Importance
The carotid arteries are the main arteries of the neck, which carry blood to the brain. Pathological changes in these arteries result in reduced blood flow and significant increase in the risk of stroke. About 25% of all strokes are caused by carotid disease, and more than half of patients have no previous neurological symptoms. Consequences of a stroke have a huge impact on the health of the general population, bearing in mind that about 15% of strokes are fatal, and 15% result in permanent disability.
Pathology
The most common cause of carotid disease is atherosclerosis, a diffuse progressive disease of all large and medium arteries in the body. Accumulation of cholesterol and other harmful substances in the walls of blood vessels leads to the formation of atherosclerotic plaque. These plaques narrow the lumen of the blood vessel and can break down, releasing harmful material into the cerebral circulation. Other pathological changes in the carotid arteries are various forms of angulation and dilation (kinking, aneurysm), which can also lead to the appearance of neurological symptoms. Risk factors for the development and progression of carotid disease are:
– smoking
– diabetes mellitus
– hypertension
– hyperlipidemia
– age
– hereditary factors.
Symptoms
Patients suffering from carotid disease often do not have any symptoms that would alert them and indicate the risk of stroke. The first typical symptoms are stroke or transient ischemic attack (TIA), which most often manifest as a sudden loss of neurological functions:
– confusion
– headache
– dizziness
– loss of consciousness
– clumsiness or poor coordination
– visual impairment (transient blindness)
– speech impairment
– paralysis or weakness of one side of the body
– numbness of one side of the body.
Diagnostics
As carotid disease is often asymptomatic, preventive ultrasound examination of the arteries of the neck should be considered in patients who already suffer from atherosclerosis in other blood vessels (coronary heart disease, peripheral arterial disease). In addition to case history and clinical examination, our institute uses several different radiological methods to help diagnose carotid disease:
– Duplex ultrasonography (DUS) is usually the first examination to diagnose carotid disease. Detection of reflected ultrasound waves provides information on the characteristics of atherosclerotic plaque, as well as its hemodynamic significance (flow rates). This method has no proven risks to the patient’s health.
– Computed tomographic angiography (CTA) is based on the use of intravenous contrast media for better visualization of blood vessels. This examination enables performing brain scan without contrast. This method is significantly more precise than ultrasonography, and enables planning of various therapeutic procedures. Special preparation is necessary for patients with renal insufficiency or allergy to the contrast agent, and there is a risk of ionizing radiation.
– Cerebral angiography is used in rare cases when previous diagnostic procedures did not yield satisfactory results or when endovascular treatment is planned after the procedure. This method carries additional risks due to its invasive nature and requires hospitalization.
Treatment
Upon completion of the diagnostics, the vascular medical advisory board of our institute proposes a precise treatment plan for each patient, based on the clinical picture, blood vessel findings and general health.
– Carotid endarterectomy
Surgical treatment of carotid disease is considered the therapy of choice in a large number of patients. Carotid arteries are accessed through a small incision in the neck, atherosclerotic plaque is removed, and the arteries are reconstructed to regain their primary shape. The operation is performed under general anesthesia and requires a one- day stay in intensive care. The risk of serious perioperative complications (stroke, myocardial infarction) is less than 1%.
– Carotid angioplasty and stenting
Endovascular treatment of carotid arteries is recommended when there is an increased risk of surgical treatment due to different patient characteristics (significant concomitant diseases, unfavorable anatomical characteristics of blood vessels, previous surgical or radiation therapy of the neck). The procedure is performed under local anesthesia by accessing through the groin arteries, under the control performed using X-rays in the angio room and by injecting a contrast agent. Narrowed blood vessels are dilated using specially designed metal stents and balloons, which push atherosclerotic plaque toward the artery wall. During the procedure, special filters are used to prevent unwanted neurological complications. Finally, the access point is closed by manual compression or a special type of shutter is used.
– Medication treatment
In some cases, when the risk of intervention outweighs potential benefits, conservative treatment of carotid disease is recommended. The best possible medication therapy (antiplatelet therapy, treatment of hypertension, statins) is recommended to the patient with regular outpatient ultrasonographic examinations.
Recovery and rehabilitation
After carotid artery surgery, patients spend one day in the intensive care unit, and then one to two days in the vascular surgery department. The most common postoperative disorders are tingling sensation of the skin on the neck, earlobes and mild hoarseness, but these problems are mostly transient.
Regular ultrasonographic follow-up examination is recommended six months after any intervention on the carotid arteries. With DUS findings patients report to the competent surgeon in the vascular outpatient unit of our institute. In case of local complications of the wound (redness, swelling, severe pain), a follow-up examination should be scheduled as soon as possible.
