Patient Information - Carotid Endarterectomy

'The information contained in this patient information sheet is not a substitute for medical advice or treatment, and the Society recommends consultation with your doctor or health care professional'

1. What is Carotid Disease?

The carotid artery in the neck provides the principal blood supply to the brain. The artery (common carotid artery) runs up the side of the neck and divides into two branches just below the angle of the jaw. One branch supplies the face (external carotid artery). The other branch passes directly to the brain with no other branches in the neck (internal carotid artery).

Arteries tend to narrow where they divide. Narrowing at the carotid bifurcation (division of common carotid artery) may directly restrict the blood supply to the brain. Additionally and more importantly, debris stuck to the narrow area may break off and fly into the brain or into the artery to the eye.

2. How is carotid disease detected clinically?

Debris flying into the brain may produce a mini-stroke. A mini-stroke (transient ischaemic attack or TIA) is a small stroke which usually lasts less than an hour. It affects one side of the body only.
Sometimes there is transient blindness (Amaurosis Fugax) affecting one eye usually lasting only a few seconds. Sometimes the speech centre in the brain is affected leading to either jumbled speech or complete loss of speech. A key feature of a TIA is that it recovers completely.
The right side of the brain supplies the left side of the body and vice versa. Symptoms of weakness are therefore found on the ‘wrong’ side in relation to the arterial narrowing. Transient blindness by contrast affects the same side, because debris passes directly into the back of the same eye.
When TIA symptoms are associated with a very tight narrowing of the artery to the brain there is a high risk of major stroke. The risk of stroke is greatest during the 3-4 months after the TIA.
When the narrowing is less severe, or when there are no symptoms, the risk of stroke is much lower.
There are several illnesses that may seem very much like TIA's. These include migraine, epileptic fits or seizures, a low blood sugar, faint, and changes in heart rhythm. TIA's do not usually cause blackouts, fainting or loss of consciousness. These other illnesses need different treatments and it is important that people with TIA symptoms are seen by a specialist to find out the cause of the trouble.

3. What tests can be used to detect carotid disease?

Sometimes narrowing can be detected with a stethoscope if there is turbulence of blood flow in the artery and a squeaking or rushing noise.
Ultrasound is the main way of diagnosing carotid disease. The ultrasound image may show narrowing on screen where the carotid bifurcation is usually easily been seen. Ultrasound can also be used to study the speed of blood flow at the point of narrowing. Red cells have to speed up to get through the narrowed segment, and the increase in flow velocity is determined by the degree of narrowing.
A carotid angiogram is an Xray of the circulation to the brain taken by injecting dye (contrast) into the carotid artery. A catheter is threaded into the artery from puncture of the femoral artery at groin level. This procedure is performed under local anaesthetic.
Some patients will have an Xray scan of the brain (CT or MRI scan). This scan can detect signs of damage to the brain, and rule out other causes of your symptoms.

4. Who is at risk?

TIA’s affect those of increasing age (usually over 60 years), and are more common in men than women.
TIA’s are much more likely in smokers, those with high blood pressure and those with high cholesterol (hyperlipidaemia).

5. Do I need treatment?

The simultaneous combination of TIA, or amaurosis fugax and tight narrowing of the carotid artery put you at risk of major stroke.
Some Surgeons recommend treatment of a tight narrowing on its own, in the absence of symptoms. In particular Cardiac Surgeons often insist on treatment of the carotid stenosis prior to heart bypass surgery.
If surgery is recommended, it should be done as soon as possible after TIA symptoms, because this is the time of greatest risk for a major stroke.
If treatment is delayed, or if you decide not to have an operation, there is a significantly increased risk of major stroke during the following 12 months but particularly during the following 3 months.
The aim of surgical treatment is to reduce the risk of major stroke posed by the tight narrowing in the neck. The risk of major stroke is reduced from approximately 1 in 5 to 1 in 25.

6. What does treatment involve?

There are two lines of treatment; medication and surgery.
All patients will be recommended to take an Aspirin-like drug. There are several available including aspirin, dipyridamole and clopidogrel. Your Surgeon or GP will discuss the options with you. Some of these drugs can cause indigestion and are contra-indicated in those with known peptic ulcer disease (gastric or duodenal ulcer).
Carotid endarterectomy is an operation to unblock the narrowed carotid artery. The artery is carefully exposed through an incision running vertically in the side of the neck. The artery is opened, cleared of the debris and carefully sewn up again. The operation can be done under local or general anaesthetic.

7. Is treatment successful?

Carotid endarterectomy reduces the threat of stroke from about 1 in 5 to 1 in 25. It normally provides very good long-term results.
The principal risk is that a small number of people (between 1 and 3 in 100) having the procedure will have a stroke during the operation. This stroke is often severe and may lead to loss of life.
There are few side effects of the operation. Very occasionally, there may be damage to adjacent nerves. This may lead to a hoarse voice, some weakness of the side of the mouth, or impaired tongue movements, which interfere slightly with speech.
After a successful operation you will return fully to normal. There will be no limitations or alterations to your lifestyle. You can drive normally and partake in all normal activities.

8. Can I help myself?

You can help yourself by stopping smoking if you smoke. Regular exercise and attention to diet are beneficial. Your cholesterol and blood sugar should be checked, and if elevated, you should have medication to control it.

SD Parvin MD FRCS
February 9th 2003
Version 2003/1.

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