Palpable carotid bruit (Cervical thrill)

Specialty: Cardiovascular.

• carotid thrill
• carotid thriller
• palpable vibration in the course of the carotid artery

Why it occurs

• Severe critical carotid stenosis (usually at the bifurcation, with >80% obstruction)
• Transmission of a murmur of severe critical aortic valve stenosis
• High-flow carotid-cavernous fistula or cervical arteriovenous fistula
• Carotid artery aneurysm with massive turbulent flow
• Severe aortic coarctation with hyperflow in supra-aortic trunks

Initial workup

Emergency carotid duplex Doppler ultrasound to document peak systolic velocity (PSV >230 cm/s indicates severe stenosis >70%) and evaluate the presence of unstable plaques or mural thrombi; Angiotomography of vessels of the neck and skull to confirm the degree of stenosis and plan the approach by endarterectomy or carotid angioplasty with stent; Brain magnetic resonance imaging and MR angiography to rule out subclinical ischemic damage.

Standard management

• Acetylsalicylic acid — immediately started antiplatelet therapy to reduce the risk of cerebral embolism; 100 mg once a day orally
• Clopidogrel — 75 mg once daily orally as a first-line alternative in case of contraindication to ASA, or adjuvant
• Atorvastatin — high-potency statin mandatory to stabilize plaque and reduce the local inflammatory response; 80 mg per day orally, with LDL goal <55 mg/dL
• Ramipril (ACEI for strict control of blood pressure levels; 5 to 10 mg per day orally, titrated cautiously to avoid ipsilateral cerebral hypoperfusion if the stenosis is bilateral and severe).