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CVD ○ paresis/numbness
○ contralateral arm/leg
onset – swift
Essential Dx Amaurosis fugax – monocular loss of vision →
Episodic motor and visual disturbance, 20% to stroke
Stroke, Ataxia, Aphasia, Sensory
dysfunction Hollen Horst plaques – emboli may be visible
Cervical bruit, pulse deficit, BP as small bright flecks
difference in arms
Duplex US confirmation
C/F
Selective arteriogram
A. Symptoms
Result of
asymptomatic →audible bruit
Emboli transient neurologic/visual
Hypoperfusion episodes
i. where embolus lodged
80% of patient with occlusive CVD
ii.size of embolus
→atherosclerosis in a surgically accessible
iii.composition of embolus
areas of neck and mediastinum
iv.abundance of collaterals
Arterial emboli from Acute unstable neurologic deficit
i. High risk
Heart
ii.Urgent treatment
Fibromuscular disease
Completed stroke
Arterial dissection
i. If recovers - intervene
Takayasu’s arteritis
Vertebrobasilar disease
Cerebral infarction i. Bilateral
ii.CF
Manifested by 1. Drop
Fixed/advancing neurologic deficit 2. Clumsiness
3. A variety of sensory
Result from phenomenon
B. Signs
Local arterial thrombosis
Cerebral embolisation (most common) Following lesions may exist without any signs
Haemorrhage
Occlusion of ICA
Embolization >90% stenosis
Occlusion and stenosis of vertebral
From atherosclerosis
arteries
occurs along the outer wall of carotid
Ulceration
bulb
mostly from ICA
neurogenic dysfunction to carotid
territory 1. Palpation
a. Distal pulses
TIA 2. Bruit
originated from ICA
1
Site of Bruit Stenosis at Treatment
At an artery At/proximal to that 1) Objective
point a) To prevent stroke and TIA
High in neck CCA bifurcation
2) Accomplished by
Over lower portion of Origin of vertebral
a) Improving the blood flow
trapezius at back of artery
b) Removing source of emboli
neck
3) NASCET study
Midpoint of clavicle Proximal subclavian
transmitted into Stenosis (%) Better Option
70 – 90 Endarterectomy +
axilla
Full length of RCCA Innominate artery aspirin
50 – 69 ±
and RSCA
< 50% Medical therapy
Precordium Cardiac
4) ACAS
3. BP ≥60 Surgery
a. Both arms
5) Medical therapy
L SCA origin – stenosed mostly
a) Antiplatelet
C. Non invasive i) Aspirin
• Duplex US analysis ii) Ticlopidine
○ Combines iii) Clopidogrel (ADP-Rc inhibitor)
High resolution B-mode b) Cessation of smoking
analysis c) Rx of HTN
• Plaque morphology d) Lowering of LDL cholesterol
Range gated Doppler e) Oral anticoagulants – not considered
spectral flow analysis as high risk
• Degree of stenosis 6) Endarterectomy
a) Arteries of choice
○ Rapid
i) CCA
○ Accurate
LCCA – needs thoracotomy; can be
○ ICA
transplanted to SCA
Velocity – low
ii) Right vertebral artery
Large diastolic flow
LVA – difficult to introduce, better
With increasing stenosis
to transplant to LCCA
• Systolic and
iii) SCA
diastolic velocity iv) Innominate artery
increase v) Subclavian – carotid bypass
D. Imaging A prosthetic graft from SCA to CCA
Arteriography beyond stenosis
i. Indication b) CI
1. Candidates of surgery i) Recent completed stroke
2. Indication of surgery (1) Risks
a. Accessible (a) Haemorrhage into infarction
b. Meets criteria (b) ↑edema
ii) Completely occluded ICA
2
7) PC carotid artery angioplasty
a) Disadvantage
i) Recurrence
ii) More complications
SC steal syndrome
Neurologic symptoms upon
exercise of upper limb ii.
SC stenosis Rx
Mx i. Anticoagulant
i. Bypass grafting from CCA to
SCA
ii.Transposition of SCA
Fibromuscular dysplasia
Takayasu’s arteritis Unknown cause
Oblterative arteriopathy Young lady
Arch of aorta branches Bilateral
Young women Primarily - ICA
Rx Overgrowth of the media
i. Steroid C/F
ii.Cyclophosphamide ○ HTN
○ Bruit
Arrest progression ○ 20% - stroke at presentation
Arteriography
○ String of beads