Intended for healthcare professionals

Clinical Review

Diagnosis and management of carotid atherosclerosis

BMJ 2013; 346 doi: (Published 18 March 2013) Cite this as: BMJ 2013;346:f1485
  1. Ankur Thapar, specialist registrar1,
  2. Ieuan Harri Jenkins, lead clinician for neurology 2,
  3. Amrish Mehta, lead clinician for stroke imaging 2,
  4. Alun Huw Davies, professor of vascular surgery3
  1. 1Princess Alexandra Hospital, Harlow, UK
  2. 2Imperial College Healthcare NHS Trust, London, UK
  3. 3Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK
  1. Correspondence to: A H Davies a.h.davies{at}
  • Accepted 21 February 2013

Summary points

  • Carotid ultrasound is recommended within 24 hours of a new carotid territory transient ischaemic attack, non-disabling ischaemic stroke, ipsilateral amaurosis fugax, or retinal artery infarction

  • Consider symptomatic patients with 50-99% carotid stenosis for carotid endarterectomy within one week of symptom onset, and ideally within 48 hours

  • Consider symptomatic patients with high bifurcation, symptomatic restenosis, and post-radiotherapy stenosis for stenting

  • Bruits are an unreliable marker of stenosis and ultrasound is preferred

  • Screening for asymptomatic carotid atherosclerosis is not recommended in the UK

  • Revascularisation for asymptomatic carotid atherosclerosis should be performed as part of a randomised trial in the UK

Sources and selection criteria

We search PubMed using the keywords “carotid AND athero* OR stenosis OR plaque”. Key randomised controlled trials and cohort studies were identified. We searched the Cochrane Library using the keyword “carotid”. The UK fourth national clinical guideline for stroke 2012, UK carotid endarterectomy audit round 4, European Society for Vascular Surgery carotid guidelines parts A-C, and European Society for Cardiology fifth guideline on cardiovascular disease prevention were consulted, along with relevant references from these articles.

Carotid atherosclerosis is a pathological thickening of the common or internal carotid intima, typically into focal areas known as plaques (or atheromata). Although atheromata can remain stable for many years, surface rupture of unstable (vulnerable) plaques leads to local thrombus formation, with subsequent embolisation to the ipsilateral ophthalmic, middle cerebral, or anterior cerebral artery territories. The resultant symptoms are ipsilateral amaurosis fugax or retinal infarction and contralateral body transient ischaemic attack (TIA) or stroke. This review discusses the risk factors, clinical presentation, investigations, and treatment options for symptomatic and asymptomatic carotid atherosclerosis. All references to stenosis use consensus North American Symptomatic Carotid Endarterectomy Trial (NASCET) measurements.1 All recommendations reflect current UK guidelines, unless stated otherwise.

Who is at risk of carotid atherosclerosis?

Moderate to severe asymptomatic carotid atherosclerotic stenosis is found in 2-5% …

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