Carotid Artery Disease

The carotid arteries in your neck carry blood to your brain. If the supply is cut off, it can cause a stroke.

Cerebrovascular Disease

Carotid Artery Stenosis

Carotid artery disease is a narrowing of the arteries in your neck that carry blood to your brain. It happens when a fatty deposit called plaque builds up inside the artery wall – a process called atherosclerosis, or hardening of the arteries. It becomes more common as you get older.

It matters because it can cause a stroke. A piece of plaque or a blood clot can break off, travel to the brain and block a smaller artery; or the narrowed artery itself can close off. Either way, part of the brain loses its blood supply.

You can lower your risk:
Don't smoke
Control diabetes, blood pressure and cholesterol
Exercise regularly
Eat a healthy diet
Keep to a healthy weight

Symptoms

Often there are no symptoms
Early on, carotid artery disease usually causes no symptoms.

Warning signs – a mini-stroke (TIA)
Sometimes the first warning is a mini-stroke, or transient ischaemic attack (TIA) – brief stroke-like symptoms that may include:

• Feeling weakness, numbness, or a tingling sensation on one side of your body, for example, in an arm or a leg

• Being unable to control the movement of an arm or a leg

• Losing vision in one eye (many people describe this sensation as a window shade coming down)

• Being unable to speak clearly

A TIA is a warning, not an all-clear
Even when the symptoms pass completely, about one in three mini-strokes have already caused a small area of brain injury. A TIA means you are at high risk of a full stroke in the days that follow.

Treat it as an emergency
Any sudden weakness, numbness, loss of vision or difficulty speaking – whether it lasts seconds or longer – needs emergency medical attention straight away. Don't wait to see if it passes.

Causes

Most carotid artery disease is caused by atherosclerosis (hardening of the arteries). The main things that damage the artery walls are smoking, high cholesterol and high blood pressure. Diabetes and a family history also raise your risk.

Less often, the narrowing is caused by other conditions, such as fibromuscular dysplasia, previous radiation to the neck, or a tear in the artery wall (dissection).

Tests

History and examination
I ask about your health, medical history and symptoms, and listen over the arteries in your neck for the sound of disturbed blood flow.
Carotid ultrasound (duplex)
A quick, painless scan of your neck that shows how narrowed the arteries are and how well blood flows through them. This is the main test and picks up most cases.
CT angiogram (CTA)
A CT scan with contrast dye that gives a detailed picture of the carotid arteries and pinpoints any narrowing. A plain CT can also show areas of previous stroke.
MRA (MRI angiogram)
Uses a magnetic field instead of x-rays to image the arteries and blood flow.
Angiography
Dye is injected directly into the arteries and x-rays are taken. It gives the most detailed pictures but carries a small risk of stroke, so it is used only when needed.

Treatment Options

Optimal Medical Therapy

Smoking cessation
Diabetes control
Blood pressure control
Cholesterol control
Regular exercising
Healthy diet
Maintaining a healthy weight

Statins
Antiplatelet drugs

Surgery

If you have had symptoms
After a mini-stroke (TIA), a minor stroke or brief loss of vision in one eye, the benefit of surgery depends on how narrowed the artery is. The percentage is measured by the NASCET method (the narrowest point compared with the normal artery above it):
70–99% – surgery is recommended.
50–69% – surgery should be considered; the benefit is smaller and depends on your age, sex and how recent the symptoms were.
Below 50% – surgery does not help; medication is the treatment.
When surgery is advised, it should be done urgently, ideally within two weeks of the symptoms.

If you have no symptoms
Modern medication lowers the risk of stroke substantially, so most people without symptoms are treated with medication alone. An operation may be considered when the artery is 60–99% narrowed and your scans or history show features linked to a higher stroke risk – provided the risk of the procedure is low and you are expected to live for more than five years (ESVS 2023).
The CREST-2 trial (published 2025–2026) studied people with 70% or more narrowing and no symptoms. Over four years, stenting plus intensive medication lowered the risk of stroke or death compared with medication alone (2.8% vs 6.0%). Endarterectomy plus intensive medication did not show a statistically significant benefit (3.7% vs 5.3%). We will discuss what this means for you.

The operation (carotid endarterectomy)
I make a small incision in your neck and remove the plaque from the lining of the artery, leaving it smooth and open again. Most people go home a day or two later, and the result is usually long-lasting.

Risks you should know about
Stroke or death within 30 days – guidelines require this to be below 6% after symptoms and below 3% without symptoms.
Heart attack – about 1–2%.
Nerve injury (hoarse voice, tongue deviation, difficulty swallowing or a weak corner of the mouth) – about 5%, nearly always temporary; permanent in under 1%.
Other – bleeding or a neck haematoma, wound infection, and, uncommonly, the artery narrowing again over the years.

Stenting

Carotid stenting
Stenting is a less invasive option: a thin tube (catheter) is passed from an artery in the groin up to the carotid, where a small balloon flattens the plaque and a metal mesh tube (stent) holds the artery open.

Compared with endarterectomy, stenting carries a somewhat higher risk of stroke around the time of the procedure – particularly in people over about 70 – while endarterectomy carries a somewhat higher risk of heart attack and of nerve injury (CREST trial). The best choice depends on your age, anatomy and general health.

This practice performs endarterectomy and does not offer carotid stenting. If stenting would suit you better, I will refer you.

References
European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg, 2023.
Society for Vascular Surgery (SVS) 2022 Clinical Practice Guidelines for Management of Extracranial Cerebrovascular Disease. J Vasc Surg, 2022.
Brott TG, Howard G, Lal BK, et al. Medical Management and Revascularization for Asymptomatic Carotid Stenosis (CREST-2). N Engl J Med 2026;394(3):219–231. doi:10.1056/NEJMoa2508800
Brott TG, Hobson RW, Howard G, et al. Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis (CREST). N Engl J Med 2010;363(1):11–23. doi:10.1056/NEJMoa0912321

General Guidelines

If you don't need surgery, make sure you and your family know the warning signs of a mini-stroke (TIA): weakness of an arm and leg on one side, brief loss of vision in one eye, or sudden difficulty speaking. Take your medications as prescribed and keep your follow-up appointments.

Lifestyle changes slow the disease. Stopping smoking is the most important step. Losing weight, exercising regularly and eating a Mediterranean-style diet (vegetables, fruit, whole grains, fish, olive oil and nuts) also help.

Patient Roadmap for Carotid EndarterectomyCarotid Endarterectomy - Informed ConsentCarotid EndarterectomyCarotid Endarterectomy - Discharge ProtocolKarotis Endarterektomie - Ontslagprotokol - Afrikaans

If you have any problems with any of these conditions, please contact your General Practitioner, or your Vascular Surgeon. If you live in Pretoria and have not seen a Vascular Surgeon before, you are more than welcome to contact our rooms for a formal consultation.