolonged residence time, shear stress

Grossly the plaque is thickest at the bifurcation, extending 2cm into distal
internal carotid.

The plaque occupies the media and intima, sparing the outer media and
adventitia.

The plaque tapers from the media into the normal intima.

Mature plaques are characterized by a heterogeneous core and fibrous

cap. Disruption of the cap leads to embolization and thrombosis. Also
exposes the non-endothelized intima to platelets (ulcer).
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A, complex reversal of flow along the posterior wall of the carotid sinus,most
vulnerable to plaque development

B, Established plaque at the carotid bifurcation

C, Soft, central necrotic core with an overlying thin fibrous cap,prone to plaque rupture

D, Disruption of the fibrous cap allows necrotic cellular debris and lipid material from
the central core to enter the lumen of the internal carotid artery - atherogenic
emboli.

E, The empty necrotic core becomes a deep ulcer in the plaque. The walls of the ulcer
are highly thrombogenic and reactive with platelets. This leads to thromboembolism
in the internal carotid artery circulation
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Risk Factors
HTN most important risk factor for stroke in
asymptomatic patients.
Male gender
Advancing age
Hyperlipidemia
Cigarette Smoking
Diabetes mellitus
Hx of Cerebrovascular Disease
Hyperhomocysteinemia
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Localization

Left carotid system TIAs manifest as:

motor dysfunction (dysarthria,weakness, paralysis, or clumsiness of the right extremities ) 1 (

and/or face)
loss of vision in the left eye (amaurosis fugax )) 2(
Sensory symptoms (numbness, including loss of sensation or involving the right upper) 3(
and/or lower extremity and/or face)
aphasia (language disturbance)) 4(

Right carotid system TIAs produce similar symptoms on the opposite

side, except that aphasia occurs only when the right hemisphere is
dominant for speech (left-handed individual)

Non hemispheric
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:Levels of Stenosis
Mild Stenosis <50%
Moderate Stenosis 50-69%
Severe Stenosis 70-99%

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Carotid Trials

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ASYMPTOMATIC CAROTID STENOSIS

Clinical trials

year risk 5

CEA

BMT

RRR

NNT

ACAS

5,1%

11,0%

54%

84

ACST

6,4%

11,8%

46%

70

13,4%

17,9%

26%

year risk 10

ACST

ACAS. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-1428

Halliday A et al. Prevention of disabling and fatal strokes by successful CEA in patients without recent
neurologic symptoms: a randomised controlled trial. Lancet 2004;363:1491-1502
Halliday A, et al. 10-year stroke prevention after successful CEA for asymptomatic carotid stenosis (ACST-1):
a multicenter randomised trial. Lancet 2010;376:1074-1084
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NASCET

NASCET, North American Asymptomatic Carotid Endartrectomy Trial, N Engl J Med. 1991;325:445-453
NASCET, North American Asymptomatic Carotid Endartrectomy Trial, N Engl J Med. 1998;339:1415-1425

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ACST- asymptomatic
endarterectomy v. medical therapy
Patients with >60%
stenosis
:day results 30 a)
CEA: 2.5%
BMT: 0.7%
:year results 5 b)

CEA
Medical

Years after randomization

CEA: 6.4%
BMT: 11.8%
P<0.0001

Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D; MRC Asymptomatic Carotid Surgery Trial (ACST)
20
Collaborative
Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent
.neurological symptoms: randomised controlled trial. Lancet. 2004 May 8;363(9420):1491-502

North American Symptomatic

Carotid Endarterectomy Trial

patients 659
day results 30
CEA: 5.8%
BMT: 3.3%

year results 2
CEA: 9%
BMT: 26%

21

North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in
.symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991 Aug 15;325(7):445-53

ESCT

ECST, European Carotid

Surgery Trial,
Lancet.
Jordan University
of Science
&
1998;351:1379-1387
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Cervical Bruit
Marker of systemic atherosclerosis
Frequency of Cervical Bruits:
4% in patients >45 yrs
12% in patients >60 yrs
Not indicative of severity of internal carotid artery
Stenosis
1/3 of patients with a 70-99% stenosis will not have a bruit.
1/3 of patients with an ICA occlusion will have an audible
Bruit
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Workup
Non contrast Brain CT
Colour- Flow Duplex Ultrasound
(Vulnerable Plaque)

MRA
CTA
Catheter Angiogram
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Treatment Modalities
Best Medical therapy
Carotid endarterectomy
Carotid artery stenting

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Stroke Prevention Strategies

Reduction in Blood Pressure
Cessation of Tobacco Use
Reduction in Serum Cholesterol
Aggressive Glycemic Control
Antiplatelet Therapy
Regular Physical Activity
Reduce Weight
Avoid Heavy consumption of alcohol
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August 7, 1953 DeBakey First CEA

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Indications for
Intervention

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Carotid Endartrectomy

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Carotid Endartrectomy

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Carotid Endartrectomy

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Post CEA Complications

The most serious > perioperative stroke.

inadequate collateral blood flow to the brain during temporary ICA
occlusion
embolization during dissection of the carotid artery
embolism or thrombosis of the reconstruction during the early
postoperative period
Embolization after carotid endarterectomy is usually secondary
to platelet aggregates forming on the surface of the
endarterectomized vessel. In contrast, thrombosis after carotid
endarterectomy usually is a result of sudden intimal dissection
due to a loose flap or inadequate distal endarterectomy endpoint.

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 Postoperative cranial nerve dysfunction (up to 35%)

recurrent laryngeal nerve, causing hoarseness

dysfunction of the hypoglossal nerve, causing deviation of the tongue

toward the side of the injury
Spinal Accessory nerve

superior laryngeal nerve dysfunction, causing easy fatigability of the voice.

Less common is injury of the marginal mandibular nerve, which results in

drooping of the nasolabial fold ipsilateral to the injury.
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 Wound Complications

Hyper perfusion Syndrome

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 Recurrent carotid stenosis (common but only rarely

serious)
less than 3% of patients experience symptomatic
recurrence.
within 6 months - is secondary to intimal hyperplasia,
characterized by both proliferation of vascular smooth
muscle cells and increased matrix deposition.
2 years or longer - recurrent atherosclerosis.

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Carotid Stenting

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Carotid Stenting

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Summary of the Winners

Incision = CAS
Cranial nerve injury = CAS
Anaesthetic = CAS
Haematoma = CAS
Hyperperfusion syndrome = CAS
Cerebral embolisation = CEA
Myocardial ischaemia = CAS
Restenosis = CEA
Generalisability and cost = CEA
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Carotid intervention for recently

symptomatic, severe carotid stenosisshould
be regarded as an emergency procedure in
patients who are neurologically stable, and
should ideally be performed within 48 hours
of a transient ischaemicattack or minor
stroke.The National Stroke Strategy. The UK
.Department of Health, 5th December 2007
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Carotid Artery Dissection

Accounts for 2% of strokes , 20% in young adults

20% of trauma patients with unexplained neurological

deficit will have suffered a dissection.
Spontaneous (FMD) , Iatrogenic , part of central Type A
dissection , Blunt trauma
Commonest presentation is ipsilateral head neck pain ,
but 50-75% will present with TIA/stroke , Painful Horners
Syndrome , ocular signs or cranial nerve palsies.
Management is conservative with anticoagulation.

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Jordan University of Science &

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Carotid Aneurysm
Rare < 4% of peripheral aneurysms
Definition : >150% of CCA , or twice the
diameter of distal ICA
CCA is most commonly affected, followed
closely by the ICA.
Etiology: AS, trauma, infection
Presentaion: Pulsatile swelling, Horners
Syndrome, TIA, dissection , rupture.
High incidence of cranial nerve compression
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Carotid Body Tumour

Neck paraganglioma arising from the bifurcation of the carotid artery
CB is located within the adventitia of the posterior aspect of the
carotid bifurcation
Monitors : blood gases and PH
5% are bilateral, 5% Malignant
More frequent at high altitudes
Accounts for 70% of extra adrenal Paragangliomas
MEN2A, MEN2B, VHL, NF1 , Familial PGL 1-4
1-3% SECRETORY (HTN, Headache , Palpitations R/O pheo)

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 There are 3 distinct types; familial (AD),

sporadic and hyperplastic forms.
Hyperplastic type is very common in
patients of COPD, patients of congenital
cyanotic heart disease and in the areas
which are more than 5000 feet above sea
level like New Mexico, Peru and Colorado.

Jordan University of Science &

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11/22/16

Jordan University of Science &

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11/22/16

Jordan University of Science &

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11/22/16