Carotid Artery Disease and Strokes

The carotid arteries are the main blood supply to most of the brain.  The right carotid artery supplies the right side of the brain.  A right sided stroke  symptom will include loss of vision in the right eye, kid of like those old movie theaters where a curtain comes down over part of the eye or all of it.  This event is called Amaurosis Fugax.  Another potential symptom of a right brain stroke is loss of motor control of the left side of your body.  You may be stirring a cup of coffee with your left hand, and all of a sudden you can lift your hand.  There is no pain associated with these events.  A left brain stroke will cause the opposite event to the right side, namely amaurosis fugax of the left eye and loss of right sided motor control.  In addition, most peoples speech centers are on the left side of the brain, so you may lose your ability to speak even though you know what you want to say, or it may come out as a string of non-sense words.

Carotid artery blockages are one of the many potential reasons for a stroke.  The risk factors for carotid artery disease are the same as the risk factors for other cardiovascular diseases.  These include   1.  Cigarette smoking

2.  Diabetes

3.  High blood pressure

4.  High cholesterol or triglycerides

5.  Age

6.  Family history of circulation problems

Most people with carotid artery narrowing do not know they have it.  If you have had a heart attack or has peripheral vascular disease, then you have a higher risk for carotid artery narrowing.  Most patients with carotid artery stenosis do not need surgery.  Age and family history you are stuck with!  Our goal is to prevent the narrowing becoming worse but making sure that your blood pressure, blood sugars, and cholesterol levels are well controlled, and that you stop smoking.

If you have been diagnosed as having carotid artery narrowing, the prognosis is really quite good.  Most people will never need their carotid artery repaired.  Th old standard for treatment of carotid artery narrowing that was 60% or greater was surgical intervention based on a study published in the New England Journal of Medicine.  However, this study was prior to the current era where we have Plavix which is like a super aspirin, and statin drugs.  Therefore, the management of carotid artery disease has changed somewhat to a more conservative approach, as outlined by the writings of Dr. Frank Veith, one of the most thoughtful and smart vascular surgeons who has been around a long time and seen  it all.  I personally discuss surgery in patients who have had a TIA or ministroke and carotid artery narrowing on the side of the TIA.  A TIA is a stroke like symptom, but by definition, you recover function within 24 hours.  If you have a TIA, and have severe carotid artery narrowing on the side that caused the TIA, then you have a high risk for a full blown stroke, and really should have intervention for the carotid artery narrowing.

In terms of treatment for carotid artery stenosis, as I mentioned most people do not need intervention, and can be managed with anti-platelet agents that thin out the blood such as aspirin or Plavix, as well as control of their cardiovascular risk factors, statin drugs as necessary, and smoking cessation.  Why not fix all carotid artery narrowing when it’s present?  Because the intervention itself carries a risk for stroke and even heart problems.  This business is all about balancing the risks versus benefits of everything we do.  If the risk of stroke is low with carotid artery narrowing, then it is better managed conservatively.  If intervention is required, the options are to either have a surgical intervention or a carotid artery stent.  There are advantages and disadvantages of both. I personally do not do carotid artery stenting; I think that is better left to someone who has experience in doing the procedure, but also in fixing problems that may arise both during and after the procedure.  If I think a patient is better served by a carotid artery stent rather than surgery, I will ask them to see a friend of mine who is a neurointerventional radiologist, basically a specialist in all things related to the blood flow to the brain.  He might come back and tell me “no, I think this case would be better served by surgery, or yes I think carotid artery stenting would be a good option.”  Remember the old adage “if your only tool is a hammer, the whole world looks like a nail.”

 

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