Management of asymptomatic carotid atherosclerotic disease
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Ronald M Fairman, MD
Ronald M Fairman, MD
- Professor of Surgery and Radiology
- University of Pennsylvania School of Medicine
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
The locations most frequently affected by carotid atherosclerosis are the proximal internal carotid artery (ie, the origin) and the common carotid artery bifurcation. Progression of atheromatous plaque at the carotid bifurcation results in luminal narrowing, often accompanied by ulceration. This process can lead to ischemic stroke or transient ischemic attack from embolization, thrombosis, or hemodynamic compromise.
This topic will review the treatment of asymptomatic extracranial carotid atherosclerotic disease. The management of symptomatic extracranial carotid disease is discussed separately. (See "Management of symptomatic carotid atherosclerotic disease".)
Other aspects of carotid occlusive disease are reviewed elsewhere. (See "Pathophysiology of symptoms from carotid atherosclerosis" and "Evaluation of carotid artery stenosis" and "Carotid endarterectomy" and "Intracranial large artery atherosclerosis".)
SCOPE OF THE PROBLEM
Asymptomatic carotid atherosclerotic disease refers to the presence of atherosclerotic narrowing of the extracranial internal carotid artery in individuals without a history of recent ipsilateral carotid territory ischemic stroke or transient ischemic attack (TIA).
In contradistinction, symptomatic carotid disease is defined as focal neurologic symptoms caused by TIAs or ischemic stroke in the carotid artery territory and ipsilateral to significant carotid atherosclerotic pathology. Although there is no precise time constraint, atherosclerotic carotid disease is considered symptomatic if carotid symptoms occurred within the previous six months. Thus, remote carotid symptoms are not considered as indicative of symptomatic carotid disease.
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- SCOPE OF THE PROBLEM
- Risk of stroke and cardiovascular events
- APPROACH TO MANAGEMENT
- Our approach
- Recommendations of others
- MEDICAL MANAGEMENT
- CAROTID ENDARTERECTOMY
- Endarterectomy trials
- Delay to benefit
- Perioperative complications
- Contralateral carotid stenosis or occlusion
- Stroke heterogeneity
- CAROTID STENTING
- Stenting trials
- Stenting in specific subgroups
- IDENTIFYING HIGH STROKE RISK
- Severity and progression of carotid stenosis
- Asymptomatic embolism
- Silent embolic infarcts
- Carotid plaque morphology
- Reduced cerebral blood flow reserve
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS