Continuous systolic-diastolic carotid murmur

Specialty: Cardiovascular.

continuous cervical murmur
murmur in neck machinery

Why it occurs

Traumatic or spontaneous carotid-cavernous arteriovenous fistula
Unilateral critical carotid stenosis with permanent turbulent collateral flow
Fistula of the vertebral artery or thyroid vessels
Arteriovenous malformation of the thyroid gland or neck
Dissection of the internal carotid artery with continuous patent false lumen

Initial workup

Computed tomography angiography (CT-Angio) of the skull, neck and orbits to map the fistula, the vascular course and assess the degree of engorgement of the superior ophthalmic vein; Carotid and orbital color Doppler ultrasound to evaluate arterialized and reversed flow in ophthalmic veins; Conventional diagnostic cerebral arteriography (gold standard) to specify the anatomy of the fistula and perform endovascular treatment through embolization with coils or occluders.

red flags

Continuous harsh murmur audible in the anterior lateral cervical region that covers systole and diastole, associated with unilateral pulsatile exophthalmos, persistent painful conjunctival injection ("red eye" with chemosis), loss of visual acuity, recurrent effort syncope, sudden onset contralateral motor weakness of the extremities or face, or aphasia or dysarthria. These findings suggest a large-caliber arteriovenous fistula (such as carotid-cavernous fistula) or unstable carotid dissection with high risk of massive bleeding, loss of vision, or extensive ischemic stroke, requiring urgent evaluation by interventional neuroradiology or vascular surgery.

Standard management

Metoprolol succinate — selective beta-1 beta blocker indicated to reduce blood pressure and heart rate, reducing the force and speed of flow through the fistula or carotid dissection; 25 to 100 mg once daily orally, titrated according to MAP
Ramipril — ACEI to help control systemic blood pressure; 5 to 10 mg per day orally
Acetylsalicylic acid — antiplatelet indicated only if the etiology is critical carotid stenosis or stabilized dissection without high-flow fistula, to prevent cerebral embolism; 100 mg per day orally
Dexamethasone (glucocorticoid useful to reduce orbital edema and local inflammation in carotid-cavernous fistulas; 4 mg intravenously every 6 to 8 hours).

Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.

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Area: Cardiovascular
Listed causes: 5
Treatment options: 4

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