• Atherosclerotic extracranial carotid disease causes symptoms by embolism, not thrombosis.
  • In fewer than half of persons is circle of Willis complete.
  • With a TIA, chance of stroke in next 30 days is 5%.


  • Doppler ultrasound of carotids is an excellent screening tool.
  • MR angiography and CT angiography can give noninvasive angiography pictures.
  • Conventional invasive angiography with digital subtraction angiography is the gold standard, though it produces stroke in 0.5% cases.

Carotid endarterectomy

  • Carotid endarterectomy or CEA is the surgery for extracranial carotid artery disease. It has been shown to be better than medical management in the NASCET, ESCT, ACAS and ACST trials. It is recommended in symptoms + >50% stenosis or no symptoms + > 80% stenosis.

Carotid artery stenting or CAS

  • This uses self expanding stents to avoid stent compression and deformation. To protect from embolisation, protection devices are used which include distal balloon occlusion with aspiration, proximal occlusion with aspiration and distal filter.
  • The BEACH, ARCHeR & SECuRITY trials found that CAS is safe.
  • The SAPPHIRE trial compared CAS (with distal emboli protection) with CEA in patients at increased risk for CEA. It found that CAS was better than CEA (for 30 day incidence of stroke, death and MI, for cranial nerve injuries and for 1 year combined endpoint). This trial led to FDA approval of CSA with distal protection for patients at increased risk of carotid surgery.
  • Studies comparing CAS with CEA for patients who are not at increased surgical risk care EVA-3S and SPACE. The EVA-3S found that CEA is better than CAS while the SPACE trial did not show superiority of either strategy.
  • Thus, currently CAS is indicated for patients at increased risk of carotid surgery with symptoms + >50% stenosis or no symptoms + > 80% stenosis.