Highlights & Basics
- Carotid artery stenosis is a narrowing of the lumen of the carotid artery. Approximately 10% to 15% of all ischemic strokes are associated with carotid artery stenosis.
- Atherosclerotic plaque in the cervical carotid artery is the most common cause. Plaque disruption and atheroembolization into the intracranial circulation is the most common mechanism for stroke.
- The majority of carotid artery stenoses are mild or moderate, and asymptomatic.
- Duplex ultrasonography is a commonly used mode of diagnosis; computed tomography angiography or magnetic resonance angiography are alternatives that also help to define the anatomy if intervention is indicated.
- Most patients with carotid artery stenosis should receive antiplatelet therapy, and all should receive risk factor modification.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Ruptured plaque with intraplaque hemorrhage explanted from a patient with carotid stenosis and a recent atheroembolic stroke
Stable plaque with a small deep-seated lipid core explanted from a patient with a high-grade carotid stenosis without neurologic symptoms
Echolucent internal carotid artery atheroma (yellow arrow) causing 70% stenosis (North American Symptomatic Carotid Endarterectomy Trial criteria). CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery, STA = superior thyroid artery
Magnetic resonance time of flight image of brain. The arrow shows the right carotid artery with a crescent-shaped appearance. This is consistent with intramural hematoma consequent upon dissection of the right carotid artery
MRI of carotid artery. The arrow shows narrowing of the lumen of the carotid artery caused by intramural hematoma
Citations
Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Circulation. 2011 Jul 26;124(4):e54-130. [Abstract][Full Text]
Naylor R, Rantner B, Ancetti S, et al. Editor's choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the management of atherosclerotic carotid and vertebral artery disease. Eur J Vasc Endovasc Surg. 2023 Jan;65(1):7-111.[Abstract][Full Text]
AbuRahma AF, Avgerinos ED, Chang RW, et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. J Vasc Surg. 2022 Jan;75(1s):4S-22S.[Abstract]
North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991 Aug 15;325(7):445-53.[Abstract][Full Text]
Grotta JC. Clinical practice. Carotid stenosis. N Engl J Med. 2013 Sep 19;369(12):1143-50.[Abstract]
- CREST-2: The carotid revascularization and medical management for asymptomatic carotid stenosis study: health and hope for patients at risk for stroke
- ClinicalTrials.gov: Endarterectomy combined with OMT vs OMT alone in patients with asymptomatic severe atherosclerotic carotid artery stenosis at higher-than-average risk of ipsilateral stroke
- European Carotid Surgery Trial 2 (ECST-2)
- Carotid stenosis risk prediction tool
1. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Circulation. 2011 Jul 26;124(4):e54-130. [Abstract][Full Text]
2. Naylor R, Rantner B, Ancetti S, et al. Editor's choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the management of atherosclerotic carotid and vertebral artery disease. Eur J Vasc Endovasc Surg. 2023 Jan;65(1):7-111.[Abstract][Full Text]
3. Song P, Fang Z, Wang H, et al. Global and regional prevalence, burden, and risk factors for carotid atherosclerosis: a systematic review, meta-analysis, and modelling study. Lancet Glob Health. 2020 May;8(5):e721-9.[Abstract][Full Text]
4. de Weerd M, Greving JP, de Jong AW, et al. Prevalence of asymptomatic carotid artery stenosis according to age and sex: systematic review and metaregression analysis. Stroke. 2009 Apr;40(4):1105-13. [Abstract][Full Text]
5. Lal BK, Meschia JF, Brott TG, et al. Race differences in high-grade carotid artery stenosis. Stroke. 2021 Jun;52(6):2053-9.[Abstract][Full Text]
6. Gensicke H, Engelter S, Bonati L. Endovascular treatment for carotid artery stenosis [in German]. Ther Umsch. 2012 Sep;69(9):523-35. [Abstract]
7. Sacco RL, Boden-Albala B, Gan R, et al. Stroke incidence among white, black, and Hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol. 1998 Feb 1;147(3):259-68.[Abstract][Full Text]
8. Martin SS, Aday AW, Almarzooq ZI, et al. 2024 heart disease and stroke statistics: a report of US and global data from the American Heart Association. Circulation. 2024 Feb 20;149(8):e347-913.[Abstract][Full Text]
9. Stary HC. Natural history and histological classification of atherosclerotic lesions: an update. Arterioscler Thromb Vasc Biol. 2000 May;20(5):1177-8.[Abstract][Full Text]
10. Zarins CK, Giddens DP, Bharadvaj BK, et al. Carotid bifurcation atherosclerosis. Quantitative correlation of plaque localization with flow velocity profiles and wall shear stress. Circ Res. 1983 Oct;53(4):502-14.[Abstract][Full Text]
11. AbuRahma AF, Avgerinos ED, Chang RW, et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. J Vasc Surg. 2022 Jan;75(1s):4S-22S.[Abstract]
12. Sacco RL, Benjamin EJ, Broderick JP, et al. American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke. Risk factors. Stroke. 1997 Jul;28(7):1507-17.[Abstract][Full Text]
13. Mathiesen EB, Joakimsen O, Bønaa KH. Prevalence of and risk factors associated with carotid artery stenosis: the Tromsø Study. Cerebrovasc Dis. 2001;12(1):44-51.[Abstract]
14. Wolf PA, D'Agostino RB, Kannel WB, et al. Cigarette smoking as a risk factor for stroke. The Framingham Study. JAMA. 1988 Feb 19;259(7):1025-9.[Abstract]
15. House AK, Bell R, House J, et al. Asymptomatic carotid artery stenosis associated with peripheral vascular disease: a prospective study. Cardiovasc Surg. 1999 Jan;7(1):44-9.[Abstract]
16. Kannel WB, Wolf PA, McGee DL, et al. Systolic blood pressure, arterial rigidity, and risk of stroke. The Framingham study. JAMA. 1981 Mar 27;245(12):1225-9.[Abstract]
17. Wolf PA, Kannel WB, Sorlie P, et al. Asymptomatic carotid bruit and risk of stroke. The Framingham study. JAMA. 1981 Apr 10;245(14):1442-5.[Abstract]
18. Wardlaw JM, Chappell FM, Stevenson M, et al. Accurate, practical and cost-effective assessment of carotid stenosis in the UK. Health Technol Assess. 2006 Aug;10(30):iii-iv;ix-x;1-182.[Abstract]
19. US Preventive Services Task Force. Asymptomatic carotid artery stenosis: screening. Feb 2021 [internet publication].[Full Text]
20. Zhu CZ, Norris JW. Role of carotid stenosis in ischemic stroke. Stroke. 1990 Aug;21(8):1131-4.[Abstract][Full Text]
21. AbuRahma AF, Srivastava M, Stone PA, et al. Critical appraisal of the Carotid Duplex Consensus criteria in the diagnosis of carotid artery stenosis. J Vasc Surg. 2011 Jan;53(1):53-9;discussion 59-60. [Abstract][Full Text]
22. Adla T, Adlova R. Multimodality imaging of carotid stenosis. Int J Angiol. 2015 Sep;24(3):179-84.[Abstract][Full Text]
23. Cassola N, Baptista-Silva JC, Nakano LC, et al. Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments. Cochrane Database Syst Rev. 2022 Jul;7(7):CD013172.[Abstract][Full Text]
24. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991 Aug 15;325(7):445-53.[Abstract][Full Text]
25. Grotta JC. Clinical practice. Carotid stenosis. N Engl J Med. 2013 Sep 19;369(12):1143-50.[Abstract]
26. Koelemay MJ, Nederkoorn PJ, Reitsma JB, et al. Systematic review of computed tomographic angiography for assessment of carotid artery disease. Stroke. 2004 Oct;35(10):2306-12.[Abstract][Full Text]
27. Nederkoorn PJ, van der Graaf Y, Hunink MG. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review. Stroke. 2003 May;34(5):1324-32. [Abstract][Full Text]
28. European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet. 1991 May 25;337(8752):1235-43.[Abstract][Full Text]
29. Rothwell PM, Gibson RJ, Slattery J, et al. Equivalence of measurements of carotid stenosis. A comparison of three methods on 1001 angiograms. European Carotid Surgery Trialists' Collaborative Group. Stroke. 1994 Dec;25(12):2435-9.[Abstract][Full Text]
30. American College of Radiology. ACR appropriateness criteria: cerebrovascular diseases - stroke and stroke-related conditions. 2023 [internet publication].[Full Text]
31. Aboyans V, Ricco JB, Bartelink MEL, et al; ESC Scientific Document Group. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Eur Heart J. 2018 Mar 1;39(9):763-816.[Abstract][Full Text]
32. Brott TG, Hobson RW 2nd, Howard G, et al; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1;363(1):11-23.[Abstract][Full Text]
33. Halliday A, Bulbulia R, Bonati LH, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet. 2021 Sep;398(10305):1065-73.[Abstract][Full Text]
34. Bonati LH, Jansen O, de Borst GJ, et al. Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol. 2022 Mar;21(3):273-83.[Abstract]
35. Wang J, Bai X, Wang T, et al. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis: a systematic review and meta-analysis. Stroke. 2022 Oct;53(10):3047-54.[Abstract][Full Text]
36. National Institute for Health and Care Excellence. Carotid artery stent placement for asymptomatic extracranial carotid stenosis. Apr 2011 [internet publication].[Full Text]
37. Ballotta E, Angelini A, Mazzalai F, et al. Carotid endarterectomy for symptomatic low-grade carotid stenosis. J Vasc Surg. 2014 Jan;59(1):25-31. [Abstract][Full Text]
38. Rerkasem A, Orrapin S, Howard DP, et al. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev. 2020 Sep;9(9):CD001081.[Abstract][Full Text]
39. Brott TG, Calvet D, Howard G, et al; Carotid Stenosis Trialists' Collaboration. Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data. Lancet Neurol. 2019 Apr;18(4):348-56.[Abstract]
40. Müller MD, Lyrer P, Brown MM, et al. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database Syst Rev. 2020 Feb;2(2):CD000515.[Abstract][Full Text]
41. Naylor AR, Cuffe RL, Rothwell PM, et al. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Vasc Endovasc Surg. 2003 May;25(5):380-9.[Abstract]
42. Jones DW, Stone DH, Conrad MF, et al. Regional use of combined carotid endarterectomy/coronary artery bypass graft and the effect of patient risk. J Vasc Surg. 2012 Sep;56(3):668-76. [Abstract][Full Text]
43. Lal BK, Beach KW, Roubin GS, et al; CREST Investigators. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012 Sep;11(9):755-63.[Abstract][Full Text]
44. Amarenco P, Bogousslavsky J, Callahan A 3rd, et al; Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006 Aug 10;355(6):549-59.[Abstract][Full Text]
45. Sillesen H, Amarenco P, Hennerici MG, et al; Stroke Prevention by Aggressive Reduction in Cholesterol Levels Investigators. Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis: a secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Stroke. 2008 Dec;39(12):3297-302. [Abstract][Full Text]
46. Lal BK, Cambria R, Moore W, et al. Evaluating the optimal training paradigm for transcarotid artery revascularization based on worldwide experience. J Vasc Surg. 2022 Feb;75(2):581-9.e1.[Abstract][Full Text]
47. Lal BK, Mayorga-Carlin M, Kashyap V, et al. Learning curve and proficiency metrics for transcarotid artery revascularization. J Vasc Surg. 2022 Jun;75(6):1966-76.e1.[Abstract]
48. Stacey BG. Explanations of the horizontal-vertical illusion and the foreshortening of receding horizontals. Life Sci. 1969 Nov;8(22):1237-46.[Abstract][Full Text]
49. Schermerhorn ML, Liang P, Eldrup-Jorgensen J, et al. Association of transcarotid artery revascularization vs transfemoral carotid artery stenting with stroke or death among patients with carotid artery stenosis. JAMA. 2019 Dec;322(23):2313-22.[Abstract][Full Text]
50. Kashyap VS, So KL, Schneider PA, et al. One-year outcomes after transcarotid artery revascularization (TCAR) in the ROADSTER 2 trial. J Vasc Surg. 2022 Aug;76(2):466-73.e1.[Abstract]
51. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7):e364-467.[Abstract][Full Text]
52. Bonati LH, Kakkos S, Berkefeld J, et al. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J. 2021 Jun;6(2):I-XLVII.[Abstract][Full Text]
53. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995;273:1421-1428.[Abstract]
54. Lal BK, Beach KW, Roubin GS, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012;11:755-763.[Abstract]
55. den Hartog AG, Achterberg S, Moll FL, et al. Asymptomatic carotid artery stenosis and the risk of ischemic stroke according to subtype in patients with clinical manifest arterial disease. Stroke. 2013 Apr;44(4):1002-7.[Abstract][Full Text]
56. Chang RW, Tucker LY, Rothenberg KA, et al. Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgical intervention. JAMA. 2022 May;327(20):1974-82.[Abstract][Full Text]
57. Doig D, Turner EL, Dobson J, et al; ICSS Investigators. Incidence, impact, and predictors of cranial nerve palsy and haematoma following carotid endarterectomy in the international carotid stenting study. Eur J Vasc Endovasc Surg. 2014 Nov;48(5):498-504. [Abstract][Full Text]
