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Carotid Bruit
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Carotid Bruit
, Carotid Artery Stenosis, Carotid Stenosis
See Also
Transient Ischemic Attack
Arteriosclerotic Carotidynia
Technique
See
Arterial Bruit
Interpretation
Carotid Bruit
Findings in which Carotid Bruit is more suggestive of significant carotid lesion
Diastolic component is the only characteristic reliably specific for significant Carotid Bruit
Carotid Bruit AND symptoms suggestive of Carotid Stenosis
Degree of stenosis by atherosclerotic
Plaque
Minimum stenosis causing bruit: 50% (<3 mm lumen)
Prolonged, high-pitched bruit: >75% (1.5 mm lumen)
Location
Plaque
involves posterior wall of common carotid
Affects bifurcation and flow into internal carotid
Risk of distal thrombus formation in internal carotid
Carotid Bruit associated risk of stroke at 1 year
Asymptomatic Carotid Bruit: 1% risk at 1 year
Transient Ischemic Attack
history: 1.7% risk
Other studies question bruit significance
Carotid Bruit has poor efficacy
Test Sensitivity
: 40% for those with >50% Carotid Stenosis
False Positive
s: 10% with Carotid Bruits have <50% Carotid Stenosis
References
Brown (2017) Stroke and
Cerebrovascular Disease
Update, Mayo Clinical Reviews, Rochester
Symptoms
Contralateral weakness or numbness
Ipsilateral blindness
Dominant hemisphere involvement
Dysphasia
Aphasia
Apraxia
Imaging
Preferred First-Line Studies
Carotid Artery
Duplex
Ultrasonography
Standard first-line diagnostic tool for Carotid Stenosis
However, do not make clinical decisions based on
Ultrasound
alone (due to
False Positive
s)
Confirm findings with either a MRA or CTA
Less expensive than MRA
Accuracy for diagnosing severe Carotid Stenosis
Test Sensitivity
: 86%
Test Specificity
: 87%
Carotid Magnetic Resonance Angiography (MRA)
Better than
Ultrasound
at defining carotid anatomy
Accuracy for diagnosing severe Carotid Stenosis
Test Sensitivity
: 95%
Test Specificity
: 90%
References
Nederkoorn (2003) Stroke 34:1324-32 [PubMed]
Imaging
Other studies
CT Angiography with 3D reconstruction
Requires intravenous iodinated contrast exposure
Emerging technology that has not been fully evaluated
Significant radiation exposure
Angiography
Gold standard which allows evaluation of the entire carotid system
Invasive procedure with risk of neurologic complications
Now used primarily to resolve imaging discrepancies in perioperative period
Management
Symptomatic Carotid Stenosis
Endarterectomy carries risk of significant morbidity
Cognitive changes may be difficult to discern
Risk of CVA within 30 days of procedure: 7%
Symptomatic patient with Carotid Stenosis >70%
Intervention offers greatest benefit (17%
Absolute Risk Reduction
at 2 years per NASCET study)
Significant benefit from carotid endarterectomy
Benefits include patients over age 75 years
Symptomatic patient with Carotid Stenosis 50 to 69%
Benefit from carotid endarterectomy
Benefits include patients over age 75 years
Symptomatic patient with Carotid Stenosis <50%
No benefit from carotid endarterectomy
See
Prevention of Ischemic Stroke
Management
Asymptomatic Carotid Stenosis >60%
Medical therapy: Indicated if Carotid Stenosis <80%
Overall CVA Risk on medical therapy: 12% CVA 5 year risk
See
Prevention of Ischemic Stroke
Hypertension
control (typical goal is <130/80)
Exercise
caution with bilateral Carotid Stenosis
Hyperlipidemia
control with
Statin
s
Antiplatelet options
Aspirin
Other antiplatelet agents are not recommended
Clopidogrel
(
Plavix
)
Do not use concurrently with
Aspirin
Aspirin
with
Dipyridamole
(
Aggrenox
)
Surgical Procedures: Indicated if Carotid Stenosis >80%
Overall CVA Risk on surgical therapy: 6% CVA 5 year risk
Relative contraindications to carotid endarterectomy
Women show less benefit in asymptomatic Carotid Stenosis
Life Expectancy
<5 years
Active cardiovascular disease
Age over 80 years
Concomitant intranial stenosis
Contralateral Carotid Stenosis
Surgical Options
Carotid endarterectomy or
Angioplasty
, stent, distal protection
As effective as carotid endarterectomy
May be preferred in patients at high risk of complications due to comorbidity
(2006) Lancet 368:1239-47 [PubMed]
Park (2006) Am J Surg 192: 583-8 [PubMed]
Recent European trials (SPACE and EVA-3S) showed high complication rate
However these trials did not consistently use distal protection devices
References
Alamowitch (2001) Lancet 357:1154-60 [PubMed]
Ellis (1992) Eur J Vasc Surg 6(2):172-7 [PubMed]
Gutierrez (1985) Am Surg 51(7):388-91 [PubMed]
Halliday (2004) Lancet 363:1491-502 [PubMed]
Rothwell (2003) Lancet 361:107-16 [PubMed]
Shorr (1998) J Gen Intern Med 13(2):86-90 [PubMed]
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