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The Carotid Bruit on September 25, 2021 by Guest AUGUST 2002 221 Pract Neurol: first published as 10.1046/j.1474-7766.2002.00078.x on 1 August 2002. Downloaded from INTRODUCTION When faced with a patient who may have had a NEUROLOGICAL SIGN stroke or transient ischaemic attack (TIA), one needs to ask oneself some simple questions: was the event vascular?; where was the brain lesion, and hence its vascular territory?; what was the cause? A careful history and focused physical examination are essential steps in getting the right answers. Although one can learn a great deal about the state of a patient’s arteries from expensive vascular imaging techniques, this does not make simple auscultation of the neck for carotid bruits redundant. In this brief review, we will therefore defi ne the place of the bruit in the diagnosis and management of patients with suspected TIA or stroke. WHY ARE CAROTID BRUITS IMPORTANT? A bruit over the carotid region is important because it may indicate the presence of athero- sclerotic plaque in the carotid arteries. Throm- boembolism from atherosclerotic plaque at the carotid artery bifurcation is a major cause of TIA and ischaemic stroke. Plaques occur preferentially at the carotid bifurcation, usually fi rst on the posterior wall of the internal carotid artery origin. The growth of these plaques and their subsequent disintegration, surface ulcera- tion, and capacity to throw off emboli into the Figure 1 Where to listen for a brain and eye determines the pattern of subse- bifurcation/internal carotid quent symptoms. The presence of an arterial http://pn.bmj.com/ artery origin bruit – high up bruit arising from stenosis at the origin of the under the angle of the jaw. internal carotid artery may therefore help to The carotid bruit on September 25, 2021 by guest. Protected copyright. clarify whether an event was vascular or not, non-laminar fl ow through a stenotic lesion, Peter A. G. identify the cause as likely to be due to athero- which causes arterial wall vibrations distal to Sandercock and Eleni matous stenosis, and the possibility that the the stenosis. The vibrations are transmitted to Kavvadia stenosis may be severe enough to justify carotid the body surface, where they can be detected Department of Clinical endarterectomy. However, not all noises in the with a stethoscope. A bruit can develop when Neurosciences, University neck indicate serious arterial disease. So, we the arterial lumen is reduced to less than 50% of of Edinburgh, Western need to review: how bruits arise, how to identify its original cross-sectional diameter. General Hospital, arterial bruits, to identify which noises in the Crewe Road, Edinburgh neck matter, and what to do once you fi nd an HOW TO LISTEN FOR BRUITS EH4 2XU, UK; E-mail: arterial bruit. Before you get out your stethoscope to listen for [email protected] a bruit, you need to have a clear idea of what you Practical Neurology, 2002, HOW BRUITS ARISE will do if you fi nd one! Table 1 gives our view of 2, 221–224 Carotid bruits generally result from turbulent, when listening to the neck is likely to be useful in © 2002 Blackwell Science Ltd 07-pnr078.indd 221 06/08/2002, 17:07:21 222 PRACTICAL NEUROLOGY Pract Neurol: first published as 10.1046/j.1474-7766.2002.00078.x on 1 August 2002. Downloaded from Table 1 When is neck ausculation clinically useful? THE BRUIT THAT MATTERS: THE ONE DUE TO CAROTID STENOSIS Situations when the presence or absence of a carotid bruit can be helpful In patients over 50 years of age with recent carotid territory TIA or stroke Bruits at the bifurcation of the common carotid – a bruit over the symptomatic carotid artery suggests the possibility of an artery are best heard high up under the angle of underlying severe stenosis, likely to benefi t from surgery the jaw (Fig. 2). At this level the common carotid – a bruit may indicate stroke or TIA is more likely due to atherosclerosis than some artery bifurcates and gives rise to its internal other nonatheromatosis pathophysiological process branch. If one hears a bruit only in the base of In patients with history of sudden onset of focal neurological signs (transient or the neck, or along the course of the common persistent) carotid artery, it is referred to as ‘diffuse’. Diffuse – the presence of a bruit increases the probability that the symptoms were bruits are not a very specifi c indicator of internal vascular in origin carotid artery disease. Bruits heard only at the In younger patients with sudden focal symptoms (transient or persistent) where a bifurcation are more specifi c for internal carotid vascular cause is thought unlikely (e.g. clinical syndrome of migraine aura without artery origin stenosis, but lack sensitivity. Un- headache) fortunately bruits at this location can also arise – absence of a bruit makes underlying vascular disease even less likely. from disease of the external carotid artery. Situations where it may be better not to auscultate the neck OTHER NOISES IN THE NECK Asymptomatic individuals Patients with nonfocal neurological symptoms See Table 2. Bruits transmitted from the heart – blackouts become attenuated as one moves the stethoscope – dizzy turns up the neck towards the angle of the jaw. Thyroid – headaches bruits are bilateral and more obviously located Patients with pulsatile tinnitus over the gland. A hyperdynamic circulation tends to cause a diffuse and bilateral bruit. Venous hums are caused by fl ow in the internal jugular vein. neurological practice. Then, get the patient into They are continuous and roaring and are obliter- a quiet room, in a relaxed and comfortable posi- ated by light pressure over the ipsilateral jugular tion. We use the diaphragm of the stethoscope, vein. These are found in over 25% of young people because it detects the higher frequency sounds but can be distinguished from bruits by their dis- of arterial bruits rather better than the bell. Ask appearance with the Valsava manoeuvre. Venous the patient to breathe in and hold their breath. hums are rarely heard with the patient lying down. Listen over an area beginning from just behind An arterial bruit in the supraclavicular fossa sug- the upper end of the thyroid cartilage to just gests either subclavian or proximal vertebral arte- http://pn.bmj.com/ below the angle of the jaw, in other words over rial disease, but a transmitted bruit from aortic the line of the common carotid artery leading up stenosis must also be considered. Normal young to the bifurcation into the internal and external adults quite often have a short supraclavicular carotid arteries. Apply only suffi cient pressure bruit; the reason is unknown. to ensure the diaphragm rests squarely on the skin (Fig. 1). Excessive pressure can compress DEGREE OF CAROTID STENOSIS on September 25, 2021 by guest. Protected copyright. the underlying artery enough to cause a bruit AND CHARACTER OF THE BRUIT even when the artery is normal. With modest arterial stenosis or irregularity, any Figure 2 The sites of maximal intensity of arterial bruits in the neck. A bruit arising from the carotid bifurcation is high up under the angle of the jaw. Localized supraclavicular bruits are caused either by subclavian or vertebral origin artery stenosis. Diffuse bruits are transmitted from the arch of the aorta or the heart. © 2002 Blackwell Science Ltd 07-pnr078.indd 222 06/08/2002, 17:07:26 AUGUST 2002 223 Pract Neurol: first published as 10.1046/j.1474-7766.2002.00078.x on 1 August 2002. Downloaded from Table 2 The source of neck bruits Carotid bifurcation arterial bruit Internal carotid artery stenosis External carotid artery stenosis Supraclavicular arterial bruit Subclavian artery stenosis Vertebral artery origin stenosis Can be normal in young adults Diffuse neck bruit Thyrotoxicosis Hyperdynamic circulation (pregnancy, anaemia, fever, haemodialysis) Transmitted bruit from the heart and great vessels Aortic valve stenosis Aortic arch atheroma Mitral valve regurgitation Patent ductus arteriosous Coarctation of the aorta bruit will be of short duration and heard just in (when none of the features was present) to a mid-systole. As the degree of stenosis increases, high of 94% (when all the features were present). the bruit is likely to become more audible and Hankey and Warlow reported the most favour- longer, expanding to be pan-systolic. Soft, able of results, the presence of a bruit in patients long duration, high frequency bruits represent with a symptomatic internal carotid artery had a haemodynamically-severe stenosis with a large sensitivity of 76% and a specifi city of 76% for the pressure gradient throughout the cardiac cycle. detection of carotid stenosis (defi ed as diameter The intensity of the bruit correlates with the de- stenosis of the ICA of 75–99%, as measured by gree of stenosis to some extent. A harsher bruit the ECST method) (Hankey & Warlow 1990). implies greater stenosis, but remember that So, in the right kind of patients, carotid bruits stenoses of more than 85% may be associated are quite good (but not perfect) at identifying with low fl ow through the carotid artery, and patients with signifi cant stenosis. A good going hence no audible bruit at all. bruit is also a reasonably robust clinical sign. http://pn.bmj.com/ Among 55 patients examined independently by SENSITIVITY AND SPECIFICITY OF two neurologists (both of whom had normal CAROTID BRUITS audiograms), the agreement beyond chance for How reliable a sign is a carotid bruit? In symp- the presence of a bruit was good, with a kappa tomatic patients, Ziegler and colleagues found a statistic of 0.67 (Chambers & Norris 1985). sensitivity of only 0.29 and a specifi city of 0.61 for on September 25, 2021 by guest.
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