What Should We Do in Case of a Possible Carotid Stenosis?german translation / full article
A 53 years old female patient asks her FP whether her carotis should be controlled because of familial risk factors (her brother as well as a nephew have a stenosis). She has a relevant hypercholesterinemia, which cannot be treated because of side effects on all possible substances. She had no ischemic insult or transient ischemic attack, no amaurosis fugax and no signs for manifest arteriosclerosis (coronary or peripheral).
According to the studies described in the guidelines of the last 5 years the benefit of diagnosing a stenosis (70% or more) by duplex sonography and treatment by endoarterectomy could be higher than just taking aspirin and treat risk factors. In asymptomatic persons the benefit of a reduced mortality or getting a clinical relevant ischemic cerebral infarction is around 5% in 5 years. But during the first 3 years operated patients have a perioperative mortality and a rate of clinical relevant infarctions of about 3%. In addition, studies show that the benefit for women is relevantly smaller than for men (abouthalf of the above given percentage). Thus guidelines propose an operation only if other risk factors or manifestations of an arteriosclerotic disease are also present.
In this patient aspirin seems to be a good choice even without a duplex-sonography, because her cholesterol cannot be treated but her risk for a cerebral ischemia is reduced by ASS. This would also spare the patient anxieties about a possible stenosis (which could make her thinking about a beginning cerebral infarction having just a simple dizziness).