Carotid Artery (Neck Artery) Disease

Carotid artery disease (carotid artery stenosis) is a serious vascular condition that occurs due to narrowing or occlusion caused by atherosclerotic plaque accumulation in the carotid arteries located on both sides of the neck, reducing blood flow to the brain and increasing the risk of stroke. Early diagnosis and appropriate treatment are of vital importance.

Symptoms of carotid artery stenosis include transient ischemic attack, sudden vision loss, speech impairment, weakness and numbness in the face or extremities. These findings develop due to insufficient blood supply to brain tissue and may serve as warning signs before a permanent stroke.

The diagnosis of carotid artery disease is made through imaging methods such as Doppler ultrasonography, magnetic resonance angiography, and computed tomography angiography. The degree of narrowing in the vascular lumen is determined, the stage of the disease is identified, and treatment planning is carried out accordingly.

Treatment of carotid artery disease includes lifestyle modifications, medical approaches such as antiplatelet and statin therapy, and in cases of advanced stenosis, carotid endarterectomy or stent placement. The aim is to reduce the risk of cerebrovascular events and preserve brain perfusion.

What Is Carotid Artery Disease?

The carotid arteries are large vessels located on both sides of the neck that carry blood to the brain. Medically known as the arteria carotis communis, these vessels are branches of the main artery (aorta) emerging from the heart and ascend upward, dividing near the brainstem into two branches: the internal carotid artery (which carries blood to the inner parts of the brain) and the external carotid artery (which carries blood to the face, scalp, and other regions of the neck).

Carotid artery disease is the narrowing or complete occlusion of these vessels due to plaque accumulation (atherosclerosis) in their walls. These plaques are usually composed of cholesterol, fat, calcium, and other substances. Plaque accumulation may progressively obstruct blood flow over time. In addition, the surface of these plaques may become rough, and clots forming on them may detach and travel to the brain. These clots can block smaller vessels in the brain, leading to ischemic stroke. Stroke occurs when brain tissue is damaged due to lack of oxygen and nutrients.

According to data from the World Health Organization (WHO), stroke is the second leading cause of death worldwide and one of the most common causes of disability. For example, in 2019, approximately 12.2 million new stroke cases were reported, and 6.5 million of these cases resulted in death. Carotid artery disease is responsible for a significant portion of these cases.

Atherosclerosis and Plaque Formation

Atherosclerosis is a chronic disease characterized by the accumulation of cholesterol and other substances in the inner walls of arteries. This buildup hardens over time and forms structures called plaques. The process of plaque formation includes the following steps:

1. Endothelial Injury: It begins with damage to the endothelial layer lining the inner surface of the artery wall. Factors such as smoking, high blood pressure, high cholesterol, and diabetes may cause this damage.
2. Lipid Accumulation: Low-density lipoprotein (LDL) cholesterol passes through the damaged endothelial layer, enters the vessel wall, and becomes oxidized.
3. Inflammation: The immune system initiates an inflammatory response to this foreign substance. Immune cells called macrophages ingest oxidized LDL, forming foam cells.
4. Plaque Formation: Foam cells and other substances accumulate to form plaques. These plaques grow over time and narrow the vessel.
5. Plaque Stabilization or Rupture: The surface of plaques may be smooth and stable or rough and unstable (prone to rupture). Unstable plaques carry a higher risk of clot detachment and vascular occlusion.

Plaque accumulation in the carotid arteries leads to serious consequences by reducing or completely blocking blood flow to the brain. This condition may result in transient ischemic attack (TIA) or stroke.

Causes and Risk Factors of Carotid Artery Disease

Multiple factors play a role in the development of carotid artery disease. The most important cause is atherosclerosis. However, atherosclerosis itself develops as a result of the combination of various risk factors. Understanding these risk factors is critical for prevention and early diagnosis.

Main Risk Factors

• Age: The risk of developing atherosclerosis increases with age. It is more common in individuals over 50.
• Gender: It tends to occur earlier and more frequently in men than in women. However, after menopause, this risk in women equals or exceeds that in men.
• Family History: Individuals with a family history of early heart or vascular disease (especially stroke or heart attack) have a higher risk.
• High Blood Pressure (Hypertension): Uncontrolled high blood pressure damages vessel walls and accelerates the atherosclerosis process. Worldwide, hypertension is one of the leading risk factors for heart disease and stroke. Approximately 1 billion people worldwide have hypertension.
• High Cholesterol (Hyperlipidemia): Especially high LDL (bad cholesterol) levels and low HDL (good cholesterol) levels trigger plaque formation. High cholesterol is responsible for approximately 20% of heart diseases worldwide.
• Diabetes: Diabetes damages blood vessels and worsens atherosclerosis. Uncontrolled blood glucose levels cause loss of elasticity in vessel walls and plaque accumulation.
• Smoking: Smoking damages vessel walls, increases blood clotting tendency, and raises blood pressure. It is one of the leading causes of preventable deaths worldwide and causes more than 8 million deaths annually.
• Obesity: Excess weight increases the risk of high blood pressure, high cholesterol, and diabetes, indirectly raising the risk of carotid artery disease.
• Physical Inactivity: Lack of regular exercise may lead to weight gain and increased blood pressure and cholesterol levels.
• Unhealthy Diet: Diets high in saturated fats, trans fats, salt, and sugar increase the risk of atherosclerosis.
• Atrial Fibrillation (AF): A condition in which the upper chambers of the heart beat irregularly and rapidly. AF may cause clot formation in the heart, and these clots traveling to the brain significantly increase stroke risk. AF affects approximately 33 million people worldwide.

Many of these risk factors can be controlled or managed through lifestyle changes. Therefore, knowing these factors and taking steps to reduce them is crucial in preventing carotid artery disease.

Specific Conditions Leading to Carotid Artery Disease

• Trauma: Blows to the neck region or surgical interventions may cause damage to the carotid arteries.
• Fibromuscular Dysplasia (FMD): A rare vascular disease that causes abnormal cell growth in artery walls, leading to narrowing, enlargement, or tears. It may also affect the carotid arteries.
• Arteritis: Inflammation of the vessels. Conditions such as Takayasu arteritis or giant cell arteritis may involve the carotid arteries and cause narrowing.

Symptoms of Carotid Artery Disease

Carotid artery disease usually does not cause symptoms until the narrowing reaches a certain level. This silent progression makes the disease more dangerous. Symptoms generally appear when blood flow to the brain is significantly reduced or when a plaque breaks off and sends a clot to the brain. These conditions manifest as transient ischemic attack (TIA) or stroke.

Symptoms of Transient Ischemic Attack (TIA)

TIA, also known as a “mini-stroke,” occurs due to a temporary interruption of blood flow to the brain. Symptoms usually last from a few minutes to one hour and resolve completely. However, TIA is an important warning sign for a future stroke; approximately 15% of individuals who experience TIA have a stroke within one year. TIA symptoms may include:

• Sudden speech impairment: Difficulty finding words, speaking incoherently, or inability to understand speech.
• Sudden vision loss: Temporary blindness in one or both eyes, blurred or double vision.
• Sudden weakness or numbness: Sudden loss of strength or sensation on one side of the body (face, arm, or leg), often unilateral.
• Sudden loss of balance or coordination: Difficulty walking, dizziness, lightheadedness.
• Sudden severe headache: Sudden and severe headache without a clear cause.

Symptoms of Stroke

Stroke symptoms are similar to TIA symptoms but are more severe and cause permanent damage. Stroke symptoms occur suddenly and require urgent medical intervention. The FAST (Face-Arm-Speech-Time) rule is an effective method to recognize stroke symptoms:

• F (Face): Ask the person to smile. Does one side of the face droop?
• A (Arm): Ask the person to raise both arms. Does one arm drift downward?
• S (Speech): Ask the person to repeat a simple sentence. Is speech slurred, unclear, or strange?
• T (Time): If any of these signs are present, call emergency services immediately. Time is critical to save brain tissue.

Other possible stroke symptoms may include:

• Sudden numbness or weakness on one side of the body.
• Sudden confusion, difficulty understanding or speaking.
• Sudden vision problems in one or both eyes.
• Sudden difficulty walking, dizziness, loss of balance or coordination.
• Sudden and unexplained severe headache.

If you or someone near you experiences any of these symptoms, seek emergency medical attention without delay. Timing is vital in stroke treatment.

Diagnosis of Carotid Artery Disease

The diagnosis of carotid artery disease is made through a combination of the patient’s medical history, physical examination, and various imaging methods. Early diagnosis significantly increases treatment success and reduces the risk of stroke.

Medical History and Physical Examination

The doctor will inquire about the patient’s general health status, existing conditions (such as hypertension, diabetes, high cholesterol), smoking habits, family history, and any previous history of stroke or TIA. During physical examination, the doctor may listen for an abnormal sound called a bruit over the carotid arteries in the neck. This bruit results from turbulent blood flow through a narrowed vessel. However, absence of a bruit does not mean there is no stenosis; in some cases of severe narrowing or complete occlusion, no bruit may be heard.

Imaging Methods

The main imaging methods used in diagnosis are as follows:

• Carotid Ultrasonography (Doppler Ultrasound): This is the most commonly used, painless, and harmless method in diagnosing carotid artery disease. Using sound waves, it visualizes vessel structure and blood flow velocity. This allows detection of the degree of stenosis (percentage of narrowing) and presence of plaques. Ultrasound may also provide information about plaque characteristics (for example, whether the plaque is stable).
• Computed Tomography Angiography (CT Angiography): In this method, contrast material is injected into the body followed by a CT scan. CT angiography provides detailed three-dimensional images of the carotid arteries and shows stenoses, occlusions, and plaques with high accuracy. It is particularly used to determine the degree of stenosis and for surgical planning.
• Magnetic Resonance Angiography (MR Angiography): Similar to CT angiography, MR angiography is used to obtain detailed images of vessels. This method uses magnetic fields and radio waves and therefore does not involve radiation. MR angiography may provide additional information about plaque structure and possible brain tissue damage.
• Conventional Angiography (Seldinger Technique): This is an invasive method and is generally preferred when a definitive diagnosis cannot be made with other methods or when treatment (stent or surgery) is planned. A catheter (thin tube) is inserted through the groin and advanced to the carotid artery, then contrast material is injected and X-ray images are taken. This method most accurately determines the location and degree of stenosis but carries higher risks.

Brain MRI and Computed Tomography (CT)

These imaging methods do not directly visualize the carotid arteries but are used to determine the extent and location of brain damage in patients who have experienced a stroke. They may also detect other vascular problems in the brain or other conditions causing stroke.

Additional Tests

• Electrocardiogram (ECG): Used to detect heart rhythm disorders (for example atrial fibrillation), which may increase stroke risk.
• Echocardiography (ECHO): Used to evaluate heart structure and function. It may help determine the risk of clots in the heart traveling to the brain.
• Blood Tests: Performed to check values such as cholesterol, blood glucose, and coagulation factors.

The doctor will determine the most appropriate diagnostic methods according to the patient’s condition. Early and accurate diagnosis is essential for establishing an effective treatment plan.

Treatment of Carotid Artery Disease

Treatment of carotid artery disease is determined based on factors such as the patient’s overall health status, degree of stenosis, presence of symptoms, and risk of stroke. The main goal of treatment is to ensure adequate blood flow to the brain, stabilize plaques, and minimize the risk of stroke.

Treatment approaches are generally grouped under two main categories: medical treatment (drug therapy) and surgical/interventional treatment.

Medical Treatment (Drug Therapy)

Medical treatment is the fundamental approach in all patients, including those undergoing surgical or interventional procedures. The aim is to slow the progression of atherosclerosis, stabilize plaques, and prevent blood clot formation.

• Antiplatelet Drugs: Medications such as aspirin and clopidogrel prevent platelets from aggregating and forming clots. These drugs are highly effective in reducing stroke risk in patients with carotid artery disease, especially those with symptoms. For example, aspirin may reduce clot formation by 20–30%.
• Statins (Cholesterol-Lowering Drugs): Statins such as atorvastatin and rosuvastatin lower blood cholesterol levels, helping plaques shrink or stabilize. They also have anti-inflammatory effects and protect vessel walls, slowing the progression of atherosclerosis. Statins may reduce the risk of heart attack and stroke by approximately 25%.
• Antihypertensive Drugs: Controlling high blood pressure reduces vessel wall damage and slows the progression of atherosclerosis. ACE inhibitors, beta blockers, and calcium channel blockers may be used.
• Antidiabetic Drugs: In diabetic patients, maintaining blood glucose control is critical for vascular health.
• Lifestyle Modifications: Quitting smoking, healthy eating, regular exercise, and weight control are integral parts of medical treatment and enhance its effectiveness.

Surgical and Interventional Treatments

In patients at high risk of stroke despite medical treatment or in those with severe stenosis (generally 70% or more), surgical or interventional methods may be considered.

• Carotid Endarterectomy (CEA): This is the surgical removal of plaque from the carotid artery in the neck. During surgery, the carotid artery is opened, the plaque material inside is carefully removed, and the artery is sutured again. CEA significantly reduces stroke risk. In stenosis of 70% or more and in symptomatic patients, it may reduce stroke risk by about 25%. This operation has been successfully performed millions of times worldwide.

• Carotid Angioplasty and Stenting (CAS): This is a less invasive method. A catheter (thin tube) is inserted through the groin artery and advanced to the carotid artery. A balloon is placed at the narrowed area and inflated to widen the vessel (angioplasty). Then, a stent (a metal mesh tube) is placed to prevent re-narrowing. CAS may be preferred especially in patients with high surgical risk or certain anatomical conditions. CAS may provide results similar to CEA, but the long-term risk of clot formation within the stent may be higher.

Treatment selection should be made by a multidisciplinary team (neurologist, cardiovascular surgeon, interventional radiologist) considering the individual condition of the patient.

Ways to Prevent Carotid Artery Disease

Carotid artery disease is largely preventable. Awareness of risk factors and making lifestyle changes accordingly play a critical role in preventing or slowing disease progression. Healthy lifestyle habits help protect not only against carotid artery disease but also against heart disease, other types of stroke, and many chronic conditions.

Lifestyle Changes and Preventive Measures

• Quit Smoking: Smoking is one of the most harmful factors for vascular health. Quitting smoking reduces inflammation in vessels, decreases blood clotting tendency, and helps control blood pressure. Within the first year after quitting smoking, the risk of heart attack decreases by 50%.
• Healthy Nutrition: Adopting a diet low in saturated fat, trans fat, cholesterol, salt, and sugar is important. Consuming plenty of fruits, vegetables, whole grains, and healthy fats (such as olive oil and fish oil) supports vascular health. Dietary models such as the Mediterranean diet have positive effects on cardiovascular health.
• Regular Physical Activity: At least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic exercise per week is recommended. Exercise helps control weight, lowers blood pressure, improves cholesterol levels, and supports overall vascular health.
• Maintain a Healthy Body Weight: Obesity increases risk factors such as high blood pressure, diabetes, and high cholesterol. Losing weight or maintaining a healthy weight reduces these risks.
• Control Blood Pressure: If you have high blood pressure, use medications regularly as prescribed and apply lifestyle modifications. The target is to maintain blood pressure below 130/80 mmHg.
• Manage Cholesterol Levels: If you have high cholesterol, controlling it with diet and medication is important. Maintaining LDL cholesterol at target levels slows the progression of atherosclerosis.
• Control Diabetes: If you have diabetes, regularly monitor blood glucose levels and adhere to treatment. Good glycemic control helps prevent vascular damage.
• Limit Alcohol Consumption: Excessive alcohol intake may raise blood pressure and cause weight gain. Keeping alcohol consumption at moderate levels is important.

Regular Health Check-Ups

If you have risk factors or are over the age of 50, regular medical check-ups are important. Your doctor can detect potential problems early by monitoring blood pressure, cholesterol levels, and blood glucose. If necessary, screenings such as carotid ultrasound may be performed.

Approach in Asymptomatic Patients

Even if carotid artery disease does not cause symptoms, if the degree of stenosis is high (for example 70% or more) and the patient has other risk factors, stroke risk is high. In these patients, lifestyle modifications and medical therapy (antiplatelets, statins) are applied. In some cases, surgical or stent treatment may also be considered.

Preventive measures and regular health check-ups enable early diagnosis and effective management of carotid artery disease, significantly reducing the risk of stroke.