Clinical Manifestations of Carotid Artery Disease

Neurologic findings vary by the location of the occlusion and the adequacy of collateral circulation. A large MCA territory stroke is usually seen in patients with MCA mainstem occlusion without good collateral flow, whereas deep or parasylvian strokes are the most common presentation when enough collateral flow is present over the convexities. Contralateral motor weakness involving the foot more than the thigh and shoulder, with relative sparing of the hand and face, is the typical manifestations of distal ACA branch occlusion. Conversely, prominent cognitive and behavioral changes associated with contralateral hemiparesis predominate in patients with proximal ACA occlusions, due to involvement of the recurrent artery of Huebner.

Hemodynamic strokes usually involve the border zone territory between ACA and MCA (anterior border zone), MCA and PCA (posterior border zone), or between deep and superficial perforators (subcortical border zone) and cause the typical clinical symptoms outlined in Plate 9-12.

Although TIAs can occur in intrinsic occlusive disease of the MCA and ACA , they are not as common as in patients with ICA disease and usually occur over a shorter period of hours or days. When strokes occur, initial symptoms are typically noticed on awakening and often fluctuate during the day, supporting a hemodynamic mechanism.

Isolated infarction of the anterior choroidal artery territory is not common. The classic clinical presentation includes hemiplegia, hemianesthesia, and homonymous hemianopsia, but incomplete forms of this syndrome are more frequently seen. Left-sided spatial neglect and mild speech difficulties may accompany right- and left-sided lesions, respectively. Small vessel disease is the most common mechanism of anterior choroidal strokes; however, large strokes in this territory have also been associated with cardioembolism and ipsilateral intracranial carotid artery disease.

Ipsilateral pain involving the eye, temple or forehead, and ipsilateral Horner syndrome secondary to involvement of sympathetic fibers along the wall of the internal carotid artery are common in patients with extracranial carotid dissection, and its presence helps with the clinical diagnosis. TIAs and/or strokes usually occur several days after onset of symptoms and are usually caused by intra-arterial embolism.

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