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 Carotid Artery Disease

By Matthew L. White MD and Joseph L. Mills, MD

Based on Curriculum outline originally prepared by: Alan M. Graham, MD, Wesley S. Moore, MD, William Baker, MD


  • Atherosclerotic Carotid Artery Disease
  • Carotid Artery Fibromuscular Dysplasia
  • Carotid Artery Coils and Kinks
  • Carotid Artery Radiation Injury
  • Carotid Body Tumor
  • Overall Management of Stroke
  • Spontaneous Carotid Artery Dissection
  • Atherosclerotic Aortic Arch and Proximal Carotid Artery Disease


I. Anatomy and Pathophysiology

1. To describe the anatomy of the arch, great vessels, and intracranial arteries.
2. To describe the embryology of the above and relate the common anomalies to the embryology.
3. To understand the different etiologies of carotid artery disease.

a. Atherosclerosis
i. Define the systemic risk factors for atherosclerosis.
ii. Define the systemic effects of atherosclerosis and how these effects impact the diagnosis and treatment of the patient with carotid stenosis.
b. Kinking and tortuosity
c. Fibromuscular dysplasia
d. Compression
e. Traumatic occlusion
f. Acute dissection
g. Inflammatory arteriopathies

4. To describe the gross pathologic and histologic characteristics of each etiology above.
5. To discuss the mechanisms (occlusion and/or embolism) by which each underlying condition produces cerebral events

II. Diagnostic Evaluation

History and Physical Examination
1. To define hemispheric, non-hemispheric, and non-specific or atypical symptoms.
2. To differentiate among transient ischemic attack (TIA), stroke in evolution and completed stroke.
3. To describe the arterial and neurologic examinations and their importance in caring for patients with carotid artery disease.
4. To describe the relationship between carotid artery atherosclerosis and the clinical syndrome of vertebrobasilar insufficiency (i.e. patients with multiple vessel or combined carotid and vertebral disease and posterior symptoms).
5. To describe and defend the appropriate evaluation for patients with each of the above clinical presentations.

Carotid Duplex Examination

1. To be able to explain the basic fundamental principles of Doppler ultrasound.
2. To describe the normal Doppler waveforms in the internal, external, and common carotid arteries.
3. To discuss the sensitivity/specificity of duplex scanning to detect and grade carotid artery stenosis.
4. To discuss the risks and benefits of relying on duplex ultrasound and eliminating angiography.
5. To understand the basics of Vascular Laboratory Accreditation process

III. Treatment

Treatment of Neurologic Syndromes in Patients with Carotid Stenosis
1. To discuss the non-surgical and surgical treatment of acute ischemic syndromes including stroke.
2. To understand the basic data underlying the role and effectiveness of medical therapy (especially antiplatelet therapy and statin therapy) in the treatment of carotid bifurcation atherosclerosis.
3. To discuss the role of thrombolytic therapy in the treatment of acute stroke syndromes.
 a. To understand the indications and contraindications for lytic therapy in acute stroke.

Complications of Carotid Endarterectomy
1. To describe the etiology and management of:
a. Wound hematoma
b. Wound infection
c. Post-operative hyper and hypotension
d. Peripheral nerve palsies
e. Perioperative stroke
f. Non-carotid (predominantly cardiac) events


I. Anatomy and Pathophysiology

1. To understand the collateral arterial communications of the extracranial and intracranial arteries.
2. To discuss the diagnosis of anomalies and collateral circulation utilizing diagnostic modalities including CT scan, MRI, SPECT, and transcranial Doppler.
3. To discuss the normal flow patterns at the carotid bifurcation, and how they influence the development of atherosclerotic disease (flow divider, shear stress).

II. Diagnostic Evaluation

Angiography and MRA
1. Angiography: to be able to discuss the technique, its limitations and complications.
2. MRA: to be able to discuss the technique, limitations and complications.
3. To discuss and compare the different methods of measuring carotid bifurcation stenosis (bulb-based versus distal ICA based).

Diagnostic Brain Scanning
1. For each of the following diagnostic modalities, explain the principles, indications, complications, and potential influence on the indications for carotid endarterectomy.
a. CT scan
b. MRI
d. Transcranial Doppler

III. Treatment

Treatment of Neurologic Syndromes in Patients with Carotid Stenosis
1. To be able to construct a logical diagnostic and treatment algorithm for various stroke syndromes.
2. To be able to discuss the potential role of endovascular treatment.

Surgical Treatment
1. To discuss the intrathoracic and extrathoracic surgical options for treatment of atherosclerotic stenosis or occlusion of the great vessels.
2. To describe the standard approach to carotid endarterectomy including intraoperative shunting, patching, anesthetic techniques, tacking sutures and methods of completion evaluation.
3. To describe the surgical treatment of less common conditions such as fibromuscular dysplasia, kinking, radiation arteritis, tumors involving the carotid artery, other arteritides, and recurrent carotid stenosis.
4. To recognize the carotid sinus syndrome and discuss its treatment.
5. To discuss the role of EC-IC bypass.
6. To discuss the indications for and performance of proximal and distal vertebral artery reconstruction.

Complications of Carotid Endarterectomy
1. To describe the etiology and management of:
a. Transient ischemic attack and stroke
b. Asymptomatic thrombosis
c. Cerebral Reperfusion or Hyperperfusion syndrome

i. Perioperative hypertension and headache
ii. Intracranial hemorrhage
ii. Post-operative seizure


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Posted September 2010