Carotid bruit

A carotid bruit is a bruit or sound heard over the carotid artery area, usually by a nurse or physician during auscultation. It is usually the result of a stenosis of the carotid artery, and is unlikely to be heard if the stenosis occludes less than 40% of the diameter of the artery. Likewise, a stenosis of greater than 90% may not be heard, as the flow may be too low.

Many carotid bruits are discovered incidentally in an otherwise asymptomatic patient. A carotid duplex ultrasound may be useful in determining the origin of the bruit, the severity of the stenosis causing it, and the bruit's hemodynamic effects.


 * Carotid bruits are best heard with the bell of the stethoscope.
 * Carotid bruits are a blowing sound or murmur over the carotid artery
 * Are usually associated with carotid stenosis, secondary to atherosclerosis
 * Depending on degree of stenosis, may imply an increased risk of stroke

A CT scan may be indicated for patients with ultrasound-proven carotid disease who are at a higher risk for cerebrovascular accidents such as stroke.

Differential Diagnosis
In alphabetical order.


 * Aortic coarctation
 * Aortic Stenosis
 * Arterial Aneurysm
 * Arteriosclerosis
 * Arteriovenous Fistula
 * Excessive compression of the stethoscope over the neck vessels (therefore causing deformities in the vessel wall and turbulence)
 * External carotid artery stenosis
 * Fever
 * Fisher's contralateral systolic bruit
 * Heart murmur with radiation to the neck
 * Hyperthyroidism
 * Internal carotid artery stenosis
 * Normal carotid arteries (yet tortuous)
 * Takayasu's Arteritis
 * Thyroid fistula
 * Vascular angioma in the skull

History and Symptoms

 * Special attention should paid to symptoms suggestive of:
 * Transient ischemic attack (TIA) symptoms
 * Cardiac risk factors

Heart

 * It is critical to assess if there is a heart murmur that is radiating to the carotids.

Abdomen

 * The presence of a carotid bruit may indicate that a renal bruit is present as well.

Extremities

 * The presence of a carotid bruit may indicate that a femoral artery bruit will be present as well. The distal pulses should be evaluated carefully.

Neurologic

 * Neurologic exam should document and focal neurologic findings that might suggest a prior stroke.

Laboratory Findings

 * Complete blood count (CBC)
 * Lipid panel
 * Folate levels
 * Vitamin B12
 * Thyroid stimulating hormone (TSH)
 * Glucose
 * Homocysteine level
 * Erythrocyte sedimentation rate (ESR)

Echocardiography or Ultrasound

 * The degree of stenosis can be evaluated by carotid duplex ultrasound

Other Imaging Findings

 * To evaluate symptomatic stenosis that may require surgery:
 * Computerized tomographic angiography (CTA)
 * Magnetic resonance angiogram (MRA)
 * Carotid arteriography

Treatment

 * Treat underlying atherosclerotic disease proceses.
 * Smoking cessation

Acute Pharmacotherapies

 * Aspirin and/or antiplatelet therapy is recommended for asymptomatic patients

Chronic Pharmacotherapies

 * Aspirin and/or antiplatelet therapy is recommended for asymptomatic patients

Surgery and Device Based Therapy

 * Symptomatic patients with stenosis of 50-69% benefit more from surgery than medical therapies
 * Symptomatic patients with stenosis of greater than 70% should consider endarterectomy

Future or Investigational Therapies

 * Carotid angioplasty is under investigation for a possible future treatment

Acknowledgements
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