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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Carotid artery disease and carotid dissection

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Any ongoing focal neurological deficit is a suspected stroke: call the acute stroke team immediately. New unilateral neck/head pain with partial Horner syndrome, retinal ischaemia or focal neurology may be carotid dissection and requires urgent brain and arterial imaging.

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.
  • NICE recommends urgent carotid endarterectomy for recent stable TIA/non-disabling stroke with symptomatic 50–99% NASCET stenosis (equivalent 70–99% ECST), alongside best medical treatment.
  • Do not offer carotid surgery for symptomatic stenosis below 50% NASCET (below 70% ECST).
  • Carotid dissection often presents with unilateral neck/head/orbital pain, partial Horner syndrome, pulsatile tinnitus or delayed retinal/cerebral ischaemia.
  • CTA or MRA of head and neck demonstrates dissection, stenosis/occlusion and pseudoaneurysm; ultrasound alone can miss high cervical disease.
  • For symptomatic extracranial dissection, ESO supports either antiplatelet or anticoagulant therapy; the stroke specialist individualises choice, duration and follow-up imaging.

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.

Acute ischaemic stroke

Persistent focal deficit, visual loss, aphasia, neglect or weakness requires immediate stroke reperfusion assessment before carotid-surgery planning.

Carotid dissection pain/Horner pattern

Unilateral neck, facial, orbital or temporal pain plus partial Horner syndrome (ptosis and miosis without anhidrosis) is a classic warning pattern.

Dissection-related ischaemia

Retinal TIA, hemispheric TIA/stroke, cranial-nerve palsy or pulsatile tinnitus may follow pain by hours or days.

Investigation priorities

01
Non-contrast CT brain or MRI brainFirst step

Distinguish haemorrhage, infarct burden and mimics in acute neurology.

02
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.

  1. First: activate the acute stroke pathway, establish last-known-well time and obtain immediate brain plus vascular imaging.
  2. Next: assess for IV thrombolysis and mechanical thrombectomy; dissection itself does not automatically exclude standard reperfusion treatment.
  3. Next: begin antithrombotic therapy only after haemorrhage and reperfusion considerations are addressed by the stroke team.
  4. Escalation: coordinate urgent carotid/vascular review if symptomatic extracranial stenosis is identified and the stroke is non-disabling/stable.

Key medicines

Aspirin300 mg orally once daily immediately for suspected TIA, unless contraindicated; the specialist then defines the ongoing antiplatelet regimen.Exclude important contraindications and use the acute stroke imaging/reperfusion pathway for ongoing deficits; review bleeding, allergy and concurrent anticoagulation.
Clopidogrel75 mg orally once daily for long-term secondary prevention when selected; short-term loading/dual therapy is stroke-specialist directed.Bleeding risk, surgery timing and interacting anticoagulants; do not improvise long-term dual antiplatelet therapy.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG128: Stroke and TIA—recommendationsImmediate aspirin, 24-hour TIA review, carotid imaging and endarterectomy thresholds.
  • ESO guideline: Extracranial and intracranial artery dissectionDissection imaging, reperfusion and antithrombotic options.
  • ESO Guideline DirectoryCurrent European stroke guidance index.
  • NICE NG238: CVD risk reduction and lipid modificationSecondary-prevention statin targets and monitoring.
  • NICE CKS: Antiplatelets for prevention of CVDLong-term clopidogrel 75 mg route after non-cardioembolic stroke or TIA.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom