I am a Neurosurgeon with advanced training in Interventional vascular Neurosurgery(FINR) from Zurich, Switzerland, and FMINS-Fellowship in minimally invasive and Endoscopic Neurosurgery from Germany. I am presently working in Columbia asia hospitals, Bangalore. My areas of interest are Vascular Neurosurgery, Stroke specialist, interventional neuroradiology, Endoscopic and minimally invasive Neurosurgery, Endoscopic spine surgery.

1. Carotid artery disease
& its Treatment
Dr. Avinash KM
MS, MRCS Ed(UK), Mch (KEM, Mumbai), FINR(Switzerland), FMINS(Germany),
• Interventional & Neurovascular surgeon and Stroke specialist,
• Endoscopic Neuro and Spine surgeon,
• Minimally invasive Neuro and Spine surgeon (FMINS).
mob: 9740866228, E mail: doc_avin@hotmail.com
Consultant Neurosurgeon and Neurointerventionist
Columbia Asia Hospital, Bangalore.

2. What is carotid artery disease?
• Carotid stenosis is a narrowing of
the carotid arteries, the two major
arteries that carry oxygen-rich blood
from the heart to the brain. Also
called carotid artery disease.
• Blood supply of the brain
To understand carotid stenosis, it is
helpful to understand the circulatory
system of the head and neck. The
carotid artery supply blood to head
and neck. Place your hands on
either side of your neck, and you
can feel your pulse in your carotid
arteries.
Near the middle of neck, the common
carotid divides into the external and
internal carotid arteries. The
external carotid arteries supply
blood to the face and scalp. The
internal carotid arteries supply blood
to the brain.

3. Common location of carotid artery disease
The most common location of atherosclerotic plaque (carotid
artery disease) build-up is the carotid bifurcation, where the
common carotid divides into the internal and external carotid
arteries.

4. What are the causes of carotid artery disease?
• Atherosclerosis is the major cause of carotid artery disease. It can begin
in early adulthood, but it usually takes decades to cause symptoms. Some
people have rapidly progressing atherosclerosis during their thirties, others
during their fifties or sixties. Atherosclerosis begins with damage to the inner
wall of the artery caused by high blood pressure, diabetes, smoking, and
high cholesterol –specifically "bad" cholesterol or low-density lipoprotein
(LDL).
• Carotid dissection
• Trauma to the artery
• Fibromuscular dysplasia can cause carotid stenosis.
• Previous surgery
• Radiation therapy to neck for head and neck tumours

5. What are the risk factors for carotid artery
disease?
• Family history of atherosclerosis (either carotid artery disease or coronary artery disease or
elsewhere in the vascular system)
• Age: In general, the risk of atherosclerosis increases as we age, and in particular, men under
age 75 have a greater risk of developing carotid artery disease than women, but after age 75,
women have a greater risk than men
• High levels of low density lipoprotein (LDL, bad cholesterol) and triglycerides in the blood.
• Smoking
• High blood pressure (hypertension)
• Diabetes
• Obesity
• Sedentary lifestyle
Typically, the carotid arteries become diseased a few years later than the
heart disease. People who have heart disease, and atherosclerosis
elsewhere (such as peripheral artery disease) have a higher risk of
developing carotid artery disease.

6. Risk factors:

7. What are the symptoms of carotid stenosis?
• Asymptomatic carotid stenosis: There may not be
any symptoms of carotid artery disease (incidentally detected).
Detected when investigations done for some other reason.
• Symptomatic Carotid stenosis:
a. Transient ischemic attack(TIA)
b. Stroke

8. What is transient ischemic attack?
A transient ischemic attack (also called TIA or "mini-stroke") is one of the most
important warning signs of a stroke. A TIA occurs when a blood clot briefly
blocks an artery that supplies blood to the brain.
The symptoms of a TIA, which are temporary and may last a few seconds to
minutes, include transient loss of vision, transient weakness in limbs, loss of
speech for a moment, can occur alone or in combination.
A TIA is a medical emergency, since it is impossible to predict if it will progress
into a major stroke. If you or someone you know experiences these
symptoms, get emergency help.
Immediate treatment can save your life or increase your chance of a full
recovery.
Don’t ignore TIA http://www.youtube.com/watch?v
=OWmDdI0_P4Q&feature=related

9. What is stroke?
A stroke, or "brain attack," occurs when a blood vessel in the brain becomes blocked.
The brain cannot store oxygen, so it relies on a network of blood vessels to provide it
with blood that is rich in oxygen. A stroke results in a lack of blood supply,
causing surrounding nerve cells to be cut off from their supply of nutrients and
oxygen. When tissue is cut off from its supply of oxygen for more than 3 to 4
minutes, it begins to die.
A stroke can occur if:
•The artery becomes extremely narrowed
by plaque
•A piece of plaque breaks off and travels
to the smaller arteries of the brain
•A blood clot forms and blocks a
narrowed artery
•A stroke also can occur as a result of
other conditions, such as atrial fibrillation,
cardiomyopathy, or blockage of the tiny
arteries inside the brain

10. How is carotid stenosis diagnosed?
There may not be any symptoms of carotid artery disease. If you are at risk, it is
important to have regular physical exams
• A doctor will listen to the arteries in your neck with a stethoscope. An abnormal rushing sound,
called a bruit (pronounced BROO-ee), may indicate carotid artery disease. However, bruits are
not always present when there are blockages, and may be heard even when the blockage is
minor.
• Diagnostic tests include:
• Magnetic resonance angiogram (MRA): MRA is a type of magnetic resonance image (MRI)
scan that uses a magnetic field and radio waves to provide pictures of the carotid arteries. This
test can provide important information about the carotid and vertebral arteries and the degree of
stenosis.
• Computerized tomography (CT Scan): a CT of the brain may be performed if a stroke or TIA
is suspected to have already occurred. During a CT scan, X-rays pass through the body and are
picked up by detectors in the scanner, which produce three-dimensional (3D) images on a
computer screen. This test may reveal areas of damage in the brain.
•Carotid duplex ultrasound: An imaging procedure that uses high-
frequency sound waves to view the carotid arteries to determine if there
is narrowing. This is the most common test utilized to evaluate for the
presence of carotid artery disease.

11. • Computed tomography angiogram (CTA): A
test that uses advanced CT technology, along with intravenous (IV) contrast
material (dye), to obtain high-resolution, 3D pictures of the carotid arteries.
CTA images enable physicians to determine the degree of stenosis in the
carotid and vertebral arteries and can also assess leading to these arteries
as well as the blood vessels in the brain.
• Carotid angiography (carotid angiogram, carotid
arteriogram, carotid angio): During this invasive imaging procedure, a catheter
(thin, flexible tube) is inserted into a blood vessel in the arm or leg, and guided to the
carotid arteries with the aid of a special X-ray machine. Contrast dye is injected
through the catheter while X-rays of the carotid arteries are taken. This test may be
performed to evaluate or confirm the presence of narrowing or blockage in the carotid
arteries, determine the risk for future stroke and evaluate the need for future
treatment, such as carotid stenting or surgery.

12. Treatment:
Why carotid stenosis be treated?
Carotid stenosis be treated because it can lead to TIA or Stroke. A stroke can
sometimes cause temporary or permanent disabilities, depending on how
long the brain suffers a lack of blood flow and which part was affected.
Complications may include:
• Paralysis or loss of muscle movement. Sometimes a lack of blood flow to
the brain can cause a person to become paralyzed on one side of the body,
or lose control of certain muscles, such as those on one side of the face.
• Difficulty talking or swallowing. A stroke may cause a person to have less
control over the way the muscles in the mouth and throat move, making it
difficult to talk, swallow or eat.
• Memory loss or trouble with understanding. It's common that people
who've had a stroke experience some memory loss. Others may develop
difficulty making judgments, reasoning and understanding concepts.
• Pain. Some people who have a stroke may have pain, numbness or other
strange sensations in parts of their bodies affected by stroke.
• Changes in behavior and self-care. People who have a stroke may
become more withdrawn and less social or more impulsive. They may lose
the ability to care for themselves and may need a caretaker to help them
with their grooming needs and daily chores.

13. Treatment
Who should be treated?
All symptomatic patients should be treated either
medically ( less than 50% stenosis) or by
procedure ( greater than 50% stenosis).
Among asymptomatic patients, stenosis of
greater than 60% should be treated by
procedure and less than 60% by medical
treatment.

14. Treatment
What are the treatment options available?
Carotid artery disease is treated by:
Making lifestyle changes
Medical therapy
procedures --carotid endarterectomy and carotid stenting.
lifestyle changes are recommended :
• Quit smoking and using tobacco products.
• Control high blood pressure, cholesterol, diabetes, and heart disease.
• Have regular checkups with your doctor.
• Lipid cholesterol management.
• Eat foods low in saturated fats, cholesterol, and sodium.
• Achieve and maintain a desirable weight.
• Exercise regularly - at least 30 minutes of exercise most days of the week.
• Limit the amount of alcohol you drink. Excessive alcohol use is defined as drinking
more than three drinks per day. (One drink equals 12 ounces of beer or wine cooler, 5
ounces of wine, or 1.5 ounces of 80-proof liquor.)
• Manage other risk factors: Find out if you have heart rhythm problems, such as atrial
fibrillation, which increases the risk of blood clots that can lead to stroke. If you have
atrial fibrillation, you should take anticoagulant (blood-thinner) medications as
prescribed.
• Talk to your doctor about circulation problems that can increase your risk for stroke.

15. Treatment
Medical therapy:
• Anti-platelet medications: All patients with carotid artery disease should
take an anti-platelet medication to reduce the risk of stroke and other
cardiovascular disease complications. The most commonly used anti-
platelet medication is aspirin.
• Other drugs that work to keep platelets from "sticking together" include
clopidogrel (Plavix) and dipyridamole (Persantine), which may be prescribed
alone or in combination with aspirin to reduce your risk of stroke. In some
cases, the anticoagulant medication warfarin (Coumadin) may be prescribed
to thin your blood and reduce the risk of blood clots.
• Tissue plasminogen activator (t-PA): A clot-dissolving medication approved
by the U.S. Food and Drug Administration (FDA) for the treatment of strokes
caused by blood clots (ischemic strokes). Eighty percent of all strokes are
ischemic. T-PA only works if it is given within 4.5 hours of the start of stroke
symptoms.

16. Treatment
What is carotid Endarterectomy?
• Carotid endarterectomy is a surgical procedure that removes the plaque
build-up from the inner lining of the carotid artery.
• Carotid endarterectomy is typically indicated for patients who have had
symptoms (stroke or TIA) and have blockage greater than 50%. It is also
recommended for patients who have no symptoms (asymptomatic) and
have blockage greater than 60%.
• Patients with 50 percent stenosis or lower do not show enough benefit
from endarterectomy to outweigh the risks of the procedure.
• Watch following videos for better understanding
https://www.youtube.com/watch?v=dVK09KdNKME
http://www.unmc.edu/surgery/Carotid_Endarterectomy.htm

17. Treatment
What is carotid angioplasty and stenting?
Carotid angioplasty / stenting is a minimally invasive endovascular
procedure that compresses the plaque and widens the lumen of
the artery. It is performed during an angiogram in an
interventional radiology suite.

18. Treatment
Which of the two modalities is better?
Endarterectomy VS Stenting?
• If you have symptoms related to carotid artery narrowing, you will likely need to have either
carotid endarterectomy or carotid stenting to correct the narrowing in the artery and reduce
your risk of stroke.
• Many clinical trials have been done to address the issue which of the two procedures is
better. The latest and the most recommended clinical trial is CREST trial.
• Brief about CREST trial: The CREST was a prospective, randomized, parallel, two-arm,
multi-centre trial with blinded endpoint adjudication. This multicenter trial enrolled 2,502
patients at 108 centers in the United States and 9 in Canada. The results of the trial was
published in july 2010 and forms the most accepted selection criteria for choosing
endarterectomy VS stenting.
CREST RESULTS Stenting group Endarterectomy group
Stroke or Heart attack or death 4
years after the procedure
7.2% of patients suffered at the end
of 4 years
6.8% of patients suffered at the end
of 4 years
Peri procedural death 0.7 ± 0.2 0.3 ± 0.2
Peri procedural MI 1.1 ± 0.3 2.3 ±0.4
Peri procedural Stroke 4.1 ± 0.6 2.3 ± 0.4
Cranial nerve paresis 0.3% 4.8%

19. Treatment
What are the complications of these
procedures?
As with any surgical procedure, complications can occur. Some possible
complications of both carotid endarterectomy and carotid angioplasty with
stenting may include, but are not limited to, the following:
• Stroke or transient ischemic attack (TIA)
• Heart attack (myocardial infarction)
• Wound hematoma (pooling of blood into surrounding tissue causing swelling)
• Cranial nerve deficits (problems with certain functions of the eyes, nose, tongue,
and/or ears that are controlled by one or more of the 12 cranial nerves)
• Intracerebral hemorrhage (bleeding into the brain)
• Seizures (bursts of abnormal electrical signals that temporarily interrupt normal
electrical brain function), which is an uncommon complication.
• Repeated blockage of the carotid artery
• Bleeding
• Infection
• Hypertension (high blood pressure)
• Arrhythmias (irregular heart beat)
• Airway obstruction from swelling
• Stent ingrowth (overgrowth of tissue where the stent is placed which may cause a
blockage) in CAS procedures