Natural History and Treatment of Extracranial Cerebrovascular Disease in the Elderly

  • George H. Meier


Cerebrovascular disease, specifically stroke, continues to increase despite improvements in the treatment and outcomes of cardiovascular disease in general. Many believe that the development of cerebrovascular atherosclerosis is simply a normal consequence of aging, as the incidence of stroke increases with age, rising almost sevenfold between the ages of 55 and 85.1 Despite a nearly 20% reduction in the death rate from stroke over the past 20 years, cerebrovascular disease remains the third leading cause of death in the United States.2 It is therefore not surprising that carotid endarterectomy remains the most common peripheral vascular operation done in the United States.3 Current estimates suggest that the population over the age of 65 will increase more than threefold over the next 25 years,4 during which time the increase in cerebrovascular disease will result in a marked impact on medical care. The correct and cost-effective management of cerebrovascular disease is therefore increasingly important as the population ages.


Internal Carotid Artery Cerebrovascular Disease Carotid Endarterectomy Carotid Stenosis Carotid Artery Disease 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Robins M, Baum HM. National survey of stroke incidence. Stroke 1981;12(suppl 1):45–57.Google Scholar
  2. 2.
    Matsumoto N, Whisnant JP, Kurland LT, et al. Natural history of stroke in Rochester, Minnesota, 1955 through 1969: an extension of a previous study, 1945 through 1954. Stroke 1973;4:20–29.PubMedCrossRefGoogle Scholar
  3. 3.
    Pokras R, Dyken ML. Dramatic changes in the performance of endarterectomy for diseases of the extracranial arteries in the head. Stroke 1988;19:1289–1296.PubMedCrossRefGoogle Scholar
  4. 4.
    Day JC. Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050. U.S. Bureau of the Census, Current Population Reports, P25–1130. Government Printing Office: Washington, DC, 1996.Google Scholar
  5. 5.
    Wolf PA, Kannel WB, Dawber TR. Prospective investigation: the Framingham study and the epidemiology of stroke. Adv Neurol 1978;19:107–120.PubMedGoogle Scholar
  6. 6.
    Tell GS, Polak JF, Ward BJ, et al. Relation of smoking with carotid artery wall thickness and stenosis in older adults: the Cardiovascular Health Study; the Cardiovascular Health Study (CHS) Collaborative Research Group. Circulation 1994;90:2905–2908.PubMedCrossRefGoogle Scholar
  7. 7.
    Glagov S, Rowley DA, Kohut R. Atherosclerosis of human aorta and its coronary and renal arteries. Arch Pathol Lab Med 1961;72:558–562.Google Scholar
  8. 8.
    Bell ET. Atherosclerotic gangrene of the lower extremities in diabetic and nondiabetic persons. Am J Clin Pathol 1957;28:27–35.PubMedGoogle Scholar
  9. 9.
    Selhub J, Jacques PF, Bostom AG, et al. Association between plasma homocysteine concentrations and extracranial carotid-artery stenosis. N Engl J Med 1995;332: 286–291.PubMedCrossRefGoogle Scholar
  10. 10.
    Kannel WB, Castelli WP, Gordon T, et al. Serum cholesterol, lipoprotein, and the risk of coronary heart disease: the Framingham study. Ann Intern Med 1971;74:1–12.PubMedCrossRefGoogle Scholar
  11. 11.
    Lipids Research Clinics Program. The Lipids Research Clinics Primary Prevention Trials results. II. The relationship of reduction and incidence of coronary heart disease to cholesterol lowering. JAMA 1984;251:365–374.CrossRefGoogle Scholar
  12. 12.
    Multiple Risk Factor Intervention Trial Research Group. Multiple Risk Factor Intervention Trial: risk factor changes and mortality rates. JAMA 1982;248:1465–1477.CrossRefGoogle Scholar
  13. 13.
    Kang SS, Wong PW, Malinow MR. Hyperho-mocyst(e)inemia as a risk factor for occlusive vascular disease. Annu Rev Nutr 1992;12:279–298.PubMedCrossRefGoogle Scholar
  14. 14.
    Ueland PM, Refsum H, Brattström L. Plasma homocysteine and cardiac disease. In: Francis RB (ed) Atherosclerotic Cardiovascular Disease, Hemostasis, and Endothelial Function. New York: Marcel Dekker, 1992:183–236.Google Scholar
  15. 15.
    Nygärd O, Nordrehaug JE, Refsum H, et al. Plasma homocysteine levels and mortality in patients with coronary artery disease. N Engl J Med 1997;337:230–236.PubMedCrossRefGoogle Scholar
  16. 16.
    Cornfeld J. Joint dependence of risk of coronary heart disease on serum cholesterol and systolic blood pressure. Fed Proc 1962;21(suppl 2):58.Google Scholar
  17. 17.
    O’Leary DH, Anderson KM, Wolf PA, et al. Cholesterol and carotid atherosclerosis in older persons: the Framingham study. Ann Epidemiol 1992;2:147–153.PubMedCrossRefGoogle Scholar
  18. 18.
    Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335:1001–1009.PubMedCrossRefGoogle Scholar
  19. 19.
    Ross R. The pathogenesis of atherosclerosis: an update. N Engl J Med 1986;14:488–500.CrossRefGoogle Scholar
  20. 20.
    Ross R. Atherosclerosis: an inflammatory disease. N Engl J Med 1999;340:115–126.PubMedCrossRefGoogle Scholar
  21. 21.
    Bild DE, Fitzpatrick A, Fried LP, et al. Age-related trends in cardiovascular morbidity and physical functioning in the elderly: the cardiovascular health study. J Am Geriatr Soc 1993;41:1047–1056.PubMedGoogle Scholar
  22. 22.
    Weber G, Bianciardi G, Bussani MD, et al. Atherosclerosis and aging: a morphometric study on arterial lesions of elderly and very elderly necropsy subjects. Arch Pathol Lab Med 1988;112:1066–1070.PubMedGoogle Scholar
  23. 23.
    Homma S, Ishida H, Hasegawa H, et al. Carotid intima-medial thickness and the occurrence of plaque in centenarians: data from the Tokyo Centenarian Study. Jpn J Geriatr 1997;34:139–146.CrossRefGoogle Scholar
  24. 24.
    Weber G, Bianciardi G, Bussani R, et al. Atherosclerosis and aging: a morphometric study on arterial lesions of elderly and very elderly necropsy subjects. Arch Pathol Lab Med 1988;112:1066–1070.PubMedGoogle Scholar
  25. 25.
    Shuaib A, Boyle C. Stroke in the elderly. Curr Opin Neurol 1994;7:41–47.PubMedCrossRefGoogle Scholar
  26. 26.
    Zarins CK, Giddens DP, Bharadvaj BK, et al. Carotid bifurcation atherosclerosis: quantitative correlation of plaque localization with flow velocity profiles and wall shear stress. Circ Res 1983;53:502–514.PubMedCrossRefGoogle Scholar
  27. 27.
    Theile BL, Strandness DE. Distribution of intracranial and extracranial arterial lesions in patients with symptomatic cerebrovascular disease. In: Bernstein EF (ed) Vascular Diagnosis, 4th ed. Mosby: St. Louis, 1993:302–307.Google Scholar
  28. 28.
    Imparato AM, Riles TS, Mintzer R, et al. The importance of hemorrhage in the relationship between gross morphologic characteristics and cerebral symptoms in 376 carotid artery plaques. Ann Surg 1983;197:195–203.PubMedCrossRefGoogle Scholar
  29. 29.
    Lusby RJ, Ferrell LD, Ehrenfeld WK, et al. Carotid plaque hemorrhage: its role in production of cerebral ischemia. Arch Surg 1982;117:1479–1488.PubMedCrossRefGoogle Scholar
  30. 30.
    Fryer JA, Myers PC, Appleberg M. Carotid intraplaque hemorrhage: the significance of neovascularity. J Vasc Surg 1987;6:341–349.PubMedGoogle Scholar
  31. 31.
    Persson AV, Robichaux WT, Silverman M. The natural history of carotid plaque development. Arch Surg 1983;118:1048–1052.PubMedCrossRefGoogle Scholar
  32. 32.
    Polak JF, O’Leary DH, Kronmal RA, et al. Sonographic evaluation of carotid artery atherosclerosis in the elderly: relationship of disease severity to stroke and transient ischemic attack. Radiology 1993;188:363–370.PubMedGoogle Scholar
  33. 33.
    Kendall RE, Marshall J. Role of hypotension in the genesis of transient focal cerebral ischemic attacks. Br Med J 1963; 2:344–248.CrossRefGoogle Scholar
  34. 34.
    Fazekas JF, Alman RW. The role of hypotension in transitory focal cerebral ischemia. Am J Med Sci 1964;248: 567–570.PubMedCrossRefGoogle Scholar
  35. 35.
    Millikin CH. The pathogenesis of transient focal cerebral ischemia. Circulation 1965;32:438–448.CrossRefGoogle Scholar
  36. 36.
    Brass LM, Fayad PB, Levine SR. Transient ischemic attacks in the elderly: diagnosis and treatment. Geriatrics 1992; 47:36–53.PubMedGoogle Scholar
  37. 37.
    Perez-Burkhardt JL, Gonzalez-Fajardo JA, Rodriguez E, Mateo AM. Amaurosis fugax as a symptom of carotid artery stenosis: its relationship with ulcerated plaque. J Cardiovasc Surg (Torino) 1994;35:15–18.Google Scholar
  38. 38.
    Alpers BJ, Berry RG, Paddison RM. Anatomical studies of the circle of Willis in normal brain. Arch Neurol Psychiatry 1959;81:409–422.CrossRefGoogle Scholar
  39. 39.
    Powers WJ, Press GW, Grubb RL, et al. The effect of hemo-dynamically significant carotid artery disease on the hemodynamic status of the cerebral circulation. Ann Intern Med 1987;106:27–35.PubMedCrossRefGoogle Scholar
  40. 40.
    Berens ES, Kouchoukos NT, Murphy SF, Wareing TH. Preoperative carotid artery screening in elderly patients undergoing cardiac surgery. J Vasc Surg 1992;15:313–321.PubMedCrossRefGoogle Scholar
  41. 41.
    Halpin DP, Riggins S, Carmichael JD, et al. Management of coexistent carotid and coronary artery disease. South Med J 1994;87:187–189.PubMedCrossRefGoogle Scholar
  42. 42.
    Sayers RD, Thompson MM, Underwood MJ, et al. Early results of combined carotid endarterectomy and coronary artery bypass grafting in patients with severe coronary and carotid artery disease. J R Coll Surg Edinb 1993;38:340–343.PubMedGoogle Scholar
  43. 43.
    Reigel MM, Hollier LH, Sundt TM, et al. Cerebral hyper-perfusion syndrome: a cause of neurologic dysfunction after carotid endarterectomy. J Vasc Surg 1987;5:628–634.PubMedGoogle Scholar
  44. 44.
    Powers AD, Smith RR. Hyperperfusion syndrome after carotid endarterectomy: a transcranial Doppler evaluation. Neurosurgery 1990;26:56–60.PubMedCrossRefGoogle Scholar
  45. 45.
    Naylor AR, Merrick MV, Gillespie I, et al. Prevalence of impaired cerebrovascular reserve in patients with symptomatic carotid artery disease. Br J Surg 1994;81:45–48.PubMedCrossRefGoogle Scholar
  46. 46.
    Syrota A, Castaing M, Rougemont D, et al. Tissue acid-base balance and oxygen metabolism in human cerebral infarction studied with positron emission tomography. Ann Neurol 1983;14:419–428.PubMedCrossRefGoogle Scholar
  47. 47.
    Zierler RE, Phillips DJ, Beach KW, et al. Noninvasive assessment of normal carotid bifurcation hemodynamics with color-flow ultrasound imaging. Ultrasound Med Biol 1987;13:471–476.PubMedCrossRefGoogle Scholar
  48. 48.
    Zierler RE, Kohler TR, Strandness DE. Duplex scanning of normal or minimally diseased carotid arteries: correlation with arteriography and clinical outcome. J Vasc Surg 1990;12:447–454.PubMedCrossRefGoogle Scholar
  49. 49.
    Moniz E. L’encéphalographie artérielle, son importance dans la localisation des tumeurs cérébrales. Rev Neurol 1927;2:72.Google Scholar
  50. 50.
    Eliasziw M, Smith RF, Singh N, et al. Further comments on the measurement of carotid stenosis from angiograms. Stroke 1994;25:2445–2449.PubMedCrossRefGoogle Scholar
  51. 51.
    Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421–1428.CrossRefGoogle Scholar
  52. 52.
    Mittl RL Jr, Broderick M, Carpenter JP, et al. Blinded-reader comparison of magnetic resonance angiography and duplex ultrasonography for carotid artery bifurcation stenosis. Stroke 1994;25:4–10.PubMedCrossRefGoogle Scholar
  53. 53.
    North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effects of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445–453.CrossRefGoogle Scholar
  54. 54.
    Barnett HJM, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998;339: 1415–1425.PubMedCrossRefGoogle Scholar
  55. 55.
    Moore WS, Barnett HJ, Beebe HG, et al. Guidelines for carotid endarterectomy: a multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation 1995;91:566–579.PubMedCrossRefGoogle Scholar
  56. 56.
    Treiman RL, Wagner WH, Foran RF, et al. Carotid endarterectomy in the elderly. Ann Vasc Surg 1992;6: 321–324.PubMedCrossRefGoogle Scholar
  57. 57.
    Nunnelee JD, Kurgan A, Auer AI. Carotid endarterectomy in elderly vascular patients: experience in a community hospital. Geriatr Nurs 1995;16:121–123.PubMedCrossRefGoogle Scholar
  58. 58.
    Perler BA, Dardik A, Burleyson GP, et al. Influence of age and hospital volume on the results of carotid endarterectomy: a statewide analysis of 9918 cases. J Vasc Surg 1998; 27:25–33.PubMedCrossRefGoogle Scholar
  59. 59.
    Fisher ES, Malenka DJ, Solomon NA, et al. Risk of carotid endarterectomy in the elderly. Am J Public Health 1989;79:1617–1620.PubMedCrossRefGoogle Scholar
  60. 60.
    Schultz RD, Feldhaus RJ. Carotid endarterectomy in octogenarians and nonagenarians. Surg Gynecol Obstet 1988;166:245–251.PubMedGoogle Scholar
  61. 61.
    Wong DT, Ballard JL, Killeen JD. Carotid endarterectomy and abdominal aortic aneurysm repair: are these reasonable treatments for patients over age 80? Am Surg 1998;64:998–1001.PubMedGoogle Scholar
  62. 62.
    Kerdiles Y, Lucas A, Podeur L, et al. Results of carotid surgery in elderly patients. J Cardiovasc Surg (Torino) 1997;38:327–334.Google Scholar
  63. 63.
    Van Damme H, Lacroix H, Desiron Q, et al. Carotid surgery in octogenarians: is it worthwhile? Acta Chir Belg 1996;96:71–77.PubMedGoogle Scholar
  64. 64.
    Thomas PC, Grigg M. Carotid artery surgery in the octogenarian. Aust NZ J Surg 1996;66:231–234.CrossRefGoogle Scholar
  65. 65.
    Favre JP, Guy JM, Frering V, et al. Carotid surgery in the octogenarian. Ann Vasc Surg 1994;8:421–426.PubMedCrossRefGoogle Scholar
  66. 66.
    Coyle KA, Smith RB, Salam AA, et al. Carotid endarterectomy in the octogenarian. Ann Vasc Surg 1994;8:417–420.PubMedCrossRefGoogle Scholar
  67. 67.
    Perler BA, Williams GM. Carotid endarterectomy in the very elderly: is it worthwhile? Surgery 1994;116:479–483.PubMedGoogle Scholar
  68. 68.
    Meyer FB, Meissner I, Fode NC, et al. Carotid endarterectomy in elderly patients. Mayo Clin Proc 1991;66:464–469.PubMedCrossRefGoogle Scholar
  69. 69.
    Brooks RH, Park RE, Chassin MR, et al. Carotid endarterectomy for elderly patients: predicting complications. Ann Intern Med 1990;113:747–753.CrossRefGoogle Scholar
  70. 70.
    Pinkerton JA, Gholkar VR. Should patient age be a consideration in carotid endarterectomy? J Vasc Surg 1990;11:650–658.PubMedGoogle Scholar
  71. 71.
    Ouriel K, Penn TE, Ricotta JJ, et al. Carotid endarterectomy in the elderly patient. Surg Gynecol Obstet 1986;162: 334–336.PubMedGoogle Scholar
  72. 72.
    Perler BA. Vascular disease in the elderly patient. Surg Clin North Am 1994;74:199–216.PubMedGoogle Scholar
  73. 73.
    Roques XF, Baudet EM, Clerc F. Results of carotid endarterectomy in patients 75 years of age and older. J Cardiovasc Surg (Torino) 1991;32:726–731.Google Scholar
  74. 74.
    Back MR, Harward TR, Huber TS, et al. Improving the cost-effectiveness of carotid endarterectomy. J Vasc Surg 1997;26:456–462.PubMedCrossRefGoogle Scholar
  75. 75.
    Allen BT, Anderson CB, Rubin BG, et al. The influence of anesthetic technique on perioperative complications after carotid endarterectomy. J Vasc Surg 1994;19:834–843.PubMedCrossRefGoogle Scholar
  76. 76.
    Yadav JS, Roubin GS, Iyer S, et al. Elective stenting of the extracranial carotid arteries. Circulation 1997;95: 376–381.PubMedCrossRefGoogle Scholar
  77. 77.
    Imparato AM, Ramirez A, Riles T, et al. Cerebral protection in carotid surgery. Arch Surg 1982;117:1703–1708.CrossRefGoogle Scholar
  78. 78.
    Hafner CD, Evans WE. Carotid endarterectomy with local anesthesia. J Vasc Surg 1988;7:231–239.Google Scholar
  79. 79.
    Stanley JC, Abbott WM, Towne JB, et al. Statement regarding carotid angioplasty and stenting. J Vasc Surg 1996;24: 900.CrossRefGoogle Scholar
  80. 80.
    Beebe HG, Archie JP, Baker WH, et al. Concern about the safety of carotid angioplasty. Stroke 1996;27:197–198.PubMedCrossRefGoogle Scholar
  81. 81.
    Bergeon P, Rudondy P, Benichou H, et al. Transluminal angioplasty for recurrent stenosis after carotid endarterectomy: prognostic factors and indications. Int Angiol 1993;12:256–259.PubMedGoogle Scholar
  82. 82.
    Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421–1428.CrossRefGoogle Scholar
  83. 83.
    Moore WS. Does tandem lesion mean tandem risk in patients with carotid artery disease? J Vasc Surg 1988;7: 454–455.PubMedGoogle Scholar
  84. 84.
    Lord RS, Raj TB, Graham AR. Carotid endarterectomy, siphon stenosis, collateral hemispheric pressure and perioperative cerebral infarction. J Vasc Surg 1987;6:391–397.PubMedGoogle Scholar
  85. 85.
    Schüler JJ, Flanigan DP, Lim LT, et al. The effect of carotid siphon stenosis on stroke rate, death, and relief of symptoms following elective carotid endarterectomy. Surgery 1982;92:1058–1067.PubMedGoogle Scholar
  86. 86.
    Borozean PG, Schuler JJ, LaRosa MP, et al. The natural history of isolated carotid siphon stenosis. J Vasc Surg 1984;1:744–749.Google Scholar
  87. 87.
    Akers DL, Bell WH, Kerstein MD. Does intracranial dye study contribute to evaluation of carotid disease? Am J Surg 1988;156:87–90.PubMedCrossRefGoogle Scholar
  88. 88.
    Ricotta JJ, Holen J, Schenk E, et al. Is routine angiography necessary prior to carotid endarterectomy? J Vasc Surg 1984;1:96–102.PubMedGoogle Scholar
  89. 89.
    Moore WS, Ziomek S, Quinones-Baldrich WJ, et al. Can clinical evaluation and noninvasive testing substitute for arteriography in the evaluation of carotid artery disease? Ann Surg 1988;298:91–94.CrossRefGoogle Scholar
  90. 90.
    Cronenwett JL, Birkmeyer JD, Nackman GB, et al. Cost-effectiveness of carotid endarterectomy in asymptomatic patients. J Vasc Surg 1997;25:298–311.PubMedCrossRefGoogle Scholar
  91. 91.
    Kelly AB. Pulsating vessels in the pharynx. Glasgow Med J 1891;49:28–30.Google Scholar
  92. 92.
    Riser MM, Geraud J, Ducoudray J, et al. Dolicho-carotide interne avec syndrome vertigneux. Rev Neurol 1951;85: 10–12.Google Scholar
  93. 93.
    Quattlebaum JK, Upson ET, Neville RL. Stroke associated with elongation and kinking of the internal carotid artery. Ann Surg 1959;150:824–832.PubMedCrossRefGoogle Scholar
  94. 94.
    Weibel J, Fields WS. Tortuosity, coiling and kinking of the internal carotid artery. I. Etiology and radiographic anatomy. Neurology 1965;15:7–11.PubMedCrossRefGoogle Scholar
  95. 95.
    Metz H, Murray-Leslie RM, Bannister RG, et al. Kinking of the internal carotid artery. Lancet 1961;1:424–426.PubMedCrossRefGoogle Scholar
  96. 96.
    Bauer R, Sheehan S, Meyer JS. Arteriographie study of cerebrovascular disease. II. Cerebral symptoms due to kinking, tortuosity, and compression of carotid and vertebral arteries in the neck. Arch Neurol 1961;4:119.PubMedCrossRefGoogle Scholar
  97. 97.
    Mascoli F, Mari C, Liboni A, et al. The elongation of the internal carotid artery: diagnosis and surgical treatment. J Cardiovasc Surg 1987;28:9–11.Google Scholar
  98. 98.
    Yardley L, Owen N, Nazareth I, Luxon L. Prevalence and presentation of dizziness in a general practice community sample of working age people. Br J Gen Pract 1998;48: 1131–1135.PubMedGoogle Scholar
  99. 99.
    Jonas HA, Kronmal RA, Psaty BM, et al. Current estrogen-progestin and estrogen replacement therapy in elderly women: association with carotid atherosclerosis: CHS Collaborative Research Group Cardiovascular Health Study. Ann Epidemiol 1996;6:314–323.PubMedCrossRefGoogle Scholar
  100. 100.
    Manolio TA, Furberg CD, Shemanski L, et al. Associations of postmenopausal estrogen use with cardiovascular disease and its risk factors in older women: the CHS Collaborative Research Group. Circulation 1993;88:2163–2171.PubMedCrossRefGoogle Scholar
  101. 101.
    Niskanen L, Rauramaa R, Miettinen H, et al. Carotid artery intima-media thickness in elderly patients with NIDDM and in nondiabetic subjects. Stroke 1996;27:1986–1992.PubMedCrossRefGoogle Scholar

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  • George H. Meier

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