Carotid artery disease

The modern period in the history of stroke began in the 1960s when C. Miller Fisher described detailed clinical and pathological observations on the features of lacunar strokes, carotid artery disease, transient ischemic attacks, and intracerebral hemorrhage. His student Louis Caplan established one of the first stroke registry... 

Carotid artery disease is one of the major causes of ischemic stroke. The predominant mechanisms by which it causes stroke are (a) arterial embolism from atherosclerotic plaques (b) hemodynamic changes, leading to watershed infarcts and (c) distal propagation of thrombus originating from acute carotid occlusion. ... 

Steinke W, Kloetzsch C, Hennerici M. Carotid artery disease assessed by color Doppler flow imaging correlation with standard Doppler sonography and angiography. AJR Am J... 

Symptomatic carotid artery disease (stroke or transient ischemic attack)... 

The clinical manifestations of PAD are associated with reduction in functional capacity and quality of life, but because of the systemic nature of the atherosclerotic process there is a strong association with coronary and carotid artery disease. Consequently, patients with PAD have an increased risk of cardiovascular and cerebrovascular ischemic events [myocardial infarction (Ml), ischemic stroke, and death] compared to the general population (4,5). In addition, these cardiovascular ischemic events are more frequent than ischemic limb events in any lower extremity PAD cohort, whether individuals present without symptoms or with atypical leg pain, classic claudication, or critical limb ischemia (6). Therefore, aggressive treatment of known risk factors for progression of atherosclerosis is warranted. In addition to tobacco cessation, encouragement of daily exercise and use of a low cholesterol, low salt diet, PAD patients should be offered therapies to reduce lipid levels, control blood pressure, control blood glucose in patients with diabetes mellitus, and offer other effective antiatherosclerotic strategies. A recent position paper... 

Pujia A, Rubba P Spencer M P Prevalence of extracranial carotid artery disease detectable by echo-Doppler in an elderly population. Stroke 1992 23 818-822. 

Kang DW, Chu K, Ko SB et al (2003b) Lesion patterns and mechanism of ischemia in internal carotid artery disease a diffusion-weighted imaging study. Arch Neurol 59 1577-1582... 

Georg Friedrich Handel s recurrent stroke is a well-documented historical case of cerebrovascular disease. He suffered from repeated palsies on his right side accompanied by speech impairment occurring in stroke-like episodes that must be considered left hemispheric ischemic events, possibly caused by left internal carotid artery disease (Bazner and Hennerici 2004). 

Fig 15.1. Diffusion-weighted imaging demonstrates different patterns of acute stroke in occlusive internal carotid artery disease 1, territorial stroke 2, subcortical stroke 3, territorial stroke with fragmentation 4, disseminated small lesions 5, borderzone infarction... 

Del Sette M, Eliasziw M, Streifler JY et al (2000) Internal borderzone infarction a marker for severe stenosis in patients with symptomatic internal carotid artery disease. Stroke 31 631-636... 

Waterston JA, Brown MM, Butler P et al (1990) Small deep cerebral infarcts associated with occlusive internal carotid artery disease. A hemodynamic phenomenon Arch Neurol 47 953-957... 

Powers WJ, Press GA, Grubb RL et al. (1987). The effect of haemodynamically significant carotid artery disease on the haemodynamic status of the cerebral circulation. Annals of Internal Medicine 106 27-34... 

Dilated episcleral vessels are a clue to abnormal anastamoses between branches of the external carotid artery and orbital branches of the internal carotid artery, distal to severe internal carotid artery disease. With extreme ischemia, ischemic oculopathy may develop, with impaired visual acuity, eye pain, rubeosis of the iris (dilated blood vessels), fixed dilated pupil, low-pressure glaucoma, cataract and corneal edema. 

Momjian-Mayor I, Baron JC (2005). The pathophysiology of watershed infarction in internal carotid artery disease review of cerebral perfusion studies. Stroke 36 567-577... 

Markus HS, Thomson ND, Brown MM (1995). Asymptomatic cerebral embolic signals in symptomatic and asymptomatic carotid artery disease. Brain 118 1005-1011... 

Schroeder T (1988). Hemodynamic significance of internal carotid artery disease. Acta Neurologica Scandinavica 77 353-372 Schroeder T, Sillesen H, Sorensen O et al. (1987). Cerebral hyperfusion following carotid endarterectomy. Journal of Neurosurgery 66 824-829 Shaw DA, Venables GS, Cartlidge NEF et al. (1984). Carotid endarterectomy in patients with transient cerebral ischaemia. Journal of Neurological Sciences 64 45-53 Silvestrini M, Vernieri F, Pasqualetti P et al. (2000). Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. 

In summary, the available data suggest that only approximately 40% of strokes complicating CABG could be attributable to ipsilateral carotid artery disease. The rate of death and... 

Carlson, C.S., Heagerty, P.J., Hatsukami, T.S., Richter, R.J., Ranchalis, J., Lewis, J., Bacus, T.J., McKinstry, L.A., Schel-lenberg, G.D., Rieder, M., Nickerson, D., Furlong, C.E., Chait, A., Jarvik, G.P. (2006). TagSNP and haplotype analyses of the paraoxonase gene cluster effects on PONl activity, LDL oxidative susceptibility, and carotid artery disease. J. Lipid Res. 47 1014-24. 

Apart from surgical and interventional therapy of occlusive carotid artery disease, the major approach to preventing vascular disease and subsequent stroke is to pay close attention to the control of modifiable risk factors such as hypertension, smoking, diabetes, and hypercholesterolemia. Coumadin, an anticoagulant, is effective for the primary and secondary prevention of stroke in patients with atrial fibrillation. Aspirin, clopidogrel, and the combination of aspirin and cUpyridamole have been proven to be effective for secondary stroke prevention along with the antihypertensive combination of indap-amide and perindopril. 

Because of all these complications spread of his cancer, hypertension, probably carotid artery disease and the aortic aneurysm, he was told by his doctors that nothing else could be done. He was sent home on one aspirin per day and some cardiac drugs. 

H NMR has been used to measure the metabolite levels in the centrum semiovale of patients with unilateral steno-occlusive carotid artery disease with... 

The Controversy 167 Risk Stratification of Patients With Asymptomatic CAS 168 Carotid Artrey Stenting for Asymptomatic Carotid Artery Disease 170 Summary 174 References 176... 

CAROTID ARTERY STENTING FOR ASYMPTOMATIC CAROTID ARTERY DISEASE... 

Carotid Artery Stenting with Embolic Protection in Asymptomatic Carotid Artery Disease... 

Eliasziw M, Kennedy J, Hill MD, Buchan AM, Barnett HJ. Early risk of stroke after a transient ischemic attack in patients with internal carotid artery disease. CMAJ 2004 Mar 30 170(7) 1105-9. 

Naylor AR, Mehta Z, Rothwell PM, Bell PRF. Carotid Artery Disease and Stroke During Coronary Artery Bypass a Critical Review of the Literature. Eur J Vase Endovasc Surg 2002 23 283-94. 

Marshall RS, Rundek T, Sproule DM, et al. Monitoring of cerebral vasodilatory capacity with transcranial Doppler carbon dioxide inhalation in patients with severe carotid artery disease. Stroke 2003 34 945-9. 

ABBREVIATIONS CHD, coronary heart disease CHD equivalent, peripheral vascular disease, abdominal aortic aneurysm, symptomatic carotid artery disease, >20% 10-year CHD risk, or diabetes mellitus LDL-C, low-density-lipoprotein cholesterol NCEP, National Cholesterol Education Program. 

Debrey, S.M., et al.. Diagnostic accuracy of magnetic resonance angiography for internal carotid artery disease a... 

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