Carotid Arteriosclerosis

Carotid arteriosclerosis is a progressive condition where fatty deposits called plaque build up inside the carotid arteries in your neck, restricting blood flow to the brain and significantly increasing the risk of stroke.

Table of contents

• What is Carotid Arteriosclerosis?
• The Carotid Arteries
• Causes and Risk Factors
• Symptoms and Warning Signs
• How the Condition is Diagnosed
• Treatment Options
• Prevention and Healthy Living

What is Carotid Arteriosclerosis?

Carotid arteriosclerosis, also known as carotid artery stenosis or carotid artery disease, occurs when fatty deposits called plaque build up and block the normal flow of blood in the carotid arteries^[1]. These clogged blood vessels significantly increase the risk of stroke, which is a medical emergency that happens when the brain loses all or much of its blood supply^[1].

The blockage is made up of plaque, which consists mainly of fatty cholesterol deposits. When plaque blocks the normal flow of blood through the carotid artery, you are at higher risk of stroke^[2]. This buildup is called atherosclerosis, or “hardening of the arteries”^[4].

Up to 3% of individuals older than 65 have this condition. The risk increases as you age and if you have a history of smoking, high blood pressure, high cholesterol, diabetes, or heart disease. Carotid artery disease is responsible for up to one-third of all strokes^[4]. The condition often develops slowly, and the first sign might be a stroke or transient ischemic attack (TIA), which is a temporary shortage of blood flow to the brain that does not cause permanent damage^[1].

• Carotid arteries
• Brain
• Neck blood vessels

The Carotid Arteries

The carotid arteries are a pair of large blood vessels that carry blood from the heart to the brain. There is one on each side of your neck^[1]. These large arteries deliver blood to your brain, face, and head^[2].

When they are healthy, these arteries are smooth and open, like a clean pipe that allows the free flow of fluid without anything in the way^[2]. The carotid artery typically splits, or bifurcates, into an internal and an external carotid artery. The internal carotid artery (ICA) supplies blood to the brain, while the external carotid artery (ECA) supplies the neck, thyroid gland, face, and scalp^[11].

You can develop carotid artery stenosis in either of the two arteries in your neck or in both. This condition can worsen over time without medical care, leading to stroke with severe complications that can include death^[2].

Causes and Risk Factors

Carotid arteriosclerosis is typically a chronic condition that affects people as they age. Excess cholesterol in the blood begins to change the blood vessel, and the body sends inflammatory cells to help. Low-density lipoprotein (LDL) cholesterol, often called “bad cholesterol,” is heavily involved in this process^[11]. After a while, the LDL cholesterol begins to get trapped inside and eventually sticks on the outside of the blood vessel. Over time, this process continues and plaque forms^[11].

Several factors can increase your chance of developing this condition over time^[2]:

• Smoking and using tobacco products
• Having obesity
• Sedentary lifestyle
• High blood pressure (hypertension)
• High cholesterol
• Diabetes
• Age
• Family history^[4]
• Lack of exercise^[4]

Some patients who have had radiation treatment for head and neck cancers can develop carotid artery stenosis from the radiation effect and not actually from plaque development. There are also some inflammatory conditions that can cause irregularities in the carotid arteries^[11].

Symptoms and Warning Signs

In its early stages, carotid artery disease often does not have symptoms. The condition might not be obvious until it is serious enough to deprive the brain of blood, causing a stroke or TIA^[1]. You might not have any symptoms in the early stages of the disease. Sometimes, the first sign of the disease is a stroke^[4].

If you have carotid artery stenosis that has not caused a stroke, you may not notice any symptoms^[2]. However, strokes typically have warning signs—mini-strokes, also called transient ischemic attacks (TIAs). TIA symptoms are usually temporary, lasting a few minutes to a few hours. TIAs should be treated as serious medical emergencies, and they require immediate medical attention^[4].

A transient ischemic attack (TIA) is a “mini-stroke” that is only a temporary blockage of a small brain artery from plaque and/or platelets. For many people, a TIA precedes an ischemic stroke. For these conditions, it is very important to seek treatment as quickly as possible in order to prevent cell death^[2].

Symptoms of a stroke or TIA include^[1]:

• Sudden numbness or weakness in the face or limbs, often on one side of the body
• Sudden trouble speaking and understanding speech
• Sudden trouble seeing in one or both eyes
• Sudden dizziness or loss of balance
• Sudden, severe headache with no known cause
• Drooping of one side of your face^[2]
• Slurred speech or trouble forming words and communicating with others^[2]
• Losing vision in one eye with the experience of a dark shade coming down over your field of vision^[2]
• Losing feeling on one side of your body^[2]
• Losing muscle strength and having weakness on one side of your body^[2]

If you have any symptoms of a stroke, seek emergency care immediately. Even if they last only a short while and then you feel OK, see a healthcare professional right away. You might have had a TIA, which puts you at risk of a stroke^[1].

How the Condition is Diagnosed

Carotid artery stenosis is often diagnosed after you have experienced symptoms of a stroke. The symptoms prompt your healthcare provider to thoroughly check for any type of blockage, which can lead to a discovery of carotid artery stenosis^[2].

Diagnosis usually starts with a medical history and physical exam. The exam generally includes listening for a swooshing sound, known as bruit, over the carotid artery in the neck. A narrowed artery causes the sound^[8]. The next step might be a test of physical and mental abilities such as strength, memory, and speech^[8].

If your doctor thinks you might have carotid artery disease, they will recommend a noninvasive carotid duplex ultrasound exam. The ultrasound results will confirm if you have the disease and its severity^[4].

Imaging tests used to diagnose carotid artery disease include^[6]:

• Carotid ultrasound (including Doppler ultrasound): This test uses sound waves to create real-time pictures of the arteries and locate blockages. Doppler is a special ultrasound technique that can detect areas of restricted blood flow in the artery.
• Computed tomography angiography (CTA): CTA uses a CT scanner to produce detailed views of the arteries anywhere in the body. The test is particularly useful for patients with pacemakers or stents.
• Magnetic resonance angiography (MRA): This noninvasive test gives information similar to that of CTA without using ionizing radiation.
• Cerebral angiography: Also known as intra-arterial digital subtraction angiography (IADSA), cerebral angiography is a minimally invasive test in which a catheter is guided through an artery in the groin to the area of interest in the brain. Contrast material is injected through the tube and images are captured with X-rays.

Additional imaging tests might include ultrasound to look at blood flow and pressure in the carotid arteries, CT and MRI to show if you have had a stroke or other issues, and CT angiography or MR angiography to give more information about blood flow in the carotid arteries^[8].

Treatment Options

Treatment of carotid artery disease usually involves lifestyle changes, medicines, and sometimes surgery^[1]. It is important to treat the disease to lower your risk of stroke or prevent another stroke. Treatment depends on how severe your condition is^[4].

Lifestyle Changes and Risk Factor Modification

Lifestyle or medical interventions are implemented to address risk factors including hypertension, high cholesterol, and smoking^[12]. Recommendations include quitting smoking, losing weight, dietary modifications to include healthy foods, reducing salt, and exercising regularly^[6].

Medication

Often a combination of medications can help slow the progression of carotid artery disease and reduce the risk of stroke^[4]. Medications that may be used include:

• Antiplatelet medications: Aspirin and other medications (like clopidogrel, prasugrel, ticagrelor) that “thin” the blood and decrease the ability of platelets in the blood to stick together and cause clots^[4][9].
• Antihyperlipidemics (statins): Medications used to lower lipids (fats) in the blood, particularly cholesterol. Studies have shown that certain statins can decrease the thickness of the carotid artery wall and increase the size of the lumen (opening) of the artery^[9].
• Antihypertensives: Medications used to lower blood pressure^[9].
• Anticoagulants: Also described as “blood thinners,” these medications work to decrease the ability of the blood to clot. An example is warfarin^[9].

Medication to control blood pressure or lower cholesterol may be recommended. Your doctor may also recommend taking a daily aspirin or other blood-thinning medication to prevent blood clots^[6].

Surgical Treatments

If blockage is severe, surgical treatment may be recommended^[6]:

Carotid Endarterectomy (CEA): Severe cases of stenosis often require carotid endarterectomy. A surgeon makes an incision to remove plaque and any diseased portion of the artery while the patient is under general anesthesia^[6]. Based on prospective randomized trials, indications for CEA include symptomatic patients with greater than 70% stenosis (clear benefit was found), symptomatic patients with greater than 50-69% stenosis (benefit is modest and appears greater for male patients), and asymptomatic patients with greater than 60% stenosis (benefit is significantly less than for symptomatic patients with greater than 70% stenosis)^[12].

Carotid Artery Angioplasty and Stenting: A less invasive option used for severe stenosis. During this procedure, the doctor threads a catheter from an incision in the groin to the site of the blockage. Once there, they inflate a balloon tip to open the artery. The doctor may place a stent in the artery to expand it and hold it open^[6].

Contraindications for carotid endarterectomy include patients with a severe neurologic deficit after a cerebral infarction, patients with an occluded carotid artery, and concurrent medical illness that would significantly limit the patient’s life expectancy^[12].

Prevention and Healthy Living

Carotid artery disease is a condition where prevention plays a crucial role. Everyone can take steps to adopt heart-healthy living. Research shows that women who have a healthy lifestyle could expect to live 14 years longer than those who do not, while men could have 12 more years of life^[18].

Steps for living healthy with carotid arteriosclerosis include^[19]:

• Stop or refrain from smoking: Smoking cigarettes makes it more likely that fatty deposits will form in your arteries. Plaques may also grow bigger and faster.
• Know your cholesterol and blood pressure: LDL (bad) cholesterol plays a role in plaque formation, while HDL (good) cholesterol helps clear LDL cholesterol from arteries. High triglyceride levels, combined with high LDL cholesterol levels, or low HDL cholesterol levels can lead to atherosclerosis. When blood pressure is high, it causes tears in artery walls that LDL cholesterol can settle into more easily.
• Get on a heart-healthy diet: Limiting saturated and trans fats from your diet by eating less red meat, fried food, and dairy products made with whole milk will help lower your cholesterol. Swap them for healthy oils, fruits, vegetables, whole grains, poultry, fish, and nuts. Eating high-fiber foods can lower cholesterol by as much as 10 percent.
• Make fitness your goal: Being sedentary lowers your HDL cholesterol levels, so there is less of it to clear your arteries. Take brisk walks, cycle, or do other exercises for 40 minutes three or four times a week to help lower cholesterol and blood pressure.
• Strive for weight loss: Carrying around extra weight raises LDL cholesterol levels and lowers HDL cholesterol levels. Dropping 10 percent of your weight improves your numbers.

Atherosclerosis does not have to be a losing battle. In fact, the disease can be reversed through lifestyle changes, according to the American College of Cardiology^[19].