Screening for asymptomatic carotid artery stenosis
- Mark O McCarron, MD, FRCP
Mark O McCarron, MD, FRCP
- Consultant Neurologist
- Altnagelvin Hospital
- Larry B Goldstein, MD, FAAN, FANA, FAHA
Larry B Goldstein, MD, FAAN, FANA, FAHA
- Professor and Chairman of Neurology
- Co-Director, Kentucky Neuroscience Institute
- KY Clinic - University of Kentucky
- David B Matchar, MD
David B Matchar, MD
- Professor and Director, Program in Health Services and Systems Research
- Duke-NUS Graduate Medical School Singapore
- Section Editors
- Joann G Elmore, MD, MPH
Joann G Elmore, MD, MPH
- Editor-in-Chief — Primary Care (Adult)
- Section Editor — General Medicine
- Professor of Medicine, Adjunct Professor of Epidemiology
- University of Washington School of Medicine
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
Stroke is the second leading cause of death worldwide and the fourth leading cause of death in the United States (US), behind heart disease, cancer, and respiratory disease . The prevalence of stroke has been rising gradually with the increasingly aging population, despite evidence of a decline in stroke incidence .
The impact of stroke is often devastating, with a 20 percent mortality from the acute event and 40 to 50 percent survival at five years [1,3]. Among survivors, data from the Framingham study reveal that 18 percent are unable to return to work, while up to 4 percent require total custodial care . One-quarter of those over age 65 years require long-term institutional care after a first stroke . Thrombolytic therapy can salvage brain tissue in some patients who present acutely with an ischemic stroke, but such patients represent only a small fraction of those having an acute stroke. Although novel interventions to promote poststroke recovery are being investigated, there is little that can be done to reverse the devastating effects of brain injury aside from standard rehabilitative interventions for the majority who go on to have a completed stroke. For this reason, the greatest impact on this disease comes from prevention.
Patients who have had a stroke or transient ischemic attack (TIA) due to carotid stenosis are considered symptomatic and often benefit from early carotid revascularization if the stroke is related to a high-grade stenosis of the extracranial carotid artery . Patients with carotid artery stenosis are considered to be symptomatic if they have had recent (within six months) transient or permanent focal neurologic symptoms related to the affected artery (eg, ipsilateral amaurosis fugax, contralateral weakness or numbness of an extremity or the face, dysarthria or aphasia). In contrast, nonspecific neurologic symptoms (eg, dizziness or syncope/near syncope) are not considered in the definition of symptomatic carotid stenosis . (See "Management of symptomatic carotid atherosclerotic disease", section on 'Carotid endarterectomy'.)
Carotid stenosis may also be identified in asymptomatic patients. The cutoff used to define clinically significant carotid artery stenosis varies among studies, ranging from 50 to 70 percent stenosis [7-9].
Optimal management of patients with asymptomatic carotid stenosis to prevent stroke is not established. The therapeutic options, which are discussed in detail elsewhere, include medical management to address risk factors for atherosclerosis, focusing on control of hypertension, diabetes mellitus, smoking, and dyslipidemia; the administration of antiplatelet drugs to prevent platelet aggregation; and surgical revascularization by carotid endarterectomy (CEA) or carotid artery stenting (CAS). (See "Overview of secondary prevention of ischemic stroke" and "Management of asymptomatic carotid atherosclerotic disease".)
- Roger VL, Go AS, Lloyd-Jones DM, et al. Executive summary: heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation 2012; 125:188.
- Rothwell PM, Coull AJ, Giles MF, et al. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004; 363:1925.
- Messina L, Zelenock G. Cerebrovascular Occlusive Disease. In: Surgery — Scientific Principles and Practice, Greenfield L (Ed), Lippincott-Raven, Philadelphia 1997. p.1745.
- Gresham GE, Fitzpatrick TE, Wolf PA, et al. Residual disability in survivors of stroke--the Framingham study. N Engl J Med 1975; 293:954.
- Rothwell PM, Eliasziw M, Gutnikov SA, et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363:915.
- Lanzino G, Rabinstein AA, Brown RD Jr. Treatment of carotid artery stenosis: medical therapy, surgery, or stenting? Mayo Clin Proc 2009; 84:362.
- Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273:1421.
- Chambers BR, Donnan GA. Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane Database Syst Rev 2005; :CD001923.
- Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363:1491.
- Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42:517.
- de Weerd M, Greving JP, de Jong AW, et al. Prevalence of asymptomatic carotid artery stenosis according to age and sex: systematic review and metaregression analysis. Stroke 2009; 40:1105.
- de Weerd M, Greving JP, Hedblad B, et al. Prevalence of asymptomatic carotid artery stenosis in the general population: an individual participant data meta-analysis. Stroke 2010; 41:1294.
- Wolff T, Guirguis-Blake J, Miller T, et al. Screening for carotid artery stenosis: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2007; 147:860.
- Naylor AR. What is the current status of invasive treatment of extracranial carotid artery disease? Stroke 2011; 42:2080.
- Raman G, Moorthy D, Hadar N, et al. Management strategies for asymptomatic carotid stenosis: a systematic review and meta-analysis. Ann Intern Med 2013; 158:676.
- Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke 2009; 40:e573.
- Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 2010; 41:e11.
- Hankey GJ, Warlow CP, Sellar RJ. Cerebral angiographic risk in mild cerebrovascular disease. Stroke 1990; 21:209.
- Chambers BR, Norris JW. Clinical significance of asymptomatic neck bruits. Neurology 1985; 35:742.
- Pickett CA, Jackson JL, Hemann BA, Atwood JE. Carotid bruits and cerebrovascular disease risk: a meta-analysis. Stroke 2010; 41:2295.
- Chambers BR, Norris JW. Outcome in patients with asymptomatic neck bruits. N Engl J Med 1986; 315:860.
- Heyman A, Wilkinson WE, Heyden S, et al. Risk of stroke in asymptomatic persons with cervical arterial bruits: a population study in Evans County, Georgia. N Engl J Med 1980; 302:838.
- Meissner I, Wiebers DO, Whisnant JP, O'Fallon WM. The natural history of asymptomatic carotid artery occlusive lesions. JAMA 1987; 258:2704.
- McColgan P, Bentley P, McCarron M, Sharma P. Evaluation of the clinical utility of a carotid bruit. QJM 2012; 105:1171.
- Wolf PA, Kannel WB, Sorlie P, McNamara P. Asymptomatic carotid bruit and risk of stroke. The Framingham study. JAMA 1981; 245:1442.
- Shorr RI, Johnson KC, Wan JY, et al. The prognostic significance of asymptomatic carotid bruits in the elderly. J Gen Intern Med 1998; 13:86.
- Van Ruiswyk J, Noble H, Sigmann P. The natural history of carotid bruits in elderly persons. Ann Intern Med 1990; 112:340.
- Rea T. The role of carotid bruit in screening for carotid stenosis. Ann Intern Med 1997; 127:657.
- O'Leary DH, Anderson KM, Wolf PA, et al. Cholesterol and carotid atherosclerosis in older persons: the Framingham Study. Ann Epidemiol 1992; 2:147.
- Bogousslavsky J, Despland PA, Regli F. Asymptomatic tight stenosis of the internal carotid artery: long-term prognosis. Neurology 1986; 36:861.
- Autret A, Pourcelot L, Saudeau D, et al. Stroke risk in patients with carotid stenosis. Lancet 1987; 1:888.
- Pickett CA, Jackson JL, Hemann BA, Atwood JE. Carotid bruits as a prognostic indicator of cardiovascular death and myocardial infarction: a meta-analysis. Lancet 2008; 371:1587.
- Blakeley DD, Oddone EZ, Hasselblad V, et al. Noninvasive carotid artery testing. A meta-analytic review. Ann Intern Med 1995; 122:360.
- Nederkoorn PJ, van der Graaf Y, Hunink MG. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review. Stroke 2003; 34:1324.
- Wardlaw JM, Chappell FM, Best JJ, et al. Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis. Lancet 2006; 367:1503.
- Johnston DC, Goldstein LB. Clinical carotid endarterectomy decision making: noninvasive vascular imaging versus angiography. Neurology 2001; 56:1009.
- Derdeyn CP, Powers WJ. Cost-effectiveness of screening for asymptomatic carotid atherosclerotic disease. Stroke 1996; 27:1944.
- Markus HS, King A, Shipley M, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol 2010; 9:663.
- Madani A, Beletsky V, Tamayo A, et al. High-risk asymptomatic carotid stenosis: ulceration on 3D ultrasound vs TCD microemboli. Neurology 2011; 77:744.
- Topakian R, King A, Kwon SU, et al. Ultrasonic plaque echolucency and emboli signals predict stroke in asymptomatic carotid stenosis. Neurology 2011; 77:751.
- Sabeti S, Schlager O, Exner M, et al. Progression of carotid stenosis detected by duplex ultrasonography predicts adverse outcomes in cardiovascular high-risk patients. Stroke 2007; 38:2887.
- King A, Shipley M, Markus H, ACES Investigators. The effect of medical treatments on stroke risk in asymptomatic carotid stenosis. Stroke 2013; 44:542.
- Côté R, Battista RN, Abrahamowicz M, et al. Lack of effect of aspirin in asymptomatic patients with carotid bruits and substantial carotid narrowing. The Asymptomatic Cervical Bruit Study Group. Ann Intern Med 1995; 123:649.
- Hebert PR, Moser M, Mayer J, et al. Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Arch Intern Med 1993; 153:578.
- Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42:e464.
- Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005; 353:2643.
- Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358:2545.
- Shepherd J, Barter P, Carmena R, et al. Effect of lowering LDL cholesterol substantially below currently recommended levels in patients with coronary heart disease and diabetes: the Treating to New Targets (TNT) study. Diabetes Care 2006; 29:1220.
- Reboldi G, Gentile G, Angeli F, et al. Effects of intensive blood pressure reduction on myocardial infarction and stroke in diabetes: a meta-analysis in 73,913 patients. J Hypertens 2011; 29:1253.
- Kawachi I, Colditz GA, Stampfer MJ, et al. Smoking cessation and decreased risk of stroke in women. JAMA 1993; 269:232.
- Amarenco P, Labreuche J. Lipid management in the prevention of stroke: review and updated meta-analysis of statins for stroke prevention. Lancet Neurol 2009; 8:453.
- Corti R, Fayad ZA, Fuster V, et al. Effects of lipid-lowering by simvastatin on human atherosclerotic lesions: a longitudinal study by high-resolution, noninvasive magnetic resonance imaging. Circulation 2001; 104:249.
- Wyman RA, Gimelli G, McBride PE, et al. Does detection of carotid plaque affect physician behavior or motivate patients? Am Heart J 2007; 154:1072.
- Hollands GJ, Hankins M, Marteau TM. Visual feedback of individuals' medical imaging results for changing health behaviour. Cochrane Database Syst Rev 2010; :CD007434.
- Johnson HM, Einerson J, Korcarz CE, et al. Long-term effects of carotid screening on patient outcomes and behaviors. Arch Intern Med 2011; 171:589.
- Rodondi N, Collet TH, Nanchen D, et al. Impact of carotid plaque screening on smoking cessation and other cardiovascular risk factors: a randomized controlled trial. Arch Intern Med 2012; 172:344.
- The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet 1997; 349:1569.
- CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet 1997; 349:1641.
- Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324:71.
- Final report on the aspirin component of the ongoing Physicians' Health Study. Steering Committee of the Physicians' Health Study Research Group. N Engl J Med 1989; 321:129.
- Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005; 352:1293.
- US Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 150:396.
- 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; 325:445.
- MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet 1991; 337:1235.
- Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351:1379.
- Schneider PA, Naylor AR. Asymptomatic carotid artery stenosis--medical therapy alone versus medical therapy plus carotid endarterectomy or stenting. J Vasc Surg 2010; 52:499.
- Woo K, Garg J, Hye RJ, Dilley RB. Contemporary results of carotid endarterectomy for asymptomatic carotid stenosis. Stroke 2010; 41:975.
- Beckman JA. Management of asymptomatic internal carotid artery stenosis. JAMA 2013; 310:1612.
- Rudarakanchana N, Dialynas M, Halliday A. Asymptomatic Carotid Surgery Trial-2 (ACST-2): rationale for a randomised clinical trial comparing carotid endarterectomy with carotid artery stenting in patients with asymptomatic carotid artery stenosis. Eur J Vasc Endovasc Surg 2009; 38:239.
- Rothwell PM, Goldstein LB. Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial. Stroke 2004; 35:2425.
- Murad MH, Shahrour A, Shah ND, et al. A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs stenting. J Vasc Surg 2011; 53:792.
- De Rango P, Parlani G, Verzini F, et al. Long-term prevention of stroke: a modern comparison of current carotid stenting and carotid endarterectomy. J Am Coll Cardiol 2011; 57:664.
- Liapis CD, Bell PR, Mikhailidis D, et al. ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009; 37:1.
- Evans BA, Wijdicks EF. High-grade carotid stenosis detected before general surgery: is endarterectomy indicated? Neurology 2001; 57:1328.
- Dubinsky RM, Lai SM. Mortality from combined carotid endarterectomy and coronary artery bypass surgery in the US. Neurology 2007; 68:195.
- Hill MD, Shrive FM, Kennedy J, et al. Simultaneous carotid endarterectomy and coronary artery bypass surgery in Canada. Neurology 2005; 64:1435.
- Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011; 41:607.
- Illuminati G, Ricco JB, Caliò F, et al. Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting. J Vasc Surg 2011; 54:993.
- Jahromi AS, Cinà CS, Liu Y, Clase CM. Sensitivity and specificity of color duplex ultrasound measurement in the estimation of internal carotid artery stenosis: a systematic review and meta-analysis. J Vasc Surg 2005; 41:962.
- Heiserman JE, Dean BL, Hodak JA, et al. Neurologic complications of cerebral angiography. AJNR Am J Neuroradiol 1994; 15:1401.
- Whitty CJ, Sudlow CL, Warlow CP. Investigating individual subjects and screening populations for asymptomatic carotid stenosis can be harmful. J Neurol Neurosurg Psychiatry 1998; 64:619.
- Matchar DB, Pauker SG. Endarterectomy in carotid artery disease. A decision analysis. JAMA 1987; 258:793.
- Feussner JR, Matchar DB. When and how to study the carotid arteries. Ann Intern Med 1988; 109:805.
- Matchar DB, Pauk JS, Lipscomb J. A health policy perspective on carotid endarterectomy: Cost, effectiveness, and cost-effectiveness. In: Surgery for Cerebrovascular Disease, Moore W (Ed), Saunders, Philadelphia 1996. p.680.
- Brett AS, Levine JD. The case against identifying carotid stenosis in asymptomatic patients. JAMA Intern Med 2014; 174:2004.
- LeFevre ML, U.S. Preventive Services Task Force. Screening for asymptomatic carotid artery stenosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014; 161:356.
- Jonas DE, Feltner C, Amick HR, et al. Screening for asymptomatic carotid artery stenosis: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med 2014; 161:336.
- STROKE RISK
- SCREENING TESTS
- Carotid bruit
- Noninvasive testing
- THERAPEUTIC OPTIONS
- Risk factor management
- Antiplatelet drugs
- Carotid revascularization
- - Carotid endarterectomy
- - Carotid angioplasty/stenting
- - Patients undergoing other surgery
- RISKS AND BENEFITS OF SCREENING
- RECOMMENDATIONS FOR SCREENING BY EXPERT GROUPS
- SUMMARY AND RECOMMENDATIONS