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Key Clinical Updates in Occlusive Cerebrovascular Disease

Transcervical carotid stenting, performed through a small incision at the base of the neck, avoids artery tortuosity and has lower embolization rates than transfemoral carotid stenting.

ESSENTIALS OF DIAGNOSIS

  • Sudden onset of weakness and numbness of an extremity or the face, aphasia, dysarthria, or unilateral blindness (amaurosis fugax).

  • Bruit heard loudest in the mid neck.

GENERAL CONSIDERATIONS

Unlike the other vascular territories, symptoms of ischemic cerebrovascular disease are predominantly due to emboli. The ischemia is reversible (transient ischemic attacks [TIAs]) when collateral flow reestablishes perfusion, but is a sign that the risk of additional emboli and a stroke is high (eFigure 12–6). Most ischemic strokes are due to emboli from the heart. One-quarter of all ischemic strokes may be due to emboli from an arterial source; approximately 90% of these emboli originate from the proximal internal carotid artery, an area uniquely prone to the development of atherosclerosis. Intracranial atherosclerotic lesions are uncommon in western populations but are the most frequent location of cerebrovascular disease in Asian populations.

eFigure 12–6.

Diagram showing common sites of stenosis and occlusion of the extracranial cerebral vasculature. (Reproduced, with permission, from Way LW [editor]. Current Surgical Diagnosis & Treatment, 10th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)

CLINICAL FINDINGS

A. Symptoms and Signs

Generally, the symptoms of a TIA last only a few seconds to minutes (but may continue up to 24 hours) while a stroke is defined as persistent symptoms beyond 24 hours. The most common lesions associated with carotid disease involve the anterior circulation in the cortex with both motor and sensory involvement. Emboli to the retinal artery cause unilateral blindness; transient monocular blindness is termed “amaurosis fugax.” Posterior circulation symptoms referable to the brainstem, cerebellum, and visual regions of the brain may be due to atherosclerosis of the vertebral basilar systems and are much less common.

Signs of cerebrovascular disease may include carotid artery bruits. However, there is poor correlation between the degree of stenosis and the presence of the bruit. Furthermore, the presence of a bruit does not correlate with stroke risk. Nonfocal symptoms, such as dizziness and unsteadiness, seldom are related to cerebrovascular atherosclerosis.

B. Imaging

Duplex ultrasonography is the imaging modality of choice with high specificity and sensitivity for detecting and grading the degree of stenosis at the carotid bifurcation (eFigure 12–7) (see Chapter 24).

eFigure 12–7.

Calcified plaque. Real-time scan of the common carotid artery and internal carotid artery demonstrates echogenic foci (arrows) with acoustical shadowing. (Reproduced, with permission, from Krebs CA, Giyanani VL, Eisenberg RL. Ultrasound Atlas of Disease Processes. Originally published by Appleton & ...

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