treatment

Last reviewed 01/2018

Modifiable risk factors for stroke should be managed.

• hypertension
• UK guidelies recommend blood pressure control of less than 130/80 mm Hg after the acute phase 
• US practice guidelines recommend that the blood pressure should be maintained less than 140/90 mm Hg in patients with asymptomatic carotid stenosis and symptomatic patients outside the hyperacute period
• hyperlipidemia
• statins to reduce low density lipoprotein to less than 2.0 mmol/L
• statins may result in stabilization and even regression of intima– media thickness of the carotid-artery wall
• cessation of smoking
• behavioral interventions
• nicotine replacement therapy
• pharmacotherapy (1,2)

In addition current guidelines recommend aspirin, clopidogrel, or the combination of aspirin and dipyridamole.

• in the UK, the Royal College of Physicians recommends lifelong antiplatelet drugs (clopidogrel 75 mg daily)
• Americal Heart Association (AHA) recommends aspirin 75 mg to 325 mg daily for all patients with carotid stenosis  to lower the risk of MI
• although the combination of aspirin and clopidogrel is not recommended (due to increased risk of bleeding), short term use (e.g., 1 to 3 months) after carotid-artery stenting has shown to be beneficial (1,2)

Surgical options

• carotid endarterectomy (CEA)
• patients with 50-99% stenosis on duplex ultrasound should be immediately referred to a vascular surgeon for consideration of confirmatory imaging and endarterectomy (1)
• has been shown to be clearly beneficial in patients with symptomatic carotid artery stenosis >=70%
• 2 randomized trials have shown that asymptomatic patients with 60% - 99% stenosis had a 50% reduction in stroke rates with CEA when compared with medical therapy of that era
• surgery is currently recommended for these patients only as part of a trial in the UK
• carotid stenting (CAS)
• is considered to be an alternative for CEA in patients at high risk for complications for CEA
• CAS has not been shown to be as safe as CEA in patients with symptomatic carotid artery stenosis in RCTs (1,2,3).

See more details in prevention of stroke after TIA section linked below.

Notes:

• comparing carotid endarterectomy versus stenting:
• in 2012, a review  analysed outcomes for symptomatic and asymptomatic patients treated with carotid angioplasty and stenting versus endarterectomy. In16 trials of 7572 symptomatic patients:
• patients who had stenting had a significantly worse risk of 30 day stroke or death, especially in  people over 70 years
• long term rates of ipsilateral stroke were similar for both procedures
• myocardial infarction and cranial nerve palsy  rates were less with stenting
• in asymptomatic patients there was no significant difference in the 30 day stroke and death risk between the two procedures
• hence endarterectomy remains the procedure of choice for symptomatic carotid atherosclerosis until perioperative stroke or death rates improve with stenting (1)

Reference:

• (1) Thapar A et al. Diagnosis and management of carotid atherosclerosis. BMJ. 2013;346:f1485.
• (2) Cleveland clinic. Centre for continuing education. Disease management. Carotid artery stenosis (2016).
• (3) Lovrencic-Huzjan A, Rundek T, Katsnelson M. Recommendations for management of patients with carotid stenosis. Stroke Res Treat. 2012;2012:175869.