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.

• Aortic dissection

Common Causes

• Atherosclerosis
• Carotid artery stenosis

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

• Anemia
• 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 body tumor
• Carotid sinus hypersensitivity
• Carotid sinus syndrome
• Carotid-cavernous fistula
• Coronary artery disease
• Coronary heart disease
• Crohn's disease
• External carotid artery stenosis
• External compression from thoracic outlet syndrome
• Fever
• Fibromuscular dysplasia

• Fisher's contralateral systolic bruit
• Flow murmur
• Gestational diabetes
• Heart murmur with radiation to the neck
• Hyperdynamic circulation
• Hyperthyroidism
• Idiopathic
• Internal carotid artery aneurysm
• Internal carotid artery stenosis
• Intraluminal turbulence in the internal carotid artery
• Neck trauma with damage to the carotid artery
• Paraganglioma
• Peripheral artery disease
• Stroke
• Supravalvular aortic stenosis
• Takayasu's arteritis
• Thyroid fistula
• Thyrotoxicosis
• Tortuous carotid arteries
• Transient ischemic attack
• Tumor
• Vascular angioma in the skull
• Vasculitis

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

• 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.
• 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

• 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

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

Acknowledgements

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

List of contributors:

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