Unilateral absent carotid pulsation

Specialty: Cardiovascular.

• absence of unilateral carotid pulse
• abolition of pulse in carotid artery

Why it occurs

• Complete occlusion of the common carotid artery due to atherosclerotic thrombosis in situ
• Dissection of the common carotid artery or the thoracic aorta with extension to the brachiocephalic or left carotid trunk
• Takayasu arteritis with critical stenosis of the great supra-aortic vessels
• Massive arterial embolism of the carotid bifurcation
• Malignant extrinsic tumor compression in the upper mediastinum or neck

Initial workup

Emergency point-of-care Doppler ultrasound of neck vessels to confirm the absence of flow in the common or internal carotid artery, or the presence of a dissection flap; Computed tomography angiography (CT-Angio) of supra-aortic arteries, aortic arch and circle of Willis to map arterial patency and extent of occlusion; Emergency non-contrast CT scan of the skull to rule out cerebral hemorrhage or early signs of large ischemic cerebral infarction.

Standard management

• Unfractionated heparin — intravenous anticoagulant indicated immediately in the absence of cerebral hemorrhage to prevent the spread of the thrombus or recurrent embolism; bolus of 80 IU/kg followed by infusion adjusted to aPTT of 1.5 to 2.5 times the control, under strict hospital protocol
• Alteplasa — recombinant tissue plasminogen activator (rt-PA) indicated for intravenous thrombolysis if the patient has an associated ischemic stroke of <4.5 hours duration and meets the inclusion/exclusion criteria; 0.9 mg/kg intravenous, maximum dose of 90 mg, bolus and continuous infusion for 1 hour
• Mannitol 20% — osmotic agent useful if there is massive herniating cerebral edema secondary to extensive cerebral infarction; 0.5 to 1.0 g/kg intravenous rapid infusion
• Atorvastatin (statin for endothelial stabilization and early initiation of secondary prophylaxis; 80 mg per day orally).