0
November 1, 1995, Vol 274, No. 17 >
ARTICLE | November 1, 1995

A 79-Year-Old Musician With Asymptomatic Carotid Artery Disease FREE

Louis R. Caplan, MD
[+] Author Affiliations

Dr Caplan is Professor and Chair of Neurology at Tufts University and the New England Medical Center, Boston, Mass.

This conference took place at the Neurology Grand Rounds of the Beth Israel Hospital, Boston, Mass, on July 18, 1995.

Reprint requests to Division of General Medicine and Primary Care, Beth Israel Hospital, 330 Brookline Ave, LY339, Boston, MA 02215 (Ms Walzer).

Clinical Crossroads at Boston's Beth Israel Hospital is produced and edited by Thomas L. Delbanco, MD, and Jennifer Daley, MD; Janet Walzer, MEd, is managing editor. Clinical Crossroads section editor: Margaret A. Winker, MD, Senior Editor, JAMA.


JAMA. 1995;274(17):1383-1389. doi:10.1001/jama.1995.03530170063034
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Article
References

Dr DALEY: Mr C, a 79-year-old married professional classical musician with a history of cardiovascular and peripheral vascular disease, was noted to have asymptomatic carotid bruits in March 1995. He is active as a teacher and performer. He is insured by Medicare and carries supplemental Medigap insurance.

In 1989, Mr C underwent coronary artery bypass grafting for progressive anginal symptoms. Angina recurred in December 1994, and cardiac catheterization revealed diffuse three-vessel coronary artery disease with patent grafts. In recent months his angina has abated with medical therapy.

His risk factors for atherosclerosis include a total cholesterol level of 6.18 mmol/L (239 mg/dL), a family history of coronary artery disease, and a history of smoking cigarettes 20 years ago. Current medications include amlodipine besylate, 5 mg daily; terazosin hydrochloride, 5 mg daily, for mild symptoms of prostatic hypertrophy; and one enteric coated aspirin daily. Hypercholesterolemia is managed by diet, although until

REFERENCES

1 +
Fisher M.  Atherosclerosis in brain ischemia.  In: Caplan LR, ed. Basic Concepts and Clinical Relevance . London, England: Springer-Verlag; 1995;: 135-150.
2 +
Gorelick PB, Caplan LR, Hier D, et al.  Racial differences in the distribution of anterior circulation occlusive disease. Neurology . 1984;;34:54-59.
3 +
Caplan LR, Gorelick PB, Hier DB.  Race, sex, and occlusive cerebrovascular disease: a review. Stroke . 1986;;17:648-655.
4 +
Mohr JP, Caplan LR, Melski J, et al.  The Harvard Cooperative Stroke Registry: a prospective registry. Neurology . 1978;;28:754-762.
5 +
Caplan LR. Stroke: A Clinical Approach . 2nd ed. Boston, Mass: Butterworth-Heinemann; 1994;.
6 +
Hennerici M, Hulsbower HB, Hefter K, et al.  Natural history of asymptomatic extracranial disease: results of a long term prospective study. Brain . 1987;;110:777-791.
7 +
Hennerici M, Trockel U, Rautenberg W, Kladetzky RG.  Spontaneous progression and regression of small carotid atheroma. Lancet . 1985;;1:1415-1419.
8 +
Norris JW, Zhu CZ.  Silent stroke and carotid stenosis. Stroke . 1992;;23:483-485.
9 +
Caplan LR, Pessin MS.  Symptomatic carotid artery disease and carotid endarterectomy. Annu Rev Med . 1988;;39:273-299.
10 +
Feinberg WM.  Coagulation in brain ischemia.  In: Caplan LR, ed. Basic Concepts and Clinical Relevance . London, England: Springer-Verlag; 1995;: 85-96.
11 +
Grotta J, Ackerman R, Correia J, et al.  Whole-blood viscosity parameters and cerebral blood flow. Stroke . 1982;;13:296-298.
12 +
Thomas D, du Boulay G, Marshall J, et al.  Effect of hematocrit on cerebral blood flow in man. Lancet . 1977;;2:941-943.
13 +
Harrison M, Pollock S, Kindoll B, et al.  Effect of hematocrit on carotid stenosis and cerebral infarction. Lancet . 1981;;2:114-115.
14 +
Coull BM, Beamer NB, de Garmo PL, et al.  Chronic blood hyperviscosity in subjects with acute stroke, transient ischemic attacks, and risk factors for stroke. Stroke . 1991;;22:162-168.
15 +
Ernst E, Resch KL.  Fibrinogen as a cardiovascular risk factor: a meta-analysis and review of the literature. Ann Intern Med . 1993;;118:956-963.
16 +
Caplan LR.  TIAs: we need to return to the question what is wrong with Mr. Jones. Neurology . 1988;;38:791-793.
17 +
Caplan LR.  Silent brain infarcts. Cerebrovasc Dis . 1994;;4( (suppl 1) ):32-39.
18 +
Murros KE, Evans GW, Toole JF, et al.  Cerebral infarction in patients with transient ischemic attack. J Neurol . 1989;;236:182-184.
19 +
Nicolaides A, Kalodiki E, Ramaswami G, Geroulakos G, Stevens J.  The significance of cerebral infarcts on CT scans in patients with transient ischemic attacks.  In: Bernstein EF, Callow AD, Nicolaides AN, Shifrin EG, eds. Cerebral Revascularization . London, England: Med-Orion Publishing Co; 1993;: 159-178.
20 +
Caplan LR, DeWitt LD, Breen J.  Neuroimaging in patients with cerebrovascular disease.  In: Greenberg J, ed. Neuroimaging . New York, NY: McGraw-Hill; 1995;:435-457.
21 +
Carter JE.  Chronic ocular ischemia and carotid arterial disease. Stroke . 1985;;16:721-728.
22 +
von Reutern G-M, von Budingen HJ. Ultrasound Diagnosis of Cerebrovascular Disease . New York, NY: Thieme Medical Publishing; 1993;.
23 +
Caplan LR, Brass LM, DeWitt LD, et al.  Transcranial Doppler ultrasound: present status. Neurology . 1990;;40:696-700.
24 +
Steinke W, Kloetzsch C, Hennerici M.  Carotid artery disease assessed by color Doppler flow imaging: correlation with standard Doppler sonography and angiography. AJNR Am J Neuroradiol . 1990;;11:259-266.
25 +
Steinke W, Hennerici M, Rautenberg W, Mohr JP.  Symptomatic and asymptomatic high-grade carotid stenoses in Doppler color-flow imaging. Neurology . 1992;;42:131-138.
26 +
Hedges TR.  Ocular ischemia in brain ischemia.  In: Basic Concepts and Clinical Relevance . London, England: Springer-Verlag; 1995;:61-73.
27 +
Markus HS, Droste DW, Brown MM.  Detection of asymptomatic cerebral embolic signals with Doppler ultrasound. Lancet . 1994;;343:1011-1012.
28 +
Ries S, Schminke U, Daffertshoffer M, Schindlmayr C, Hennerici M.  High intensity transient signals and carotid artery disease. Cerebrovasc Dis . 1995;; 5:124-127.
29 +
Muller H, Lyrer P, Boccalini P.  Doppler monitoring of middle cerebral artery emboli from carotid stenoses. J Neuroimaging . 1995;;5:71-75.
30 +
Piepgras A, Schmiedek P, Leisinger G, et al.  A simple test to assess cerebrovascular reserve capacity using transcranial Doppler and acetazolamide. Stroke . 1990;;21:1306-1311.
31 +
Ringelstein EB, Sievers C, Ecker S, et al.  Non-invasive assessment of CO2-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusion. Stroke . 1988;;19:963-969.
32 +
Kido DK, Panzer RJ, Szumowski J, et al.  Clinical evaluation of stenosis of the carotid bifurcation with magnetic resonance angiographic techniques. Arch Neurol . 1991;;48:484-489.
33 +
Anderson CM, Saloner D, Lee RE, et al.  Assessment of carotid artery stenosis by MR angiography: comparison with x-ray angiography and color-coded Doppler ultrasound. AJNR Am J Neuroradiol . 1992;;13:989-1003.
34 +
Riles TS, Eidelman EM, Litt AW, et al.  Comparison of magnetic resonance angiography and duplex scanning. Stroke . 1992;;23:341-346.
35 +
Fisher M, Sotak CH, Minematsu K, Li T.  New magnetic resonance techniques for evaluating cerebrovascular disease. Ann Neurol . 1992;;32:115-122.
36 +
Barnett HJM.  Delayed cerebral ischemic episodes distal to occlusion of major cerebral arteries. Neurology . 1978;;28:769-774.
37 +
Cote R, Barnett HJM, Taylor D.  Internal carotid occlusion: a prospective study. Stroke . 1983;;14:898-902.
38 +
Bogousslavsky J, Despland P-A, Regli F.  Asymptomatic tight stenosis of the internal carotid artery: long-term prognosis. Neurology . 1986;;36:861-863.
39 +
Chambers BR, Norris JW.  Outcome in patients with asymptomatic neck bruits. N Engl J Med . 1986;;315:860-865.
40 +
Ford CS, Frye JL, Toole JF, Lefkowitz D.  Asymptomatic carotid bruit and stenosis. Arch Neurol . 1986;;43:219-222.
41 +
Roederer DG, Langlois YE, Jager KA, et al.  The natural history of carotid arterial disease in asymptomatic patients with cervical bruits. Stroke . 1984;; 15:605-613.
42 +
Colgan MP, Kingston W, Shanik DG.  Asymptomatic carotid stenosis: is prophylactic endarterectomy justifiable? Br J Surg . 1985;;72:313-314.
43 +
Durward QJ, Ferguson GG, Barr HW.  The natural history of asymptomatic carotid bifurcation plaques. Stroke . 1982;;13:459-464.
44 +
Humphries AW, Young JR, Santilli PH, et al.  Unoperated, asymptomatic significant internal carotid artery stenosis: a review of 182 instances. Surgery . 1976;;80:695-698.
45 +
Norris JW, Zhu CZ, Bornstein N, Chambers BR.  Vascular risks of asymptomatic carotid stenosis. Stroke . 1991;;22:1485-1490.
46 +
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.  Endarterectomy for asymptomatic carotid artery stenosis. JAMA . 1995;;273: 1421-1428.
47 +
Norris JW.  Risk of cerebral infarction, myocardial infarction and vascular death in patients with asymptomatic carotid disease, transient ischemic attack and stroke. Cerebrovasc Dis . 1992;;2( (suppl 1) ):2-5.
48 +
Breen JC, Caplan LR, DeWitt LD, et al.  Brain edema after carotid surgery. Neurology . In press.
49 +
Lehv MS, Salzman EW, Silen W.  Hypertension complicating carotid endarterectomy. Stroke . 1970;;1:307-313.
50 +
Sundt TM, Sharbrough FW, Piepgras DG, et al.  Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy. Mayo Clin Proc . 1981;;56:533-543.
51 +
Sundt T, Sandok BA, Whisnant JP.  Carotid endarterectomy: complications and preoperative assessment of risk. Mayo Clin Proc . 1975;;50:301-306.
52 +
Easton JD, Sherman DG.  Stroke and mortality rate in carotid endarterectomy: 228 consecutive operations. Stroke . 1977;;8:565-568.
53 +
Brott T, Thalinger K.  The practice of carotid endarterectomy in a large metropolitan area. Stroke . 1984;;15:950-955.
54 +
Hertzer NH, Avellone JC, Farrell CJ, et al.  The risk of vascular surgery in a metropolitan community, with observations on surgeon experience and hospital size. J Vase Surg . 1984;;1:13-21.
55 +
Fode N, Sundt TM, Robertson JT, et al.  Multicenter retrospective review of results and complications of carotid endarterectomy in 1981 . Stroke . 1986;; 17:370-376.
56 +
Toronto Cerebrovascular Study Group.  Risks of carotid endarterectomy. Stroke . 1986;;17:848-852.
57 +
Brook RH, Park RE, Chassin MR, et al.  Carotid endarterectomy for elderly patients: predicting complications. Ann Intern Med . 1990;;113:747-753.
58 +
NASCET Collaborators.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med . 1991;; 325:445-453.
59 +
European Carotid Surgery Trialists Collaborative Group.  MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet . 1991;;337:1235-1243.
60 +
The CASANOVA Study Group.  Carotid surgery versus medical therapy in asymptomatic carotid stenosis. Stroke . 1991;;22:1229-1235.
61 +
Hobson RW, Weiss DG, Fields WS, et al.  Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med . 1993;;328:221-227.
62 +
Plecha FR, Bertin VJ, Plech EJ, et al.  The early results of vascular surgery in patients 75 years of age and older: an analysis of 3259 cases. J Vase Surg . 1985;;2:769-774.
63 +
Hennerici M, Kleophas W, Gries FA.  Regression of carotid plaques during low density lipoprotein cholesterol elimination. Stroke . 1991;;22:989-992.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Fisher M.  Atherosclerosis in brain ischemia.  In: Caplan LR, ed. Basic Concepts and Clinical Relevance . London, England: Springer-Verlag; 1995;: 135-150.
2 +
Gorelick PB, Caplan LR, Hier D, et al.  Racial differences in the distribution of anterior circulation occlusive disease. Neurology . 1984;;34:54-59.
3 +
Caplan LR, Gorelick PB, Hier DB.  Race, sex, and occlusive cerebrovascular disease: a review. Stroke . 1986;;17:648-655.
4 +
Mohr JP, Caplan LR, Melski J, et al.  The Harvard Cooperative Stroke Registry: a prospective registry. Neurology . 1978;;28:754-762.
5 +
Caplan LR. Stroke: A Clinical Approach . 2nd ed. Boston, Mass: Butterworth-Heinemann; 1994;.
6 +
Hennerici M, Hulsbower HB, Hefter K, et al.  Natural history of asymptomatic extracranial disease: results of a long term prospective study. Brain . 1987;;110:777-791.
7 +
Hennerici M, Trockel U, Rautenberg W, Kladetzky RG.  Spontaneous progression and regression of small carotid atheroma. Lancet . 1985;;1:1415-1419.
8 +
Norris JW, Zhu CZ.  Silent stroke and carotid stenosis. Stroke . 1992;;23:483-485.
9 +
Caplan LR, Pessin MS.  Symptomatic carotid artery disease and carotid endarterectomy. Annu Rev Med . 1988;;39:273-299.
10 +
Feinberg WM.  Coagulation in brain ischemia.  In: Caplan LR, ed. Basic Concepts and Clinical Relevance . London, England: Springer-Verlag; 1995;: 85-96.
11 +
Grotta J, Ackerman R, Correia J, et al.  Whole-blood viscosity parameters and cerebral blood flow. Stroke . 1982;;13:296-298.
12 +
Thomas D, du Boulay G, Marshall J, et al.  Effect of hematocrit on cerebral blood flow in man. Lancet . 1977;;2:941-943.
13 +
Harrison M, Pollock S, Kindoll B, et al.  Effect of hematocrit on carotid stenosis and cerebral infarction. Lancet . 1981;;2:114-115.
14 +
Coull BM, Beamer NB, de Garmo PL, et al.  Chronic blood hyperviscosity in subjects with acute stroke, transient ischemic attacks, and risk factors for stroke. Stroke . 1991;;22:162-168.
15 +
Ernst E, Resch KL.  Fibrinogen as a cardiovascular risk factor: a meta-analysis and review of the literature. Ann Intern Med . 1993;;118:956-963.
16 +
Caplan LR.  TIAs: we need to return to the question what is wrong with Mr. Jones. Neurology . 1988;;38:791-793.
17 +
Caplan LR.  Silent brain infarcts. Cerebrovasc Dis . 1994;;4( (suppl 1) ):32-39.
18 +
Murros KE, Evans GW, Toole JF, et al.  Cerebral infarction in patients with transient ischemic attack. J Neurol . 1989;;236:182-184.
19 +
Nicolaides A, Kalodiki E, Ramaswami G, Geroulakos G, Stevens J.  The significance of cerebral infarcts on CT scans in patients with transient ischemic attacks.  In: Bernstein EF, Callow AD, Nicolaides AN, Shifrin EG, eds. Cerebral Revascularization . London, England: Med-Orion Publishing Co; 1993;: 159-178.
20 +
Caplan LR, DeWitt LD, Breen J.  Neuroimaging in patients with cerebrovascular disease.  In: Greenberg J, ed. Neuroimaging . New York, NY: McGraw-Hill; 1995;:435-457.
21 +
Carter JE.  Chronic ocular ischemia and carotid arterial disease. Stroke . 1985;;16:721-728.
22 +
von Reutern G-M, von Budingen HJ. Ultrasound Diagnosis of Cerebrovascular Disease . New York, NY: Thieme Medical Publishing; 1993;.
23 +
Caplan LR, Brass LM, DeWitt LD, et al.  Transcranial Doppler ultrasound: present status. Neurology . 1990;;40:696-700.
24 +
Steinke W, Kloetzsch C, Hennerici M.  Carotid artery disease assessed by color Doppler flow imaging: correlation with standard Doppler sonography and angiography. AJNR Am J Neuroradiol . 1990;;11:259-266.
25 +
Steinke W, Hennerici M, Rautenberg W, Mohr JP.  Symptomatic and asymptomatic high-grade carotid stenoses in Doppler color-flow imaging. Neurology . 1992;;42:131-138.
26 +
Hedges TR.  Ocular ischemia in brain ischemia.  In: Basic Concepts and Clinical Relevance . London, England: Springer-Verlag; 1995;:61-73.
27 +
Markus HS, Droste DW, Brown MM.  Detection of asymptomatic cerebral embolic signals with Doppler ultrasound. Lancet . 1994;;343:1011-1012.
28 +
Ries S, Schminke U, Daffertshoffer M, Schindlmayr C, Hennerici M.  High intensity transient signals and carotid artery disease. Cerebrovasc Dis . 1995;; 5:124-127.
29 +
Muller H, Lyrer P, Boccalini P.  Doppler monitoring of middle cerebral artery emboli from carotid stenoses. J Neuroimaging . 1995;;5:71-75.
30 +
Piepgras A, Schmiedek P, Leisinger G, et al.  A simple test to assess cerebrovascular reserve capacity using transcranial Doppler and acetazolamide. Stroke . 1990;;21:1306-1311.
31 +
Ringelstein EB, Sievers C, Ecker S, et al.  Non-invasive assessment of CO2-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusion. Stroke . 1988;;19:963-969.
32 +
Kido DK, Panzer RJ, Szumowski J, et al.  Clinical evaluation of stenosis of the carotid bifurcation with magnetic resonance angiographic techniques. Arch Neurol . 1991;;48:484-489.
33 +
Anderson CM, Saloner D, Lee RE, et al.  Assessment of carotid artery stenosis by MR angiography: comparison with x-ray angiography and color-coded Doppler ultrasound. AJNR Am J Neuroradiol . 1992;;13:989-1003.
34 +
Riles TS, Eidelman EM, Litt AW, et al.  Comparison of magnetic resonance angiography and duplex scanning. Stroke . 1992;;23:341-346.
35 +
Fisher M, Sotak CH, Minematsu K, Li T.  New magnetic resonance techniques for evaluating cerebrovascular disease. Ann Neurol . 1992;;32:115-122.
36 +
Barnett HJM.  Delayed cerebral ischemic episodes distal to occlusion of major cerebral arteries. Neurology . 1978;;28:769-774.
37 +
Cote R, Barnett HJM, Taylor D.  Internal carotid occlusion: a prospective study. Stroke . 1983;;14:898-902.
38 +
Bogousslavsky J, Despland P-A, Regli F.  Asymptomatic tight stenosis of the internal carotid artery: long-term prognosis. Neurology . 1986;;36:861-863.
39 +
Chambers BR, Norris JW.  Outcome in patients with asymptomatic neck bruits. N Engl J Med . 1986;;315:860-865.
40 +
Ford CS, Frye JL, Toole JF, Lefkowitz D.  Asymptomatic carotid bruit and stenosis. Arch Neurol . 1986;;43:219-222.
41 +
Roederer DG, Langlois YE, Jager KA, et al.  The natural history of carotid arterial disease in asymptomatic patients with cervical bruits. Stroke . 1984;; 15:605-613.
42 +
Colgan MP, Kingston W, Shanik DG.  Asymptomatic carotid stenosis: is prophylactic endarterectomy justifiable? Br J Surg . 1985;;72:313-314.
43 +
Durward QJ, Ferguson GG, Barr HW.  The natural history of asymptomatic carotid bifurcation plaques. Stroke . 1982;;13:459-464.
44 +
Humphries AW, Young JR, Santilli PH, et al.  Unoperated, asymptomatic significant internal carotid artery stenosis: a review of 182 instances. Surgery . 1976;;80:695-698.
45 +
Norris JW, Zhu CZ, Bornstein N, Chambers BR.  Vascular risks of asymptomatic carotid stenosis. Stroke . 1991;;22:1485-1490.
46 +
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.  Endarterectomy for asymptomatic carotid artery stenosis. JAMA . 1995;;273: 1421-1428.
47 +
Norris JW.  Risk of cerebral infarction, myocardial infarction and vascular death in patients with asymptomatic carotid disease, transient ischemic attack and stroke. Cerebrovasc Dis . 1992;;2( (suppl 1) ):2-5.
48 +
Breen JC, Caplan LR, DeWitt LD, et al.  Brain edema after carotid surgery. Neurology . In press.
49 +
Lehv MS, Salzman EW, Silen W.  Hypertension complicating carotid endarterectomy. Stroke . 1970;;1:307-313.
50 +
Sundt TM, Sharbrough FW, Piepgras DG, et al.  Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy. Mayo Clin Proc . 1981;;56:533-543.
51 +
Sundt T, Sandok BA, Whisnant JP.  Carotid endarterectomy: complications and preoperative assessment of risk. Mayo Clin Proc . 1975;;50:301-306.
52 +
Easton JD, Sherman DG.  Stroke and mortality rate in carotid endarterectomy: 228 consecutive operations. Stroke . 1977;;8:565-568.
53 +
Brott T, Thalinger K.  The practice of carotid endarterectomy in a large metropolitan area. Stroke . 1984;;15:950-955.
54 +
Hertzer NH, Avellone JC, Farrell CJ, et al.  The risk of vascular surgery in a metropolitan community, with observations on surgeon experience and hospital size. J Vase Surg . 1984;;1:13-21.
55 +
Fode N, Sundt TM, Robertson JT, et al.  Multicenter retrospective review of results and complications of carotid endarterectomy in 1981 . Stroke . 1986;; 17:370-376.
56 +
Toronto Cerebrovascular Study Group.  Risks of carotid endarterectomy. Stroke . 1986;;17:848-852.
57 +
Brook RH, Park RE, Chassin MR, et al.  Carotid endarterectomy for elderly patients: predicting complications. Ann Intern Med . 1990;;113:747-753.
58 +
NASCET Collaborators.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med . 1991;; 325:445-453.
59 +
European Carotid Surgery Trialists Collaborative Group.  MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet . 1991;;337:1235-1243.
60 +
The CASANOVA Study Group.  Carotid surgery versus medical therapy in asymptomatic carotid stenosis. Stroke . 1991;;22:1229-1235.
61 +
Hobson RW, Weiss DG, Fields WS, et al.  Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med . 1993;;328:221-227.
62 +
Plecha FR, Bertin VJ, Plech EJ, et al.  The early results of vascular surgery in patients 75 years of age and older: an analysis of 3259 cases. J Vase Surg . 1985;;2:769-774.
63 +
Hennerici M, Kleophas W, Gries FA.  Regression of carotid plaques during low density lipoprotein cholesterol elimination. Stroke . 1991;;22:989-992.

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