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Asymptomatic Carotid Bruit Asymptomatic Carotid Bruit: Long-term Outcome of Patients Having Endarterectomy Compared with Unoperated Controls JESSE E. THOMPSON, M.D., R. DON PATMAN, M.D., C. M. TALKINGTON, M.D. During 20 years (1957-1977), 1286 carotid endarterectomies From the Department of General Surgery were performed on 1022 private patients with cerebrovascular Baylor University Medical Center, insufficiency. Included were 132 patients undergoing 167 end- Dallas, Texas arterectomies for asymptomatic cervical carotid bruits. Ages ranged from 42 to 82 years (mean: 64.7). Operative mortality was zero. There were two transient and two permanent opera- tion-related neurologic deficits. Complete follow-up was and the incidence of subsequent strokes is markedly achieved, extending to 184 months. During postoperative fol- reduced.21'24 low-up, six patients (4.5%) developed TIA's appropriate to The most controversial area at present concerns the the unoperated artery, three patients had strokes (2.3%), and advisability of performing arteriography and operation three patients died of strokes (2.3%). To characterize the natu- on ral history of asymptomatic bruit and determine proper in- patients with asymptomatic carotid bruits. Asympto- dications for prophylactic endarterectomy, a control series matic subclavian bruits, even with a demonstrated sub- of 138 additional patients with asymptomatic bruits not op- clavian steal syndrome, do not require operative in- erated upon when the bruit was discovered was studied. Ages tervention. However, the midcarotid bruit, which re- ranged from 39 to 86 years (mean: 65.7). During follow-up flects the presence of atherosclerosis at the common extending to 180 months, 77 patients (55.8%) remained neu- rologically asymptomatic, 37 patients (26.8%) developed TIA's carotid bifurcation, is another matter. Ninety per cent one month to 99 months after detection of bruit, and 24 pa- of such bruits arise from internal carotid plaques, the tients (17.4%) sustained mild to profound frank strokes one rest coming from external carotid plaques or other un- week to 124 months postdetection. Three ofthese 24 (2.2%) died common lesions.20 The indications for endarterectomy of stroke. Asymptomatic carotid bruits may be potential stroke in patients with asymptomatic carotid bruits, however, hazards, the risk of which can be significantly reduced by have not yet been clearly defined. appropriately applied endarterectomy. A protocol for manage- ment is presented. Auscultation of the neck for the presence of carotid bruits is an important examination in patients with cere- brovascular insufficiency syndromes. In fact, this should D URING THE PAST TWO DECADES it has been clearly Jestablished that in many patients with cerebro- be done in every routine physical examination, es- vascular insufficiency the responsible atherosclerotic pecially in patients over the age of 40 and in those with occlusions are in the extracranial vasculature. In fact, evidence of atherosclerosis elsewhere in the body. Re- Hass et al.11 state that 74% ofsuch patients have at least cently developed sophisticated stethoscopes for the one significant lesion at a surgically accessible site. heart are inadequate for the head and neck. The stand- Therefore, it is technically feasible to increase cerebral ard 3 cm bell stethoscope remains the most satisfactory blood flow or remove sources of emboli by surgical one for cervical auscultation. means. Carotid endarterectomy is highly effective in The differential diagnosis of cervical murmurs in- the treatment of patients with transient cerebral cludes physiologic murmurs of no significance; venous ischemia since symptoms are relieved in most instances hum; arteriovenous fistula; angiomatous malforma- tions; intracranial neoplasm; Paget's disease ofthe skull; fever; anemia; thyrotoxicosis; atherosclerosis ofthe in- nominate, subclavian, vertebral and carotid arteries; Presented at the Annual Meeting of the American Surgical As- sociation April 26-28, 1978, Dallas, Texas. loops, kinks, and fibromuscular dysplasia ofthe carotid Reprint requests: Jesse E. Thompson, M.D., Suite 505, 3600 Gas- artery; and transmitted cardiac murmurs. In children ton Avenue, Dallas, Texas 75246. and young adults cervical murmurs are of little sig- 0003-4932/78/0900/0308 $01.05 X J. B. Lippincott Company 308 Vol. 188.9 No. 3 ASYMPTOMATIC CAROTID BRUIT 309 TABLE 1. Operative Morttality Followting Carotid Endarterectomy (Total experience -20 years) Clinical No. of No. of No. of Patient Procedure Category Patients Operations Deaths Mortality Mortality Frank stroke 296 358 20 6.8% 5.6% Transient ischemia 575 737 7 1.2% 0.9% Chronic ischemia 19 24 0 0 0 Asymptomatic bruit 132 167 0 0 0 Totals 1022 1286 27 2.6% 2.1% nificance. They are usually heard at the base of the the natural history of the untreated patient with an neck and their incidence decreases rapidly with in- asymptomatic bruit to determine ifthis lesion poses any creasing age. Over the age of 40, however, cervical stroke hazard. The second objective was to determine murmurs are much more significant, the carotid bruits the long-term outcome, as regards development of cere- being those most commonly encountered, with a re- bral ischemic episodes, of patients with asymptomatic ported incidence of about 10%.9.16 bruits subjected to primary carotid endarterectomy, The most important cervical bruit is the midcarotid, and to compare these results with those found in the heard over the carotid bifurcation near the angle of untreated group. The third is to propose a practical the jaw. It is usually highly localized and disappears and reasonable protocol for management of patients quickly as one listens inferiorly. Carotid bruits vary in with asymptomatic carotid bruits. intensity from soft to very harsh and may be graded from zero to four-plus on a quantitative basis. They Materials and Methods appear when stenosis is 50% or greater and may ac- During a 20-year period from April 16, 1957 through tually disappear at 85-90% stenosis or when the lumen April 30, 1977, we performed 1286 carotid endarterec- is only 0.5-1 mm in diameter." 20 They vary in timing tomies on 1022 from systolic to continuous. private patients for the various syn- dromes of cerebrovascular insufficiency (Table 1). 19 The most frequent cause of a midcarotid bruit is an In our first analysis in 1965,20 we were struck by the atherosclerotic plaque at the bifurcation of the com- finding that among 16 patients with asymptomatic bruits mon carotid artery, which usually involves the origin and first few centimeters of the internal carotid but not operated upon, five ofthe 16 sustained frank strokes without episodes of transient ischemia. Consequently, occasionally is limited to the external carotid. Rarely, two series, an operated group and a non-operated con- a bruit is present in the absence of any radiograph- trol group, have been followed pari-passu over the ically demonstrable carotid pathology. It has been at- years. A total of 270 patients with asymptomatic mid- tributed to a hemodynamic phenomenon whch may carotid result from total occlusion of the opposite carotid.2 bruits have been studied. Of these 132 were subjected to endarterectomy primarily, while 138 were Several studies have been done on patients with overt cerebrovascular insufficiency, correlating stenotic followed but were not operated upon when the bruit was first detected. The follow-up study extended lesions demonstrated on arteriograms with carotid bruits through November 15, 1977, so that all patients had a heard in the neck.6 9'16 The degree of correlation is very minimal follow-up of at least six months. high when bruits are audible, ranging from 75 to 85%. Overall correlation between demonstrable carotid dis- Table 2 shows the basic data on the two groups, which were quite similar as to age and sex distribution and ease and bruits is about 60%, since lesions may be other medical characteristics. All patients were white. present on the arteriogram yet no bruit be audible. The indications for operating upon or These include stenoses of less than 50%, ulcerated following these patients warrant explanation. In the early days of the plaques without stenosis, severe stenosis with a lumen study we were unsure as to whether they should be diameter of 1 mm or less, and total occlusions of the internal carotid artery.'9 A carotid bruit when present TABLE 2. Basic Patient Data thus constitutes a significant finding in patients with cerebrovascular insufficiency. The controversy arises as Operated Non-operated to the significance of the bruit in the absence of cere- No. of patients 132 138 bral symptoms.7'12 Age: range 42-82 years 39-86 years This paper reports our experience with asymptomatic Age: mean 64.7 years 65.7 years Males 76 (57.6%) 74 (53.6%) carotid bruits, including both non-operated and op- Females 56 (42.4%) 64 (46.4%) erated patients. The first objective was to characterize 310 THOMPSON, PATMAN AND TALKINGTON Ann. Surg. * September 1978 _gS:}._.....,...:.!'i:.,.' FIG. 1. Right lateral carotid arteriogram showing severe stenosis at the bifurcation of the common carotid with involvement of the in- ternal carotid giving rise to a loud, harsh carotid bruit, in a patient with- out neurologic symp- toms. On the left is the preoperative appearance and on the right the postoperative appear- ance three years after carotid endarterectomy through a linear arteri- otomy closed without a patch graft. considered for operation at all. Indications for arteriog- turn for regular follow-up after other operations, al- raphy were based on clinical judgment aimed at pre- though instructed to do so. venting strokes, and included patients with harsh bruits In recent years, with increasing safety of retrograde and those about to undergo major surgery of another arteriography under local anesthesia, this procedure sort. In a few cases the referring physicians or the has been recommended and carried out more liberally. patients were insistent on arteriography. Operation was In the last year of the study the noninvasive examina- performed if a significant lesion was seen on the x-rays.
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