Assessment of carotid artery stenosis following TIA and minor stroke and referral for carotid endarterectomy

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This Protocol is primarily aimed at Consultant Physicians and staff responsible for carrying out Carotid Ultrasound / CT angiograms, CT scans or involved with Carotid Endarterectomy post-TIA or stroke.

  • Patients who have had an Anterior Circulation TIA, Temporary Monocular Blindness (TMB) or Non-disabling Stroke who are found to have high-grade stenosis on the appropriate side should be considered for Carotid Endarterectomy.
  • The benefits of surgery are greatest if it is performed within two weeks of the event.
  • Urgent referral to the Vascular Surgery Team is essential.
Patient has had an anterior circulation TIA, TMB or non-disabling stroke
  • Carotid imaging is usually of no value in the management of posterior circulation events

TIA symptoms related to  cerebral circulation

 Symptom    Circulation Involved 
Anterior Either Posterior
Dysphasia      
Unilateral weakness Usually    
Unilateral sensory disturbance Usually    
Dysarthria   Plus other  
Homonymous hemianopia      
Unsteadiness/ataxia   Plus other  
Dysphagia   Plus other  
Diplopia     Plus other
Vertigo     Plus other
Bilateral simultaneous visual loss      
Bilateral simultaneous weakness      
Bilateral simultaneous sensory disturbance      
Crossed sensory/motor loss      
Assessment of patient
  • Patient has made good recovery (Rankin equal to or below 3)
  • Patient is without major co-morbidity and pre-existing disability
  • Patient is willing to undergo surgery

Fitness for carotid endarterectomy (CEA)

  • CEA is routinely performed under local anaesthesia
  • Most patients should be considered to be a candidate for surgery. Exceptions are:
    • Severe cognitive impairment/dementia
    • Patient bedbound prior to neurological event
    • Advanced malignant disease
  • The final decision rests with the Surgical and Anaesthetic team
Carotid Duplex Ultrasound or alternative imaging

Carotid imaging
The first line imaging depends on local facilities:

  • Raigmore Hospital: Duplex scan
  • Belford Hospital and Caithness General Hospital: CT angiogram aortic arch to head
  • Corroborative imaging will be done at the discretion of Vascular Surgeon

Exclusion cirteria for carotid imaging

  • Posterior circulation events
  • Patient with severe disability from stroke [Rankin  greater than 3]
  • Patient unfit for carotid endarterectomy 
  • Asymptomatic carotid bruits
  • Patient would not consent for surgery
  • Advanced malignant disease
  • Severe cognitive impairment or dementia
  • Patient bedbound prior to neurological event

Start on secondary prevention

Is Carotid Stenosis greater than 50% for male; greater than 70% for female diameter on the appropriate side?

  • Secondary imaging is recommended for borderline/unclear duplex images.

Radiology referral and consultation

  • Discuss referral for CT angiogram with Duty Radiologist at Raigmore Hospital
  • Referrals will be accepted Monday to Friday between 09:00am and 5:00pm
  • The referring Clinician is responsible for acting on the result on the same day as scan (this may require a discussion with the Duty Radiologist)
  • The Vascular Surgeon on-call can give an opinion on the CT angiogram if Radiologist is not available
Urgent referral to Vascular Surgeon
  • If not already performed, arrange for urgent CT head scan
  • CT should be performed before further assessment to exclude other diagnoses
  • If diagnosis unclear please contact Stroke Team for advice
  • Refer to Vascular Surgeon on-call at Raigmore Hospital on same day when carotid artery stenosis diagnosed
Assessment and treatment
  • Potential risks and benefits should be discussed with the patient
  • Surgery should be performed within 14 days of the event
Secondary prevention

Refer to Secondary Prevention post-TIA or Ischaemic Stroke for further details

  • All patients with a clinical diagnosis of TIA and Ischaemic stroke should be commenced on secondary prevention immediately.
  • A combination of ACE inhibitor and thiazide diuretics should be considered in all patients with ischaemic stroke and TIA even if they are normotensive.  If appropriate it should be started 14 days post-event.
  • Stopping smoking, healthy eating, reduction in alcohol intake and regular exercise will benefit most patients.
  • All stroke and TIA patients must refrain from driving for a minimum of 28 days or until certified fit to drive.
Contact details

Stroke Team: Dr P Findlay / Dr A MacAden / Dr W Rutherford (01463) 705432 or Consultant HDU Raigmore on Bleep 3600

Duty Radiologist: (01463) 704000 ask for Duty Radiologist

Vascular Surgeon: (01463) 704000 ask for Consultant Vascular Surgeon on call

Editorial Information

Last reviewed: 31 January 2019

Next review: 31 December 2020

Author(s): NHS Highland Clinical Network for Stroke

Version: 1

Approved By: TAM subgroup of ADTC