Dr Aidin Rawshani

Carotid artery disease (carotid stenosis): symptoms, causes, risks, treatments

Contents

Atherosclerotic stenosis of the carotid arteries (carotid artery disease) are a disease that occurs when plaques build up inside the carotid artery (vein thickening). The carotid artery is located on either side of the neck. Initially, these are blood vessels that originate from the main artery (aorta), which then split into two smaller blood vessels on each side of the neck. These smaller blood vessels are called carotis internal (intre) and external (external), in medical language. The internal carotid arteries supply oxygen-rich blood to the brain. The external carotid arteries supply oxygen-rich blood to the face, scalp and neck.

An illustration showing the anatomy of the carotid artery. The carotid artery divides into an internal (internal) and an external (external) blood vessel that supplies different parts of the head with oxygen-rich blood.

Fatty plaque in the carotid arteries is serious because it can cause a stroke. A stroke occurs if the blood flow to different parts of your brain is cut off. If the blood flow ceases for more than a few minutes, the cells in the brain begin to die. Stroke is a collective name for various diseases that affect blood flow to different parts of the brain. An acute or chronic cerebral hemorrhage is defined as a stroke. Fatty plaque that bursts and causes a sudden blockage of blood flow is also considered to be a stroke, this is called lacunar cerebral infarction in medical language. Another variant of stroke is blood clots that form in other parts of the body but are then transferred with blood circulation to the brain where they get stuck in smaller blood vessels, this is called embolus or emboli in medical language. Regardless of how a stroke occurs, the brain cells and the body functions for which the brain cells were responsible. A stroke can lead to persistent brain damage, prolonged disability, such as visual or speech problems or paralysis (inability to move) or death.

Background

Vascular thickening or arteriosclerosis is the dominant cause of the build-up of fatty plaques in the carotid arteries (carotid arteries). Fat plaque builds up over time and usually contains inflammatory cells such as dead, fat (lipids) and calcifications. Some fatty plaques are soft (lipidric) and these have a greater tendency to crack (rupture). Fatty plaques that tend to crack are called unstable plaques, when the material inside the fat plaque leaks into the bloodstream, a blood clot (embolus) forms. Blood clots can travel to different parts of the body, but since the blood clot is formed right at the neck and the carotid arteries supply the brain with blood, the clot will in principle always travel with the blood to different parts of the brain.

Fatty plaque in the carotid arteries is a major cause of stroke. Fattening of the veins can affect any artery in the body. For example, if plaques build up in the coronary arteries (blood vessels supplying the heart), a heart attack may occur. If the plaque builds up in the carotid arteries, a stroke may occur. Some people have pronounced narrowing of the carotid artery without even experiencing any symptoms or signs. For some people, a stroke is the first sign of the disease.

An illustration showing how blood flow stops in one hemisphere as a result of a blood clot. The blue-coloured area shows how a part of the brain suffers when oxygen-rich blood cannot reach the brain cells as a result of a blood clot thrown away from the carotid artery.

Lifestyle changes, medicines and medical procedures can help prevent or treat carotid artery constrictions and may reduce the risk of stroke.

If you think that you have a stroke, you need urgent treatment directly. Do not drive yourself to the hospital. You have the best chance of complete recovery if treatment is started within 4 hours after the onset of symptoms. The earlier the treatment occurs, the better your chances of recovery.

Risk factors

High age smoking Obesity and excess weight Type 1 diabetes and type 2 diabeesInsulated sensitivity (insulin resistance) Impaired sugar tolerance (IGT) High levels of certain fats (hyperlipidemia) and blood cholesterol High blood pressure Heredity for carotid stenoLow physical activityMetabolic syndromeUnhealthy dietary habits

The above risk factors cause damage to the blood vessels. When damage occurs, your body starts a healing process. The healing can lead to the build-up of fatty plaque. Diabetes is one of the main risk factors for carotid stenosis. Diabetes is a disease that affects the body’s ability to handle blood sugar because the body does not produce enough insulin or does not use its insulin properly. People who have diabetes are four times more likely to develop constrictions of the carotid artery than people who do not have diabetes.

People who have a family history of arteriosclerosis are more likely to develop constrictions of the carotid artery. High blood pressure (hypertension), is considered high if it exceeds 140/90 mmHg. If you have diabetes or chronic kidney disease, hypertension is defined as 130/80 mmHg or higher (mmHg is millimeters of mercury, the units used to measure blood pressure).

In diabetes, the pancreas (pancreas) suffers. The ability of the organ to release the hormone insulin is impaired.

Too low level of physical activity (sedentary lifestyle) and lack of aerobic activity can exacerbate other risk factors contributing to the development of carotid stenosis, such as elevated cholesterol levels in the blood, hypertension, diabetes and overweight or obesity. Metabolic syndrome is the name of a group of risk factors that increase the risk of stroke and other health problems, such as diabetes and heart disease. The five risk factors include abdominal obesity, high triglyceride level (a type of fat found in the blood), low HDL cholesterol level, high blood pressure and high blood sugar. Metabolic syndrome is diagnosed if you have at least three of these risk factors.

As you age, the risk of atherosclerosis increases. The process of atherosclerosis begins already in adolescence and usually develops for many decades before complications occur. Smoking damages the blood vessels and also leads to unhealthy cholesterol levels and high blood pressure. Smoking can also limit the amount of oxygen that reaches the body’s tissues.Unhealthy cholesterol levels and unhealthy diet increase the risk of carotid stenosis. Foods high in saturated fats and trans fats, cholesterol, sodium (salt) and sugar can exacerbate other risk factors for this disease.

Having any of these risk factors does not guarantee that you will develop carotid stenosis, but if you know that you have one or more risk factors, you can take measures to prevent or delay the complication.

Taking measures to control your risk factors can help prevent or delay carotid artery disease and stroke. Your risk of carotid arteries increases with the number of risk factors you have.

Lifestyle changes

Cardiac Healthy Eating: Adhering to a healthy diet is an important part of a healthy lifestyle. There are several diets that help to improve the risk factors for this disease. Learn more about LCHF, DAST diet, Mediterranean diet and other diets that improve your risk factors.Aim for a healthy weight: If you are overweight, work with your doctor to create a reasonable plan for weight loss. Controlling your weight will help you control risk factors for the disease.Physical activity: Be as physically active as possible. Physical activity can improve your fitness and health. Ask your doctor what types and amounts of activity are safe for you. Quit Smoking: If you smoke, stop. Talk to your doctor about programs and products that can help you stop.

If lifestyle changes are not enough, your doctor may prescribe drugs to control the risk factors. Take all your medicines as your doctor recommends.

An illustration showing the build-up of fatty plaques in the blood vessels. Fat plaque risks to crack eventually, when the plaque ruptures, a blood clot arises, which can block the blood flow acutely.

Symptoms

Constrictions of the carotid artery can not cause signs or symptoms until the blood vessel becomes much smaller or almost completely blocks a carotid artery.

A constriction that does not give rise to any symptoms (asymptomatic stenosis) ‘Transient Stroke’ which gives rise to symptoms such as paralysis, numbness, loss of sensitivity and speech disorder. Symptoms are reversible within 24 hours, usually within a few hours. This is called TIA (transient ischemic attack) in medical language.Another symptom of stroke as a result of carotid stenosis is transient blindness (amaurosis fugax). Permanent blindness (retinal infarction) .A minor stroke (apoplexy) that is non-disabling. Stroke with improvement of symptoms over time with only mild residual symptoms, this is called minor stroke in medical language.A large disabling stroke (major stroke).

Cast noise

During a physical examination, your doctor can listen to your carotid arteries with a stethoscope. Your doctor should identify a heart murmur. This sound may suggest altered or decreased blood flow due to plaque build-up in the blood vessel. To find out more, your doctor may prescribe examinations and blood tests.

TIA (transient ischemic attack = mini-stroke)

For some people, the first sign of carotid artery disease may be that it suffers from transient ischemic attack (TIA) or “mini-stroke”. During a mini-stroke, you may have some or all symptoms of a stroke. However, the symptoms usually go away on their own within 24 hours.

Stroke and mini-stroke symptoms may include:

A sudden, severe headache with no known cause Dizziness or sudden balance problemAability to move one or more of your limbs, i.e. arms and legs Suddenly problem seeing in one or both eyes Sudden weakness or numbness of the face or extremities, often on just one side of the Body Problems with speaking or understanding speech

Even if the symptoms cease quickly, call for an ambulance for emergency help. Do not drive yourself to the hospital. It is important to be controlled and begin treatment as soon as possible.

A mini-stroke is usually a “warning symptom” that you are at high risk of suffering a major stroke. You should not ignore these symptoms. Getting medical care can help find possible causes of a mini-stroke and help you cope with risk factors. These measures can prevent a future stroke. People suffering from TIA should be observed for at least one day, because the risk of a major stroke is significantly increased during the first few days.

Although a mini-stroke is considered a warning sign for a stroke, it does not predict when a stroke will happen. A stroke can occur days, weeks or even months after a mini-stroke.

Stroke

Symptoms of stroke are the same as for a mini-stroke, but the complications are not as persistent. A stroke can cause persistent brain damage, prolonged disability, such as visual or speech problems or paralysis (inability to move) or death. Most people who suffered a stroke have not previously experienced TIA attack.

Getting treatment for stroke directly is very important. You have the best chance of complete recovery if treatment is given within 4 hours of the onset of symptoms. The earlier the treatment occurs, the better your chances of recovery.

Make them close to you aware of stroke symptoms and the need for urgent measures. Learning the signs and symptoms of a stroke allows you to help yourself or someone close to you reduce the risk of brain damage or death due to a stroke.

Investigation of narrowing of the carotid artery

Medical history

Your doctor will find out if you have any of the main risk factors for carotid stenosis. Your doctor should also ask if you have had any signs or symptoms of a TIA or stroke.

Physical examination

To check your carotid arteries, your doctor will listen to them with a stethoscope. The doctor will listen for a heart murmur. This sound may indicate altered or decreased blood flow due to plaque build-up. Your doctor should also examine your entire body, such as listening to your heart, lungs and examining your blood vessels.

Diagnostic tests

The following tests are common for diagnosing carotid stenosis. If you have symptoms of a TIA or stroke, your doctor may also use other tests.

Ultrasound

Ultrasound (also called sonography) of the carotid artery is the most common test for diagnosing narrowing of the carotid artery. It’s a painless, harmless test that uses sound waves to produce images on the inside of your blood vessels. This test can show if plaques have narrowed your carotid arteries and how narrow they are.

Ultrasound examinations show blood flow in the blood vessels and can detect constrictions or decreased blood flow.

Angiography

Angiography is a special type of X-ray examination. This test can be used if the ultrasound results are unclear or do not provide your doctor with sufficient information.

For this test, your doctor will inject a substance (contrast agent) into a vein, usually in your arm. The paint travels to your carotid arteries and then pictures are taken with various X-ray examinations.

Magnetic resonance angiography

Magnetic resonance angiography (MRA) uses a large magnet and radio waves to take pictures of your carotid arteries. Your doctor may see these pictures on a computer monitor. For this test, your doctor may give you contrast agents to mark your blood vessels in the pictures.

Computed tomography

Computer tomography, or CT angiography, takes X-rays of the body from many angles. A computer combines the images into two- and three-dimensional images. Also for this test, your doctor may give you contrast media to mark your carotid arteries in the pictures.

Treatment

Treatments for carotid artery disease may include lifestyle changes, medicines and medical procedures. The goals of the treatment are to stop the disease from getting worse and to prevent a stroke. Your treatment depends on your symptoms, the severity of the disease and your age and general health.

Drugs to prevent blood clots are the main treatment for people who have carotid artery disease. They prevent platelets from lumping together, forming blood clots in the carotid artery, which can lead to a stroke.

Common Medicines

Antiplatelet (Trombyl) Clopidogrelstatins blood pressure reducesIncreasing blood sugar lowering

Sometimes lifestyle changes are not enough to control your cholesterol levels. For example, you may also need statins to control or lower your cholesterol. By lowering the level of cholesterol in the blood, you can reduce the risk of heart attack or stroke. Doctors usually prescribe statins for people who have:

Diabetic heart disease or having had a stroke high LDL cholesterol levelsDoctors can discuss statin therapy with those who have an elevated risk of developing heart disease or stroke.

Medical procedures

You may need a medical procedure if you have symptoms caused by narrowing of the carotid artery. Doctors use one of two methods of opening narrowed or blocked blood vessels: carotid endarterectomy, angioplasty or stenting.

Carotid endarterectomy — mainly for people whose carotid arteries are blocked 50 percent or more.Carotid artery angioplasty and stenting — Doctors use a procedure called angioplasty to widen carotid arteries and restore blood flow to the brain.

A thin tube with a balloon on the end is passed through a blood vessel to the narrow or blocked carotid artery. In place, the balloon is inflated to push the metal tube outward against the wall of the artery. A stent (a small metal tube) is then inserted into the artery to support the internal artery wall. The stent also helps prevent the artery from becoming narrower or blocked again.

If you have carotid artery disease, you can take measures to cope with the condition, reduce risk factors and prevent complications. These steps include making healthy lifestyle changes, following your treatment plan and receiving ongoing care.

Most people who have the disease will need to check blood pressure regularly, and their blood sugar and blood cholesterol levels are tested once or more times a year. If you have diabetes, you need routine blood sugar tests and other tests.

The test will show if these conditions are under control or if your doctor needs to adjust your treatment for better results. If you have had a stroke or procedures to restore blood flow in your carotid arteries, you most likely need an annual ultrasound test. This test shows how well blood flows through your carotid arteries. The results can also show how well treatments for your arteries have worked.

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