Definition
Extracranial arterial disease is a common disorder characterized by atherosclerosis of the carotid or vertebral arteries resulting in cerebral (stroke, TIA), ocular (amaurosis fugax) or cerebellar (vertigo, ataxia, drop attacks) ischaemic symptoms. A transient ischaemic attack (TIA) is defined as: a focal neurological or ocular deficit lasting not more than 24 hours. A newer definition is: a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction (American Heart Association, 2009). A stroke (brain attack) is a neurological deficit which lasts for more than 24 hours. New definition: an infarction of central nervous system tissue.
- All patients with transient neurological symptoms should undergo duplex ultrasound examination for carotid disease – clinical examination is not accurate.
- All patients should be treated with antiplatelet agents, statins and risk factor control.
- Carotid endarterectomy (CEA) offers optimal risk benefit for stroke prevention in well identified groups of patients.
- Carotid artery stenting (CAS) should be performed only in high-risk for CEA patients.
Epidemiology
Male > female before 65 years. Increasing risk with increasing age.
Aetiology
- Atherosclerosis and thrombosis.
- Thromboemboli.
- Fibromuscular dysplasia.
Risk Factors
- Cigarette smoking.
- Hypertension.
- Cardiac disease.
- Hyperlipidaemia.
- Diabetes
- Obesity.
Pathophysiology
- The most common extracranial lesion is an atherosclerotic plaque at the carotid bifurcation. Platelet aggregation and subsequent platelet embolization cause ocular or cerebral symptoms.
- Symptoms due to flow reduction are rare in the carotid territory, but vertebrobasilar symptoms are usually flow-related. Reversed flow in the vertebral artery in the presence of ipsilateral subclavian occlusion leads to cerebral symptoms as the arm ‘steals’ blood from the cerebellum – subclavian steal syndrome.
Clinical Features
- Cerebral symptoms (contralateral):
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