Cvd Csdt

short lived (minutes) ○ paresis/numbness ○ contralateral arm/leg onset – swift

CVD Essential Dx Episodic motor and visual disturbance, Stroke, Ataxia, Aphasia, Sensory dysfunction Cervical bruit, pulse deficit, BP difference in arms Duplex US confirmation Selective arteriogram Result of Emboli Hypoperfusion 80% of patient with occlusive CVD →atherosclerosis in a surgically accessible areas of neck and mediastinum Arterial emboli from Heart Fibromuscular disease Arterial dissection Takayasu’s arteritis Cerebral infarction Manifested by Fixed/advancing neurologic deficit Result from Local arterial thrombosis Cerebral embolisation (most common) Haemorrhage Embolization From atherosclerosis occurs along the outer wall of carotid bulb mostly from ICA neurogenic dysfunction to carotid territory TIA

Amaurosis fugax – monocular loss of vision → 20% to stroke Hollen Horst plaques – emboli may be visible as small bright flecks

C/F A. Symptoms asymptomatic →audible bruit transient neurologic/visual episodes i. where embolus lodged ii.size of embolus iii.composition of embolus iv.abundance of collaterals Acute unstable neurologic deficit i. High risk ii.Urgent treatment Completed stroke i. If recovers - intervene Vertebrobasilar disease i. Bilateral ii.CF 1. Drop 2. Clumsiness 3. A variety of sensory phenomenon B. Signs Following lesions may exist without any signs Occlusion of ICA >90% stenosis Occlusion and stenosis of vertebral arteries Ulceration

1. Palpation a. Distal pulses 2. Bruit

originated from ICA 1

Site of Bruit At an artery High in neck Over lower portion of trapezius at back of neck Midpoint of clavicle transmitted into axilla Full length of RCCA and RSCA Precordium

Stenosis at At/proximal to that point CCA bifurcation Origin of vertebral artery Proximal subclavian

Innominate artery Cardiac

Treatment 1) Objective a) To prevent stroke and TIA 2) Accomplished by a) Improving the blood flow b) Removing source of emboli 3) NASCET study Stenosis (%) Better Option 70 – 90 Endarterectomy + aspirin 50 – 69 ± < 50% Medical therapy 4) ACAS ≥60

3. BP

Surgery

a. Both arms L SCA origin – stenosed mostly C. Non invasive • Duplex US analysis ○ Combines  High resolution B-mode analysis • Plaque morphology  Range gated Doppler spectral flow analysis • Degree of stenosis ○ Rapid ○ Accurate ○ ICA  Velocity – low  Large diastolic flow  With increasing stenosis • Systolic and diastolic velocity increase D. Imaging Arteriography i. Indication 1. Candidates of surgery 2. Indication of surgery a. Accessible b. Meets criteria

5) Medical therapy a) Antiplatelet i) Aspirin ii) Ticlopidine iii) Clopidogrel (ADP-Rc inhibitor) b) Cessation of smoking c) Rx of HTN d) Lowering of LDL cholesterol e) Oral anticoagulants – not considered as high risk 6) Endarterectomy a) Arteries of choice i) CCA LCCA – needs thoracotomy; can be transplanted to SCA ii) Right vertebral artery LVA – difficult to introduce, better to transplant to LCCA iii) SCA iv) Innominate artery v) Subclavian – carotid bypass A prosthetic graft from SCA to CCA beyond stenosis b) CI i) Recent completed stroke (1) Risks (a) Haemorrhage into infarction (b) ↑edema ii) Completely occluded ICA

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7) PC carotid artery angioplasty a) Disadvantage i) Recurrence ii) More complications

SC steal syndrome Neurologic symptoms upon exercise of upper limb SC stenosis Mx i. Bypass grafting from CCA to SCA ii.Transposition of SCA

ii. Rx i. Anticoagulant

Fibromuscular dysplasia Takayasu’s arteritis Oblterative arteriopathy Arch of aorta branches Young women Rx i. Steroid ii.Cyclophosphamide Arrest progression

Unknown cause Young lady Bilateral Primarily - ICA Overgrowth of the media C/F ○ HTN ○ Bruit ○ 20% - stroke at presentation Arteriography ○ String of beads

Internal carotid artery dissection Trauma Young adult Primary lesion – intimal tear Cerebral symptoms i. Ischemia of ipsilateral hemisphere ii.Acute neck pain iii.Localized cervical tenderness adjacent to mandibular angle Arteriography i. Narrowing at or just beyond the distal portion of carotid bulb

Surgical results Late restenosis – uncommon in endarterectomy Main complication – stroke Transient nerve injury (20%)

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