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Monday, March 17, 2014

Carotid Stenosis






Carotid artery atherosclerosis

  • The carotid arteries (common carotid, internal carotid, and external carotid) provide the main blood supply to the brain. These may become narrowed due to cholesterol plaque build up, leading to a condition known as carotid artery atherosclerosis.
  • Should there be significant narrowing of the carotid arteries, or ulcerations in the cholesterol-causing micro-emboli (plaque travels to the brain and blocks off small blood vessels), a Stroke or Transient Ischemic Attack ("mini-Stroke") can occur.

  • May have none (asymptomatic)
  • Signs of Stroke: loss of vision, weakness (partial or total paralysis), speech difficulties, or other neurological signs
  • Signs of TIA (Transient Ischemic Attack) are the same as signs of Stroke except that they completely resolve in 24 hours

  • Hypercholesterolemia (high cholesterol)
  • Diabetes Mellitus
  • Chronic hypertension

  • Examination may reveal carotid bruits (a sound heard by the stethoscope)
  • Carotid ultrasound/duplex scans will make the diagnosis
  • An MRA scan (a type of scan performed with an MRI) can be more accurate and at times helpful
  • Carotid angiograms are used to prepare for surgery, or if diagnosis is not clear (dye is injected into the carotid arteries and X-Rays taken)

  • Asymptomatic -- occurs when the doctor, on examination, finds carotid stenosis, but there are no symptoms. In patients with severe stenosis (>70% blockage), treatment is still controversial.
  • Some medical literature supports doing early surgery to remove the cholesterol blockage using a procedure known as carotid endarterectomy. The procedure itself carries a risk of Stroke(about 2.7%). Overall, as suggested by the studies, the risk of Stroke will be decreased as a result of these procedures. However, a recent article in the New England Journal of Medicine suggests that not all patients with severe carotid artery stenosis may need surgery (especially in the light of other risk factors).
  • Symptomatic -- the patient has had TIAs or Stroke in the distribution of the carotid stenosis):
  1. If carotid stenosis is >70%--surgery (carotid endarterectomy)
  2. If carotid stenosis is 50-69%--surgery has also been found to be beneficial
  3. If carotid stenosis is less than 50%--medical management with aspirin or Plavix
  4. Aspirin or Plavix may be given after surgery as well
  5. Cholesterol should be aggressively controlled (diet and/or medication)

  • Low cholesterol diet
  • Cholesterol lowering medications, especially the "statins" such as Pravachol and Lipitor (may decrease the risk of Stroke by 30%)
  • All other risk factors for Stroke should also be carefully evaluated and treated, e.g., blood pressure should be controlled, smoking should be discontinued, diabetes controlled, etc.

  • Special Consideration
- Both asymptomatic and symptomatic carotid artery disease often are often warning signs for coronary artery disease (cholesterol blockages in the arteries of the heart). Patients with carotid artery atherosclerosis should be carefully evaluated for coronary artery disease.

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