Carotid bruit

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]

Overview

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.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Causes by Organ System

Cardiovascular Aneurysms, aortic coarctation, aortic dissection, aortic stenosis, arterial aneurysm, arteriosclerosis, arteriovenous fistula, arteriovenous malformations, atherosclerosis, carotid artery disease, carotid artery dissection, carotid artery stenosis, carotid sinus hypersensitivity, carotid sinus syndrome, carotid-cavernous fistula, coronary artery disease, coronary heart disease, external carotid artery stenosis, Fisher's contralateral systolic bruit, flow murmur, heart murmur with radiation to the neck, hyperdynamic circulation, internal carotid artery aneurysm, internal carotid artery stenosis, intraluminal turbulence in the internal carotid artery, peripheral artery disease, stroke, supravalvular aortic stenosis, Takayasu's arteritis, tortuous carotid arteries, transient ischemic attack, vasculitis
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic Vasculitis
Drug Side Effect No underlying causes
Ear Nose Throat Carotid body tumor
Endocrine Gestational diabetes, hyperthyroidism, thyroid fistula, thyrotoxicosis
Environmental No underlying causes
Gastroenterologic Crohn's disease
Genetic Crohn's disease
Hematologic Anemia
Iatrogenic No underlying causes
Infectious Disease Fever
Musculoskeletal/Orthopedic No underlying causes
Neurologic Arteriovenous malformations, carotid artery disease, carotid artery stenosis, external carotid artery stenosis, external compression from thoracic outlet syndrome, internal carotid artery aneurysm, internal carotid artery stenosis, intraluminal turbulence in the internal carotid artery, stroke, transient ischemic attack
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic Carotid body tumor, paraganglioma, tumor, vascular angioma in the skull
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte Fibromuscular dysplasia
Rheumatology/Immunology/Allergy Crohn's disease, vasculitis
Sexual No underlying causes
Trauma Neck trauma with damage to the carotid artery
Urologic No underlying causes
Miscellaneous Fever, idiopathic

Causes in Alphabetical Order [1] [2]

Diagnosis

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

History and Symptoms

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

Physical Examination

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

Echocardiography or Ultrasound

  • The degree of stenosis can be evaluated by carotid duplex ultrasound.
  • 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.

Other Imaging Findings

Treatment

  • Treat underlying atherosclerotic disease proceses.
  • Smoking cessation

Pharmacotherapy

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

References

  1. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  2. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  3. ↑ Sauvé J, Laupacis A, Østbye T, Feagan B, Sackett DL. Original article: does this patient have a clinically important carotid bruit? In: Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. New York, NY: McGraw-Hill; 2009. http://www.jamaevidence.com/content/3476758. Accessed 1/7/2015
  4. ↑ Demiryoguran NS, Karcioglu O, Topacoglu H, Aksakalli S (2006). "Painless aortic dissection with bilateral carotid involvement presenting with vertigo as the chief complaint". Emerg Med J. 23 (2): e15. doi:10.1136/emj.2005.027862. PMC 2564071. PMID 16439729.
  5. ↑ Sauvé J, Laupacis A, Østbye T, Feagan B, Sackett DL. Original article: does this patient have a clinically important carotid bruit? In: Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. New York, NY: McGraw-Hill; 2009. http://www.jamaevidence.com/content/3476758. Accessed 1/7/2015
  6. ↑ Rymer JA, Anderson LL, Posenau JT, Jones WS (2013). "Remote Stab Wound Resulting in AV Fistula and High-Output Heart Failure". Case Rep Cardiol. 2013: 902719. doi:10.1155/2013/902719. PMC 4008354. PMID 24826298.
  7. ↑ Bavinzski G, Richling B, Killer M, Gruber A, Levy D (1996). "Evolution of different therapeutic strategies in the treatment of cranial dural arteriovenous fistulas--report of 30 cases". Acta Neurochir (Wien). 138 (2): 132–8. PMID 8686535.
  8. ↑ Lawrence PF, Oderich GS (2002). "Ophthalmologic findings as predictors of carotid artery disease". Vasc Endovascular Surg. 36 (6): 415–24. PMID 12476231.
  9. ↑ Hill SL, Holtzman GL, Berry R, Arnold JF (1997). "The appropriate use of the duplex scan in carotid arterial disease". Am Surg. 63 (8): 720–5. PMID 9247441.
  10. ↑ Chambers BR, Norris JW (1985). "Clinical significance of asymptomatic neck bruits". Neurology. 35 (5): 742–5. PMID 3887214.
  11. ↑ Wu HC, Chen YC, Chen CJ, Chen ST, Lee TH (2006). "Spontaneous bilateral internal carotid artery dissection with acute stroke in young patients". Eur Neurol. 56 (4): 230–4. doi:10.1159/000096491. PMID 17057383.
  12. ↑ Lindsay FW, Mullin D, Keefe MA (2003). "Subacute hypoglossal nerve paresis with internal carotid artery dissection". Laryngoscope. 113 (9): 1530–3. doi:10.1097/00005537-200309000-00022. PMID 12972929.
  13. ↑ Santilli JD, Santilli SM, Rodnick JE (1996). "Prevention of stroke caused by carotid bifurcation stenosis". Am Fam Physician. 53 (2): 549–56, 559–60. PMID 8629537.
  14. ↑ 14.0 14.1 Morales-Gisbert SM, Plaza-Martínez Á, Sala-Almonacil VA, Olmos-Sánchez D, Gomez-Palonés FJ, Ortiz-Monzón E (2013). "[Natural history of moderate-degree carotid stenosis in patients with peripheral artery disease]". Med Clin (Barc). 140 (8): 337–42. doi:10.1016/j.medcli.2012.06.031. PMID 23339889.
  15. ↑ Lacerda Gde C, Pedrosa RC, Lacerda RC, Santos MC, Perez Mde A, Teixeira AB; et al. (2008). "Cardioinhibitory carotid sinus hypersensitivity: prevalence and predictors in 502 outpatients". Arq Bras Cardiol. 90 (3): 148–55. PMID 18392392.
  16. ↑ Ebina K, Iwabuchi T (1978). "[Closure of traumatic internal carotid-cavernous fistula with an improved type of captive embolus (author's transl)]". No Shinkei Geka. 6 (1): 59–66. PMID 628507.
  17. ↑ Garland SD, Maloney PL, Doku HC (1977). "Carotid-cavernous sinus fistula after trauma to the head". J Oral Surg. 35 (10): 832–5. PMID 269234.
  18. ↑ Subramani KS, Kolhari VB, Manjunath CN, Bhairappa S (2013). "Familial hypercholesterolaemia presenting with coronary artery disease in a young patient". BMJ Case Rep. 2013. doi:10.1136/bcr-2013-008718. PMID 23519510.
  19. ↑ Frost PH, Davis BR, Burlando AJ, Curb JD, Guthrie GP, Isaacsohn JL; et al. (1996). "Coronary heart disease risk factors in men and women aged 60 years and older: findings from the Systolic Hypertension in the Elderly Program". Circulation. 94 (1): 26–34. PMID 8964114.
  20. ↑ 20.0 20.1 Taddio A, Maschio M, Martelossi S, Barbi E, Ventura A (2013). "Crohn's disease and Takayasu's arteritis: an uncommon association". World J Gastroenterol. 19 (35): 5933–5. doi:10.3748/wjg.v19.i35.5933. PMC 3793150. PMID 24124342.
  21. ↑ Olin JW, Sealove BA (2011). "Diagnosis, management, and future developments of fibromuscular dysplasia". J Vasc Surg. 53 (3): 826–36.e1. doi:10.1016/j.jvs.2010.10.066. PMID 21236620.
  22. ↑ Sauvé J, Laupacis A, Østbye T, Feagan B, Sackett DL. Original article: does this patient have a clinically important carotid bruit? In: Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. New York, NY: McGraw-Hill; 2009. http://www.jamaevidence.com/content/3476758. Accessed 1/7/2015

Acknowledgements

The content on this page was first contributed by Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]

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