Snap Shot A 62-year-old man with history of Type 2 diabetes mellitus, coronary artery disease and a 40 pack-year smoking history complains of a sensation of a "curtain coming down" over his left eye 3 days ago. Examination reveals carotid bruit bilaterally. Ultrasound duplex of his carotids demonstrates right and left carotid stenosis of 30% and 80% respectively. He is prescribed aspirin and statins and will undergo left carotid endarterectomy. Introduction Carotid artery narrowing or stenosis caused by atherosclerosis formation of atherosclerotic plaques Neurological sequelae embolization (most common) thrombosis stenosis Risks family history of stroke or TIA other diseases peripheral artery disease coronary artery disease (including AMI, angina pectoris) hypercholesterolemia smoking hypertension diabetes >55 years old males Presentation Symptoms may be asymptomatic neurological sequelae TIA transient hemiparesis paresthesia (loss of sensation or tingling on 1 side of the body) amaurosis fugax (transient monoocular blindness) tinnitus dizziness RIND (>24 hours but <72 hours) stroke Physical exam carotid bruit Imaging Carotid duplex CT angiogram of neck MR angiogram of neck CT or MR head to look for old or new infarcts Treatment Aim of treatment is prevention of stroke Conservative antiplatelet drugs aspirin ticlopidine (Ticlid) clopidogrel (Plavix) statins carotid angioplasty and stenting indications symptomatic patients with > 70% stenosis asymptomatic patients with > 80% stenosis Operative carotid endarterectomy gold standard indications clear benefit - symptomatic patients with >70% stenosis marginal benefit - symptomatic patients with >50-69% stenosis small benefit - asymptomatic patients with >60% stenosis contraindications 100% carotid stenosis previous stroke with persistent neurological symptoms poor surgical candidacy