Carotid artery stenosis

Last updated
Carotid artery stenosis
Other namesTIA - carotid artery [1]
Carotid artery stenosis.png
Carotid artery disease
Specialty Vascular surgery

Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, usually caused by atherosclerosis. [2]

Contents

Signs and symptoms

The common carotid artery is the large artery whose pulse can be felt on both sides of the neck under the jaw. On the right side it starts from the brachiocephalic artery (a branch of the aorta), and on the left side the artery comes directly off the aortic arch. At the throat it forks into the internal carotid artery and the external carotid artery. The internal carotid artery supplies the brain, and the external carotid artery supplies the face. This fork is a common site for atherosclerosis, an inflammatory build-up of atheromatous plaque inside the common carotid artery, or the internal carotid arteries that causes them to narrow. [3] [4]

The plaque can be stable and asymptomatic, or it can be a source of embolization. Emboli break off from the plaque and travel through the circulation to blood vessels in the brain. As the vessels get smaller, an embolus can lodge in the vessel wall and restrict the blood flow to parts of the brain. This ischemia can either be temporary, yielding a transient ischemic attack (TIA), or permanent resulting in a thromboembolic stroke. [5]

Transient ischemic attacks are a warning sign and may be followed by severe permanent strokes, particularly within the first two days. TIAs by definition last less than 24 hours and frequently take the form of weakness or loss of sensation of a limb or the trunk on one side of the body or the loss of sight (amaurosis fugax) in one eye. Less common symptoms are artery sounds (bruits), or ringing in the ears (tinnitus). [6]

In asymptomatic individuals with a carotid stenosis, the risk of developing a stroke is increased above those without a stenosis. The risk of stroke is possibly related to the degree of stenosis on imaging. Some studies have found an increased risk with increasing degrees of stenosis [7] while other studies have not been able to find such a relationship. [8]

Pathophysiology

Atherosclerosis causes plaque to form within the carotid artery walls, usually at the fork where the common carotid artery divides into the internal and external carotid artery. The plaque build-up can narrow or constrict the artery lumen, a condition called stenosis. Rupture of the plaque can release atherosclerotic debris or blood clots into the artery. A piece of this material can break off and travel (embolize) up through the internal carotid artery into the brain, where it blocks circulation, and can cause death of the brain tissue, a condition referred to as ischemic stroke. [9]

Sometimes the stenosis causes temporary symptoms first, known as TIAs, where temporary ischemia occurs in the brain, or retina without causing an infarction. [10] Symptomatic stenosis has a high risk of stroke within the next 2 days. National Institute for Health and Clinical Excellence (NICE) guidelines recommend that people with moderate to severe (50–99% blockage) stenosis, and symptoms, should have "urgent" endarterectomy within 2 weeks. [11]

When the plaque does not cause symptoms, people are still at higher risk of stroke than the general population, but not as high as people with symptomatic stenosis. The incidence of stroke, including fatal stroke, is 1–2% per year. The surgical mortality of endarterectomy ranges from 1–2% to as much as 10%. Two large randomized clinical trials have demonstrated that carotid surgery done with a 30-day stroke and death risk of 3% or less will benefit asymptomatic people with ≥60% stenosis who are expected to live at least 5 years after surgery. [12] [13] Surgeons are divided over whether asymptomatic people should be treated with medication alone or should have surgery. [14] [15]

The common carotid artery is the large vertical artery in red. The blood supply to the carotid artery starts at the arch of the aorta (bottom). The carotid artery divides into the internal carotid artery and the external carotid artery. The internal carotid artery supplies the brain. Plaque often builds up at that division and causes a narrowing (stenosis). Pieces of plaque can break off and block the small arteries above in the brain, which causes a stroke. Plaque can also build up at the origin of the carotid artery at the aorta.[ citation needed ]

Diagnosis

70 percent stenosis of the right internal carotid artery as seen by ultrasound. Arrow marks the lumen of the artery. 70PerBlockedRtCarotidA.png
70 percent stenosis of the right internal carotid artery as seen by ultrasound. Arrow marks the lumen of the artery.
CT image of a 70 percent stenosis of the right internal carotid artery 70PerBlockedRtCarotidACT.png
CT image of a 70 percent stenosis of the right internal carotid artery

Carotid artery stenosis is usually diagnosed by color flow duplex ultrasound scan of the carotid arteries in the neck. This involves no radiation, no needles and no contrast agents that may cause allergic reactions. This test has good sensitivity and specificity. [16]

Typically duplex ultrasound scan is the only investigation required for decision making in carotid stenosis as it is widely available and rapidly performed. However, further imaging can be required if the stenosis is not near the bifurcation of the carotid artery. [17]

One of several different imaging modalities, such as a computed tomography angiogram (CTA) [18] [19] [20] or magnetic resonance angiogram (MRA) may be useful. Each imaging modality has its advantages and disadvantages - Magnetic resonance angiography and CT angiography with contrast is contraindicated in patients with chronic kidney disease, catheter angiography has a 0.5% to 1.0% risk of stroke, MI, arterial injury or retroperitoneal bleeding. The investigation chosen will depend on the clinical question and the imaging expertise, experience and equipment available. [21]

Based on the NASCET (The North American Symptomatic Carotid Endarterectomy Trial) criteria, the degree of carotid stenosis is defined as: [22]

percent stenosis = ( 1 − ( minimum diameter within stenosis) / ( poststenotic diameter ) ) × 100%.

Calculators have been developed to facilitate grading of carotid stenosis per NASCET criteria. [23]

Screening

The U.S. Preventive Services Task Force recommends against routine screening for carotid artery stenosis in those without symptoms as of 2021. [24]

While routine population screening is not advised, the American Heart Association [25] and the Society for Vascular Surgery [26] recommend screening in those diagnosed with related medical conditions or have risk factors for carotid artery disease. [27] Screening is recommended for people who have:[ citation needed ]

The American Heart Association also recommends screening if a physician detects a carotid bruit, or murmur, over the carotid artery by listening through a stethoscope during a physical exam. For people with symptoms, the American Heart Association recommends initial screening using ultrasound.[ citation needed ]

Treatment

The goal of treating carotid artery stenosis is to reduce the risk of stroke. The type of treatment depends on the severity of the disease and includes:[ citation needed ]

Medication

Clinical guidelines (such as those of the American Heart Association (AHA) [28] and National Institute for Clinical Excellence (NICE) [29] ) recommend that all patients with carotid stenosis be given medications to control their vascular risk factors, usually blood pressure lowering medications (if they have hypertension), diabetes medication (if they have diabetes), and recommend exercise, weight reduction (if overweight) and smoking cessation (for smokers). In addition, they would benefit from anti-platelet medications (such as aspirin or clopidogrel) and cholesterol lowering medication (such as statins, which were originally prescribed for their cholesterol-lowering effects but were also found to reduce inflammation and stabilize plaque).[ citation needed ]

Revascularization

According to the American Heart Association, interventions beyond medical management is based upon whether patients have symptoms:[ citation needed ]

All interventions for carotid revascularization (carotid endarterectomy, carotid stenting, and transcarotid artery revascularization) carry some risk of stroke; however, where the risk of stroke over time from medical management alone is high, intervention may be beneficial. Carotid artery stenting and carotid endarterectomy have been found to have similar benefits in patients with severe degree of carotid artery stenosis. [32] [33]

See also

Related Research Articles

A transient ischemic attack (TIA), commonly known as a mini-stroke, is a minor stroke whose noticeable symptoms usually end in less than an hour. A TIA causes the same symptoms associated with a stroke, such as weakness or numbness on one side of the body, sudden dimming or loss of vision, difficulty speaking or understanding language, slurred speech, or confusion.

<span class="mw-page-title-main">Angioplasty</span> Procedure to widen narrow arteries or veins

Angioplasty, also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis.

<span class="mw-page-title-main">Atherosclerosis</span> Inflammatory disease involving buildup of lesions in the walls of arteries

Atherosclerosis is a pattern of the disease arteriosclerosis, characterized by development of abnormalities called lesions in walls of arteries. This is a chronic inflammatory disease involving many different cell types, and driven by elevated levels of cholesterol in the blood. These lesions may lead to narrowing of the arterial walls due to buildup of atheromatous plaques. At onset there are usually no symptoms, but if they develop, symptoms generally begin around middle age. In severe cases, it can result in coronary artery disease, stroke, peripheral artery disease, or kidney disorders, depending on which body part(s) the affected arteries are located in the body.

<span class="mw-page-title-main">Cerebrovascular disease</span> Condition that affects the arteries that supply the brain

Cerebrovascular disease includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation. Arteries supplying oxygen and nutrients to the brain are often damaged or deformed in these disorders. The most common presentation of cerebrovascular disease is an ischemic stroke or mini-stroke and sometimes a hemorrhagic stroke. Hypertension is the most important contributing risk factor for stroke and cerebrovascular diseases as it can change the structure of blood vessels and result in atherosclerosis. Atherosclerosis narrows blood vessels in the brain, resulting in decreased cerebral perfusion. Other risk factors that contribute to stroke include smoking and diabetes. Narrowed cerebral arteries can lead to ischemic stroke, but continually elevated blood pressure can also cause tearing of vessels, leading to a hemorrhagic stroke.

<span class="mw-page-title-main">Vascular surgery</span> Medical specialty of the blood/lymph vessels

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

<span class="mw-page-title-main">Stroke</span> Death of a region of brain cells due to poor blood flow

Stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke:

<span class="mw-page-title-main">Amaurosis fugax</span> Medical condition

Amaurosis fugax is a painless temporary loss of vision in one or both eyes.

<span class="mw-page-title-main">Atheroma</span> Accumulation of degenerative material in the inner layer of artery walls

An atheroma, or atheromatous plaque, is an abnormal accumulation of material in the inner layer of an arterial wall.

<span class="mw-page-title-main">Henry J. M. Barnett</span> Physician and stroke researcher

Henry Joseph Macaulay Barnett, known by his colleagues and friends as "Barney", was a Canadian physician and neurologist. He was also a leading clinical stroke researcher as a result of being the principal investigator in several major clinical trials. As a clinical scientist, he did pioneering research in stroke prevention, beginning with the use of aspirin.

<span class="mw-page-title-main">Carotid endarterectomy</span> Surgical procedure

Carotid endarterectomy is a surgical procedure used to reduce the risk of stroke from carotid artery stenosis. In endarterectomy, the surgeon opens the artery and removes the plaque. The plaque forms and thickens the inner layer of the artery, or intima, hence the name of the procedure which simply means removal of part of the internal layers of the artery.

<span class="mw-page-title-main">Cerebral infarction</span> Stroke resulting from lack of blood flow

Cerebral infarction, also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain. In mid to high income countries, a stroke is the main reason for disability among people and the 2nd cause of death. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia). This is most commonly due to a thrombotic occlusion, or an embolic occlusion of major vessels which leads to a cerebral infarct. In response to ischemia, the brain degenerates by the process of liquefactive necrosis.

<span class="mw-page-title-main">Watershed stroke</span> Medical condition

A watershed stroke is defined as a brain ischemia that is localized to the vulnerable border zones between the tissues supplied by the anterior, posterior and middle cerebral arteries. The actual blood stream blockage/restriction site can be located far away from the infarcts. Watershed locations are those border-zone regions in the brain supplied by the major cerebral arteries where blood supply is decreased. Watershed strokes are a concern because they comprise approximately 10% of all ischemic stroke cases. The watershed zones themselves are particularly susceptible to infarction from global ischemia as the distal nature of the vasculature predisposes these areas to be most sensitive to profound hypoperfusion.

<span class="mw-page-title-main">Fibromuscular dysplasia</span> Human arterial disease

Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory disease of the blood vessels that causes abnormal growth within the wall of an artery. FMD has been found in nearly every arterial bed in the body, although the most commonly affected are the renal and carotid arteries.

<span class="mw-page-title-main">Hollenhorst plaque</span> Medical condition

A Hollenhorst plaque is a cholesterol embolus that is seen in a blood vessel of the retina. It is usually found when a physician performs ophthalmoscopy, during which a plaque will appear as a small, bright crystal that is refractile and yellow. This is a medical exam finding, and is not a medical condition, though it may be related to cardiovascular conditions such as atherosclerosis of the internal carotid artery. It was first described by American ophthalmologist Robert Hollenhorst in 1961.

<span class="mw-page-title-main">Carotid artery dissection</span> Human disease


Carotid artery dissection is a serious condition in which a tear forms in one of the two main carotid arteries in the neck, allowing blood to enter the artery wall and separate its layers (*dissection*). This separation can lead to the formation of a blood clot, narrowing of the artery, and restricted blood flow to the brain, potentially resulting in stroke. Symptoms vary depending on the extent and location of the dissection and may include a sudden, severe headache, neck or facial pain, vision changes, a drooping eyelid, and stroke-like symptoms such as weakness or numbness on one side of the body, difficulty speaking, or loss of coordination.

<span class="mw-page-title-main">Carotid stenting</span>

Carotid artery stenting is an endovascular procedure where a stent is deployed within the lumen of the carotid artery to treat narrowing of the carotid artery and decrease the risk of stroke. It is used to treat narrowing of the carotid artery in high-risk patients, when carotid endarterectomy is considered too risky.

Andrew Nicolaides is a British-Greek Cypriot surgeon, and an expert in cardiovascular disease and stroke prevention.

John David Spence is a Canadian medical doctor, medical researcher and Professor Emeritus at the University of Western Ontario. He is affiliated with the University of Western Ontario and the Robarts Research Institute, one of Canada's leading medical research organizations. Before his retirement from clinical practice in July 2022, he was also affiliated with the London Health Sciences Centre's University Hospital. He is a recognized expert in stroke prevention and stroke prevention research, with more than 600 peer-reviewed publications since 1970. He delivered more than 600 lectures on stroke prevention in 42 countries. In 2015, he received the Research Excellence Award from the Canadian Society for Atherosclerosis, Thrombosis and Vascular Biology. In 2019, he was appointed a Member of the Order of Canada, and in 2020 he received the William Feinberg Award from the American Heart Association for excellence in clinical stroke research.

Embolic stroke of undetermined source (ESUS) is an embolic stroke, a type of ischemic stroke, with an unknown origin, defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources. As such, it forms a subset of cryptogenic stroke, which is part of the TOAST-classification. The following diagnostic criteria define an ESUS:

<span class="mw-page-title-main">Brajesh K. Lal</span> American surgeon

Brajesh K. Lal, born in 1963 in Varanasi, India and of Indian origin, is an American surgeon, and an expert in vascular disease, particularly the prevention and treatment of stroke and venous disease. He is a tenured Professor of Vascular Surgery at the University of Maryland and Professor of Neurology at Mayo Clinic. He holds additional appointments at the Departments of Bioengineering at the University of Maryland and George Mason University. He founded and currently directs the multi-specialty Center for Vascular Research and the NIH Vascular Imaging Core Facility at the University of Maryland. He has been elected as a Distinguished Fellow of the Society for Vascular Surgery and Distinguished Fellow of the American Venous Forum.

References

  1. ↑ "Carotid artery disease: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 29 May 2019.
  2. ↑ "Atherosclerosis". The Lecturio Medical Concept Library. Retrieved 2 July 2021.
  3. ↑ Ashrafian H (March 2007). "Anatomically specific clinical examination of the carotid arterial tree". Anatomical Science International. 82 (1): 16–23. doi:10.1111/j.1447-073X.2006.00152.x. PMID   17370446. S2CID   12109379.
  4. ↑ Manbachi A, Hoi Y, Wasserman BA, Lakatta EG, Steinman DA (December 2011). "On the shape of the common carotid artery with implications for blood velocity profiles". Physiological Measurement. 32 (12): 1885–97. doi:10.1088/0967-3334/32/12/001. PMC   3494738 . PMID   22031538.
  5. ↑ Easton, J. Donald; Saver, Jeffrey L.; Albers, Gregory W.; Alberts, Mark J.; Chaturvedi, Seemant; Feldmann, Edward; Hatsukami, Thomas S.; Higashida, Randall T.; Johnston, S. Claiborne; Kidwell, Chelsea S.; Lutsep, Helmi L.; Miller, Elaine; Sacco, Ralph L.; American Heart Association; American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Interdisciplinary Council on Peripheral Vascular Disease (June 2009). "Definition and Evaluation of Transient Ischemic Attack: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease: The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists". Stroke. 40 (6): 2276–2293. doi: 10.1161/STROKEAHA.108.192218 . PMID   19423857.
  6. ↑ Easton, J. Donald; Saver, Jeffrey L.; Albers, Gregory W.; Alberts, Mark J.; Chaturvedi, Seemant; Feldmann, Edward; Hatsukami, Thomas S.; Higashida, Randall T.; Johnston, S. Claiborne; Kidwell, Chelsea S.; Lutsep, Helmi L.; Miller, Elaine; Sacco, Ralph L.; American Heart Association; American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Interdisciplinary Council on Peripheral Vascular Disease (June 2009). "Definition and Evaluation of Transient Ischemic Attack: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease: The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists". Stroke. 40 (6): 2276–2293. doi: 10.1161/STROKEAHA.108.192218 . PMID   19423857.
  7. ↑ Howard, Dominic P J; Gaziano, Liam; Rothwell, Peter M (March 2021). "Risk of stroke in relation to degree of asymptomatic carotid stenosis: a population-based cohort study, systematic review, and meta-analysis". The Lancet Neurology. 20 (3): 193–202. doi:10.1016/s1474-4422(20)30484-1. ISSN   1474-4422. PMC   7889579 . PMID   33609477.
  8. ↑ den Hartog, Anne G.; Achterberg, Sefanja; Moll, Frans L.; Kappelle, L. Jaap; Visseren, Frank L.J.; van der Graaf, Yolanda; Algra, Ale; de Borst, Gert Jan (April 2013). "Asymptomatic Carotid Artery Stenosis and the Risk of Ischemic Stroke According to Subtype in Patients With Clinical Manifest Arterial Disease". Stroke. 44 (4): 1002–1007. doi: 10.1161/strokeaha.111.669267 . ISSN   0039-2499. PMID   23404720. S2CID   7567725.
  9. ↑ "What Are the Signs and Symptoms of Atherosclerosis? - NHLBI, NIH". www.nhlbi.nih.gov. 22 June 2016. Retrieved 2 July 2021.
  10. ↑ Easton, J. D.; Saver, J. L.; Albers, G. W.; Alberts, M. J.; Chaturvedi, S.; Feldmann, E.; et al. (2009). "Definition and Evaluation of Transient Ischemic Attack: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease: The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists". Stroke. 40 (6): 2276–2293. doi: 10.1161/STROKEAHA.108.192218 . ISSN   0039-2499. PMID   19423857.
  11. ↑ Swain S, Turner C, Tyrrell P, Rudd A (July 2008). "Diagnosis and initial management of acute stroke and transient ischaemic attack: summary of NICE guidance". BMJ. 337: a786. doi:10.1136/bmj.a786. PMID   18653633. S2CID   19624935.
  12. ↑ Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (ACAS) (1995). "Endarterectomy for asymptomatic carotid artery stenosis". JAMA. 273 (18): 1421–1428. doi:10.1001/jama.273.18.1421.
  13. ↑ Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D (2004). "Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial". Lancet. 363 (9420): 1491–1502. doi:10.1016/s0140-6736(04)16146-1. PMID   15135594. S2CID   22814764.
  14. ↑ Sila CA, Higashida RT, Clagett GP (April 2008). "Clinical decisions. Management of carotid stenosis". N. Engl. J. Med. 358 (15): 1617–21. doi:10.1056/NEJMclde0800741. PMID   18403770.
  15. ↑ Drug Therapy Gains Favor to Avert Stroke, By THOMAS M. BURTON, Wall Street Journal, MARCH 3, 2009. Layman's summary of surgery vs. medication-only debate.
  16. ↑ Jahromi, AS; Cinà, CS; Liu, Y; Clase, CM (June 2005). "Sensitivity and specificity of color duplex ultrasound measurement in the estimation of internal carotid artery stenosis: a systematic review and meta-analysis". Journal of Vascular Surgery. 41 (6): 962–72. doi: 10.1016/j.jvs.2005.02.044 . PMID   15944595.
  17. ↑ Saxena, A; Yin Kwee, E; Lim, S (2019). "Imaging modalities to diagnose carotid artery stenosis: progress and prospect". BioMedical Engineering OnLine. 18 (1): 66. doi: 10.1186/s12938-019-0685-7 . PMC   6537161 . PMID   31138235 . Retrieved 2 July 2021.
  18. ↑ Bartlett ES, Walters TD, Symons SP, Fox AJ (January 2006). "Quantification of carotid stenosis on CT angiography". AJNR. American Journal of Neuroradiology. 27 (1): 13–19. PMC   7976065 . PMID   16418349.
  19. ↑ White JH, Bartlett ES, Bharatha A, Aviv RI, Fox AJ, Thompson AL, Bitar R, Symons SP (July 2010). "Reproducibility of semi-automated measurement of carotid stenosis on CTA". The Canadian Journal of Neurological Sciences. 37 (4): 498–503. doi: 10.1017/s0317167100010532 . PMID   20724259.
  20. ↑ Lian K, White JH, Bartlett ES, Bharatha A, Aviv RI, Fox AJ, Symons SP (May 2012). "NASCET percent stenosis semi-automated versus manual measurement on CTA". The Canadian Journal of Neurological Sciences. 39 (3): 343–6. doi: 10.1017/s0317167100013482 . PMID   22547515.
  21. ↑ Solomon, Caren G.; Grotta, James C. (19 September 2013). "Carotid Stenosis". New England Journal of Medicine. 369 (12): 1143–1150. doi:10.1056/NEJMcp1214999. PMID   24047063.
  22. ↑ Ferguson, Gary G.; Eliasziw, Michael; Barr, Hugh W. K.; Clagett, G. Patrick; Barnes, Robert W.; Wallace, M. Christopher; Taylor, D. Wayne; Haynes, R. Brian; Finan, Jane W.; Hachinski, Vladimir C.; Barnett, Henry J. M. (September 1999). "The North American Symptomatic Carotid Endarterectomy Trial: Surgical Results in 1415 Patients". Stroke. 30 (9): 1751–1758. doi:10.1161/01.STR.30.9.1751. ISSN   0039-2499.
  23. ↑ "ECST & NASCET Calculator for Carotid Stenosis". Rad At Hand. Retrieved 2024-07-17.
  24. ↑ US Preventive Services Task, Force.; Krist, AH; Davidson, KW; Mangione, CM; Barry, MJ; Cabana, M; Caughey, AB; Donahue, K; Doubeni, CA; Epling JW, Jr; Kubik, M; Ogedegbe, G; Pbert, L; Silverstein, M; Simon, MA; Tseng, CW; Wong, JB (2 February 2021). "Screening for Asymptomatic Carotid Artery Stenosis: US Preventive Services Task Force Recommendation Statement". JAMA. 325 (5): 476–481. doi: 10.1001/jama.2020.26988 . ISSN   0098-7484. PMID   33528542.
  25. ↑ Brott, Thomas G.; Halperin, Jonathan L.; Abbara, Suhny; Bacharach, J. Michael; Barr, John D.; Bush, Ruth L.; Cates, Christopher U.; Creager, Mark A.; Fowler, Susan B.; Friday, Gary; Hertzberg, Vicki S. (2011-07-26). "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: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery". Circulation. 124 (4): 489–532. doi: 10.1161/CIR.0b013e31820d8d78 . ISSN   0009-7322. PMID   21282505.
  26. ↑ Ricotta, John J.; AbuRahma, Ali; Ascher, Enrico; Eskandari, Mark; Faries, Peter; Lal, Brajesh K. (September 2011). "Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: Executive summary". Journal of Vascular Surgery. 54 (3): 832–836. doi: 10.1016/j.jvs.2011.07.004 . ISSN   0741-5214. PMID   21889705.
  27. ↑ "Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease" (PDF). American Heart Association. Archived from the original (PDF) on 2017-11-17. Retrieved 2018-08-22.
  28. ↑ Archived copy Archived 2017-11-17 at the Wayback Machine
  29. ↑ "Carotid Artery Stenosis information. Internal carotis occlusion". patient.info. Retrieved 2018-10-08.
  30. ↑ Barnett, H. J.; Taylor, D. W.; Eliasziw, M.; Fox, A. J.; Ferguson, G. G.; Haynes, R. B.; Rankin, R. N.; Clagett, G. P.; Hachinski, V. C.; Sackett, D. L.; Thorpe, K. E.; Meldrum, H. E.; Spence, J. D. (1998-11-12). "Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators". The New England Journal of Medicine. 339 (20): 1415–1425. doi: 10.1056/NEJM199811123392002 . ISSN   0028-4793. PMID   9811916.
  31. ↑ Kleindorfer, Dawn O.; Towfighi, Amytis; Chaturvedi, Seemant; Cockroft, Kevin M.; Gutierrez, Jose; Lombardi-Hill, Debbie; Kamel, Hooman; Kernan, Walter N.; Kittner, Steven J.; Leira, Enrique C.; Lennon, Olive; Meschia, James F.; Nguyen, Thanh N.; Pollak, Peter M.; Santangeli, Pasquale (July 2021). "2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association". Stroke. 52 (7): e364–e467. doi: 10.1161/STR.0000000000000375 . ISSN   1524-4628. PMID   34024117. S2CID   235169226.
  32. ↑ Halliday, Alison; Bulbulia, Richard; Bonati, Leo H.; Chester, Johanna; Cradduck-Bamford, Andrea; Peto, Richard; Pan, Hongchao; ACST-2 Collaborative Group (2021-09-18). "Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy". Lancet. 398 (10305): 1065–1073. doi:10.1016/S0140-6736(21)01910-3. ISSN   1474-547X. PMC   8473558 . PMID   34469763.{{cite journal}}: CS1 maint: numeric names: authors list (link)
  33. ↑ Mott, Meghan; Koroshetz, Walter; Wright, Clinton B. (May 2017). "CREST-2: Identifying the Best Method of Stroke Prevention for Carotid Artery Stenosis: National Institute of Neurological Disorders and Stroke Organizational Update". Stroke. 48 (5): e130–e131. doi:10.1161/STROKEAHA.117.016051. ISSN   1524-4628. PMC   5467643 . PMID   28386040.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.