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 Carotid Artery Disease

Alan M. Graham, M.D., Wesley S. Moore, M.D., William Baker, M.D.

Includes:

  • Atherosclerotic Carotis 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 Disease Leading to Proximal
  • Carotid Artery Stenosis

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. Discuss the collateral arterial communications of the extracranial and intracranial arteries.

4. To discuss the diagnosis of anomalies and collateral circulation utilizing diagnostic modalities including CT scan, MRI, SPECT, and transcranial doppler .

5. 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

6. To describe the gross pathologic and histologic characteristics of each etiology above.

7. To discuss how each etiology produces cerebral events in terms of occlusion and/or embolism.

8. To discuss the normal flow patterns at the carotid bifurcation, and how they are affected by the atherosclerotic process.

II . Diagnostic Evaluation

History and Physical Examination

1. To define hemispheric, non-hemispheric, and non-specific symptoms.

2. To differentiate among transient ischemic attack (TIA), reversible ischemic neurologic deficit (RIND), stroke in evolution and completed stroke.

3. To describe the arterial and neurologic examination 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 vertibrobasilar insufficiency.

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 principles of doppler ultrasound.

2. To describe the normal doppler signals in the internal, external, and common carotid arteries.

3. To discuss the sensitivity and specificity of duplex scanning in detecting carotid artery stenosis .

4. To discuss the risks and benefits of relying on duplex ultrasound and eliminating angiography.

5. To understand the basics of P.V. Lab Accreditation.

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 stenosis .

Diagnostic Brain Scanning

1. For each of the following modalities, explain the principles, indications, complications, and its influence upon the indications for carotid endarterectomy .

a. CT scan

b. MRI

c. SPECT

d. Transcranial doppler

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 discuss the role of thrombolytic therapy in the treatment of stroke syndrome.

3. To be able to construct a diagnostic and treatment algorithm for various stroke syndromes.

4. To be able to discuss the potential role of endovascular treatment.

Surgical Treatment

1. To discuss the intrathoracic and extrathoracic 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 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 EC-IC bypass.

6. To discuss the indication and performance of proximal and distal vertebral artery reconstruction.

Complication 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. Transient ischemic attack and stroke

f. Asymptomatic thrombosis

g. Intracranial hemorrhage

h. Post -operative seizure

i . Extracarotid (cardiac) events

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Posted June 2010