Epistemis

Carotid arterial murmurs

Specialty: Cardiovascular.

  • auscultable carotid murmurs
  • murmurs in the carotid bifurcation

Why it occurs

  • Atherosclerotic stenosis of the internal or common carotid artery
  • Apical or base transmission of murmurs of severe aortic valve stenosis
  • Arteriovenous fistula in the neck or base of the skull
  • Giant cell arteritis of the temporalis with involvement of great vessels
  • Fibromuscular dysplasia of supra-aortic vessels
  • Hyperdynamic circulatory states (anemia, fever, hyperthyroidism)

Initial workup

Carotid duplex Doppler ultrasound to quantify the degree of stenosis, characterize the morphology of the atheromatous plaque (presence of ulceration, floating thrombus or calcification) and measure maximum systolic velocities; Computed tomography angiography (CT-Angio) of supra-aortic arteries and circle of Willis to accurately map the arterial tree and plan invasive procedures; Magnetic resonance imaging of the brain to rule out the presence of previous lacunar or silent cerebral infarcts.

red flags

Auscultable murmur in the anterior lateral cervical region that is harsh, prolonged and of high pitch, associated with transient or permanent motor weakness or loss of sensation in an extremity or hemiface on the contralateral side (TIA or CVA), sudden unilateral vision loss (amaurosis fugax), difficulty or inability to articulate language (aphasia, dysarthria), syncope recurrent orthostatic headache, or severe and unexplained unilateral headache of acute onset. Requires emergency medical evaluation in a stroke unit due to the high risk of embolic or thrombotic ischemic stroke.

Standard management

  • Acetylsalicylic acid — antiplatelet of choice for prevention of ischemic events in significant carotid stenosis; 100 mg once a day orally
  • Clopidogrel — 75 mg once a day orally as monotherapy in case of allergy to ASA, or in combination for double antiplatelet therapy after angioplasty with carotid stent
  • Atorvastatin — high potency statin indicated on a mandatory basis to stabilize carotid plaque and reduce the risk of stroke; 80 mg per day orally, aiming for LDL levels <55 mg/dL
  • Ramipril (ACEI for hemodynamic and blood pressure control; 5 to 10 mg per day orally, titrated according to tolerance).

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

PreviousAbdominal arterial murmurs (Bruit)
Area
Cardiovascular
Listed causes
6
Treatment options
4
Download Epistemis