Your carotid arteries are the two large blood vessels on either side of your neck that carry blood to your brain, face and head. In carotid artery disease, plaque made of cholesterol, fat, calcium and inflammatory cells builds up inside the artery wall and narrows the channel, a process called atherosclerosis. The narrowing is known as carotid stenosis.
Carotid disease usually causes no symptoms until something goes wrong. The main danger is stroke: a piece of plaque or a clot that forms on it can break off and travel into the brain, or the artery can narrow enough to reduce blood flow. Sometimes the first sign is a transient ischemic attack (TIA), a brief episode of stroke symptoms that resolves on its own. A TIA is a warning that a stroke may follow and needs urgent attention.
At NYMD Center our vascular and interventional radiology team evaluates carotid disease, manages the risk factors that drive it, and coordinates procedures with vascular specialists when a narrowing is significant. For more detail on vascular conditions and treatments, see our dedicated vascular site, 1Vascular.
If you or someone near you has sudden weakness or numbness on one side of the body, a drooping face, slurred speech or trouble finding words, or sudden loss of vision in one eye, call 911 immediately, even if the symptoms fade.
Who is at risk and what the symptoms are
The risk factors for carotid disease are the same ones that drive heart disease: smoking, high blood pressure, high LDL cholesterol, diabetes, older age, excess weight, inactivity and a family history of atherosclerosis or stroke. People who already have coronary artery disease, peripheral artery disease or an aortic aneurysm are more likely to have carotid plaque as well.
Most people with carotid narrowing feel nothing. Sometimes a doctor hears a whooshing sound called a bruit when listening to the neck with a stethoscope, although a bruit is neither a reliable sign of significant narrowing nor its absence proof that none exists. When symptoms occur, they are those of a TIA or stroke: sudden one-sided weakness, numbness or clumsiness, facial droop, difficulty speaking or understanding speech, or a temporary loss of vision in one eye, sometimes described as a shade coming down.
Should you be screened?
For people without symptoms, the U.S. Preventive Services Task Force recommends against screening for carotid artery stenosis in the general adult population. That recommendation applies to adults with no history of stroke or TIA symptoms. The reasoning is that routine screening finds many narrowings that would never cause harm, and procedures done because of those findings carry their own risk of stroke and other complications. What does help people without symptoms is treating their risk factors, which we address through heart and stroke risk factor screening. Testing is a different matter when you have had symptoms or when your physician has a specific clinical reason to look.
How we evaluate carotid artery disease at NYMD Center
Evaluation begins with your history, especially any episodes of one-sided weakness, speech trouble or vision loss, however brief, along with a review of your risk factors and an examination that includes listening to the neck. The main test is a carotid duplex ultrasound. It is painless, uses no radiation or dye, takes place in the office, and shows both the plaque and how fast blood is moving through the narrowed segment, which is how the degree of stenosis is estimated. When more detail is needed, particularly before a procedure, CT angiography or MR angiography can map the arteries. Blood work for cholesterol, blood sugar and kidney function is part of the workup.
Treatment options, least invasive first
Treatment depends on how narrow the artery is, whether you have had symptoms, and your overall health and risk from a procedure.
Risk factor treatment and medication
For most people with carotid disease, and for everyone who has it, medical treatment is the foundation. This means a statin to lower cholesterol and stabilize plaque, an antiplatelet medicine such as aspirin when appropriate, control of high blood pressure and high cholesterol, good diabetes control, and stopping smoking. These treatments involve no procedure and no recovery time. Their costs are side effects that need monitoring, such as bleeding with antiplatelet drugs or muscle aches with statins, and the need to keep taking them long term. Periodic ultrasound follows the narrowing over time.
Carotid endarterectomy
For significant narrowing, particularly after a TIA or minor stroke, a surgeon may remove the plaque through an incision in the neck. Endarterectomy is a long-established operation. It requires anesthesia and usually a short hospital stay, and it carries a small risk of stroke, heart attack, and nerve injury that can affect swallowing or the voice. When it is indicated, we refer you to a vascular surgeon.
Carotid stenting
In carotid stenting, a stent is placed across the narrowing through a catheter, usually from an artery in the groin or wrist, or through a small incision at the base of the neck. It avoids a neck incision under general anesthesia and may suit patients whose anatomy or health make surgery riskier. It also carries a risk of stroke during the procedure and requires antiplatelet medication afterward. The choice between endarterectomy and stenting is made with the vascular specialist based on your anatomy and health.
What to expect at your visit
Bring any prior ultrasound or scan reports and a list of your medications. We will ask detailed questions about symptoms, examine you, and perform a carotid duplex ultrasound in our office when it is indicated. You will leave with a clear picture of your stroke risk factors, a plan to treat them through our vascular care program, and, if the narrowing is significant or you have had symptoms, a referral to a vascular specialist to discuss a procedure.
When to seek care urgently
Call 911 at once for sudden weakness or numbness of the face, arm or leg on one side, facial droop, slurred or confused speech, sudden loss of vision in one eye, or sudden severe dizziness or loss of balance. Do not wait to see whether symptoms pass and do not drive yourself. If symptoms have already resolved, you still need same-day emergency evaluation, because the risk of stroke is highest in the period right after a TIA.
Questions patients ask
What is the difference between a TIA and a stroke?
A TIA, or transient ischemic attack, causes the same symptoms as a stroke, such as one-sided weakness, facial droop, speech trouble or vision loss in one eye, but they resolve on their own, often within minutes. A stroke causes lasting damage. Because a TIA is often a warning that a stroke may follow, it needs emergency evaluation even after symptoms go away.
Should I get a carotid ultrasound if I have no symptoms?
For most adults without symptoms, no. The US Preventive Services Task Force recommends against screening the general adult population for carotid stenosis, because the harms of screening and resulting procedures can outweigh the benefits. Your physician may still order an ultrasound for a specific clinical reason, and risk factor control is worthwhile for everyone.
Can medication alone treat carotid artery disease?
For many people, yes. A statin, an antiplatelet medicine when appropriate, blood pressure and diabetes control, and quitting smoking form the core treatment and lower stroke risk. Procedures are considered mainly when the narrowing is significant, especially after a TIA or stroke, and are added to medical treatment rather than replacing it.
What is a carotid duplex ultrasound like?
You lie on your back while a technologist moves a gel-covered probe along both sides of your neck. The test is painless, uses no radiation or contrast, and usually takes under an hour. It shows the plaque and measures blood flow speed through the artery, which is used to estimate how narrow it is.
How do I choose between endarterectomy and stenting?
Both remove or bypass the effect of a significant narrowing, and both carry a small risk of stroke. Endarterectomy is open surgery through a neck incision; stenting is done through a catheter. Your age, the plaque's location and shape, prior neck surgery or radiation, and heart and lung health guide which is safer for you, decided together with a vascular specialist.