Carotid artery disease and carotid dissection — Rapid

Synopsis

Recognise symptomatic carotid stenosis and cervical carotid dissection, start immediate stroke/TIA care and route patients to timely imaging and specialist intervention.

Symptomatic carotid disease causes ipsilateral retinal ischaemia or contralateral cerebral TIA/stroke; dizziness or syncope alone is rarely a carotid-territory syndrome.
Give aspirin 300 mg immediately for suspected TIA unless contraindicated, and arrange specialist assessment within 24 hours; do not use ABCD2 to delay referral.
A patient who may be suitable for carotid endarterectomy needs urgent carotid imaging after specialist assessment.

Key red flags

Carotid-territory TIA

Transient monocular visual loss or contralateral face/arm/leg weakness or language disturbance; treat as an emergency even after symptoms resolve.

Investigation priorities

Non-contrast CT brain or MRI brainFirst step

Distinguish haemorrhage, infarct burden and mimics in acute neurology.

Carotid duplex ultrasoundFirst line

First-line quantification of extracranial carotid stenosis and plaque flow characteristics.

Management branches

strokeOngoing focal deficit

Persistent retinal or cerebral neurological deficit.

First: activate the acute stroke pathway, establish last-known-well time and obtain immediate brain plus vascular imaging.
Next: assess for IV thrombolysis and mechanical thrombectomy; dissection itself does not automatically exclude standard reperfusion treatment.

Key medicines

Aspirin300 mg orally once daily immediately for suspected TIA, unless contraindicated; the specialist then defines the ongoing antiplatelet regimen.

Clopidogrel75 mg orally once daily for long-term secondary prevention when selected; short-term loading/dual therapy is stroke-specialist directed.

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