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Carotid artery stenosis
In symptomatic carotid stenosis (TIA, minor stroke or transient monocular blindness on the side of the stenosis) of 70%–99%, endarterectomy reduces stroke and should be done quickly — ideally within two weeks; in asymptomatic stenosis the basis is best medical therapy, with surgery only in selected patients.
Why it matters in the exam
The central question is whether the patient is symptomatic: an event on the side of the stenosis within the last six months — TIA, non-disabling stroke or amaurosis fugax (transient blindness in one eye, a "curtain" coming down). In a symptomatic patient with 70%–99% stenosis surgery is clearly recommended, at 50%–69% it is considered (smaller benefit, mainly in men), and below 50% treatment is medical only. Timing matters: the risk of recurrent stroke is highest in the first days, so surgery is done early, ideally within 14 days.
The first test is duplex ultrasound, confirmed by CT or MR angiography. In an asymptomatic patient the basis is best medical therapy — an antiplatelet, a statin and control of blood pressure and glucose — and surgery is considered only for significant stenosis with high-risk features, at low surgical risk and with reasonable life expectancy. Carotid stenting is an alternative for high surgical risk, after neck radiotherapy or for restenosis. Candidates are also asked about complications of surgery: stroke, myocardial infarction, injury to the hypoglossal nerve (the tongue deviates towards the injured side), the facial nerve's marginal mandibular branch and the recurrent laryngeal nerve, neck haematoma and hyperperfusion syndrome.
Key points
- Symptomatic = an event on the side of the stenosis within the last six months.
- Symptomatic 70%–99% — endarterectomy, ideally within 14 days.
- Symptomatic 50%–69% — consider; below 50% — drugs.
- Asymptomatic — best medical therapy; surgery only in selected patients.
- Stenting — high surgical risk, neck radiotherapy or restenosis.
Summary table
| Situation | Stenosis | Treatment |
|---|---|---|
| Symptomatic | 70%–99% | Endarterectomy, ideally within 14 days, and best medical therapy |
| Symptomatic | 50%–69% | Consider endarterectomy (smaller benefit, mainly in men) |
| Symptomatic | Below 50% | Medical therapy only |
| Asymptomatic | 60%–99% | Best medical therapy; surgery only in selected patients with high-risk features and low surgical risk |
| Complete occlusion | 100% | No surgery; medical therapy |
| High surgical risk, neck radiotherapy or restenosis | — | Carotid stenting as an alternative |
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Sources
- ESVS Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease, 2023 — Symptomatic and asymptomatic stenosis, timing and choice of intervention
- AHA/ASA Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack, 2021 — Carotid revascularisation
- Sabiston Textbook of Surgery, 21st edition (2022) — Cerebrovascular Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.