Case of Asymptomatic Carotid Artery Stenosis in a Hypertensive Patient.

This is the case of a hypertensive patient with an asymptomatic carotid stenosis. This is a very common situation that neurologists have to manage. The case is a 75-year-old man with an history of hypertension for 10 years, treated with amlodipine, 5 mg once a day, and perindopril, 8 mg once a day. His hypertension was considered to be controlled. He was also treated for a hyperlipidemia for 5 years with atorvastatin, 10 mg, once a day. His general practitioner recommended an echo-Doppler of cervical and intracranial arteries as part of a systematic screening because of his vascular risk factors. Echo-Doppler showed an atherosclerotic stenosis at the site of the left carotid bifurcation. On grayscale, this stenosis was characterized as a uniformly echogenic plaque (homogeneous plaque). On sonographic NASCET index (North American Symptomatic Carotid Endarterectomy Trial), there was a peak systolic velocity increase of 280 cm/s that translated to a high internal carotid artery/common carotid artery peak systolic velocity ratio of 4.5. Morphology and hemodynamic data were consistent with a severe carotid stenosis estimated about 70% per NASCET criteria. A computed tomographic angiography, already planned by the general practitioner, confirmed a calcified severe stenosis of the bifurcation. The degree of narrowing was also estimated to be about 70% according to NASCET criteria. Contralateral internal carotid artery and intracranial arteries were normal. Arterial work-up was consistent with an isolated severe asymptomatic left carotid stenosis. The patient had no previous history of cerebral vascular disease. His neurological examination was normal. His blood pressure was slightly elevated with systolic blood pressure of 160 mm Hg and a diastolic blood pressure of 95 mm Hg. His recent blood sample showed low-density lipoprotein cholesterol <1 g/L, and his glomerular filtration rate was normal. This case addresses several issues, in particular estimation of the absolute risk of ischemic stroke ipsilateral to carotid stenosis and the need for prophylactic revascularization. The issue of management of patients with asymptomatic carotid stenosis is very common because it is estimated that almost 1 million French people have an asymptomatic carotid stenosis of ≥50%. Of course, not all are aware of this condition.