History and exam

Key diagnostic factors

common

asymptomatic

Many people with carotid stenosis have no signs or symptoms.

The most frequent reason for suspecting the diagnosis is the presence of atherosclerotic high-risk factors (i.e., patients with peripheral arterial occlusive disease, coronary artery occlusive disease, hypertension, diabetes, hypercholesterolaemia, or aged ≥55 years with active smoking).​[14]​

uncommon

cervical bruit

Not a sensitive or specific sign; however, its presence often prompts evaluation for the condition.

Although the presence of a bruit is associated with a carotid stenosis of any severity in 47% of patients, a clinically high-grade stenosis is found in only <2% of individuals with a bruit.[20][23]

focal neurological deficit lasting >24 hours (i.e., stroke)

Ischaemic stroke most commonly presents with sudden onset of visual loss or visual field deficit, weakness, aphasia, altered sensation, or dysarthria.

Carotid stenosis predisposes to watershed infarction in the border zones between the main arterial territories of the brain where cerebral perfusion pressure is lowest.[28]

focal neurological deficit lasting <24 hours (i.e., transient ischaemic attack [TIA])

Stereotypical and temporary loss of sensory/motor/visual function with return to baseline at the end of an attack. The deficit generally lasts for <60 minutes, but may last up to 24 hours. High-grade stenoses may also cause repetitive, very brief TIAs lasting <1 minute.[28]

In people who have had a stroke attributable to carotid disease, a history of TIA can be elicited in at least half.[28]

Other diagnostic factors

uncommon

transient visual symptoms

Patients may present with a variety of visual symptoms, such as transient monocular blindness (amaurosis fugax, temporary loss of vision in the ipsilateral eye), homonymous hemianopia (decrease in visual field from emboli to the optic radiation), intermittent retinal blindness with loss of vision on exposure to bright light, neovascularisation of iris (resulting from ophthalmic artery ischaemia), and, rarely, complete blindness (resulting from ischaemic optic neuropathy). Asymptomatic retinal artery emboli may be noted on fundoscopy or during retinal screening for diabetic eye disease, and these commonly arise from an ipsilateral carotid stenosis.

Risk factors

strong

older age

Age is the single most important risk factor for stroke and also increases the risk for carotid artery stenosis.[14]​ For each successive 10 years after the age of 55 years, the stroke rate doubles.[15]

Asymptomatic carotid artery stenosis affects approximately 7% of women and 12% of men >70 years of age.[4]

smoking

Smoking is an independent predictor of carotid artery stenosis.[3][14]​[16]​​

Smokers may have a 50% increased risk for atheroembolic stroke compared with non-smokers.[17]

history of cardiovascular disease

The prevalence of high-grade carotid artery stenosis among patients with symptomatic peripheral vascular disease or significant coronary artery disease warranting an intervention is approximately 20%, regardless of the patient's age.[14]​[18]

weak

history of hypertension

High systolic blood pressure is an independent predictor of carotid artery stenosis.[3][14]​[16]​​

The age-adjusted relative risk of stroke among hypertensive patients (i.e., blood pressure >160/95 mmHg) compared with normotensive people (i.e., blood pressure <140/90 mmHg) is 3.0 in men and 2.9 in women.[19]

history of hypercholesterolaemia

Hypercholesterolaemia is an independent predictor of carotid artery stenosis.[14]

diabetes

The presence of diabetes is an independent predictor of carotid artery stenosis.[3][14]

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