​Extracranial/Intracranial Vascular Disease (Carotid Stenosis, Intracranial Atherosclerosis)

What is Extracranial Cerebrovascular Disease?

The brain receives its blood supply from two sets of arteries.

The carotid arteries travel up the front of the neck and supply blood to the front part of the brain where important functions are located, including:

• Speech
• Personality
• Thinking
• Sensory
• Motor functions

The vertebral arteries run through the spine and supply blood to the back of the brain (brainstem and cerebellum).  

When any of these arteries are narrowed or blocked, it creates a condition called stenosis that drastically increases the risk of stroke, aneurysm, and other neurovascular disorders

What is extracranial/intracranial vascular disease?

Extracranial vascular disease refers to carotid or vertebral stenosis outside the skull.

Intracranial vascular disease involves the arteries within the skull or at the base of the skull.

Atherosclerosis, the hardening and narrowing of the walls of these vessels due to deposits of fats that form plaques within the arteries, is the most common cause of extracranial and intracranial vascular disease. As the plaque deposits gradually enlarge, they interfere with blood flow.

Atherosclerosis can affect any large-to-medium-sized artery in the body and cause serious health problems.

In rare cases, the narrowing of carotid arteries can be caused by other conditions such as:

• Marfan syndrome
• Fibromuscular dysplasia
• Other disorders

One type of intracranial vascular disease is moyamoya disease, the narrowing and ultimate closure of the internal carotid arteries, which has its own symptoms and recommended treatments.

At UPMC, extracranial and intracranial vascular disease may be treated medically or surgically, depending upon the severity of the disease.

Diagnosing Extracranial/Intracranial Vascular Disease

To diagnose extracranial vascular disease, your doctor will:

• Perform a full physical exam
• Ask about your medical and family history
• Perform several imaging tests

Testing to diagnose extracranial/Intracranial vascular disease

Your doctor may request imaging tests to examine how blood flows through your arteries. These diagnostic tests include:

• Arteriograms or angiography using x-rays
• Doppler test
• Magnetic resonance arteriography (MRA), a type of MRI scan
• CT angiography

Extracranial/Intracranial vascular disease symptoms

Symptoms vary depending on whether carotid or vertebral arteries are affected.

Carotid stenosis generally shows no symptoms until a complication occurs, such as a stroke or brain aneurysm occurs. However, some people experience warning symptoms of a stroke called a transient ischemic attack (TIA), which should be treated as a medical emergency, even if the symptoms go away.

Symptoms of transient ischemic attacks (TIA)

TIAs are often warning signs of an imminent stroke.

Symptoms of a TIA include:

• Weakness or numbness on one side of the body
• Difficulty speaking or understanding speech
• Sudden, severe headache
• Changes in vision
  

Vertebral artery disease symptoms

Symptoms of vertebral artery disease overlap with those of carotid artery disease and may include:

• Dizziness
• Vertigo
• Double vision
• Numbness around the mouth
• Tinnitus (ringing in the ears)
• Difficulty speaking
• Partial blindness

Extracranial/Intracranial Vascular Disease Treatments

In cooperation with neurologists, cardiologists, and radiologists, UPMC’s neurovascular doctors take a multidisciplinary approach to recommend treatments that are least disruptive to a person's brain, critical nerves, and offer the ability to return to normal functioning.

Treatment for extracranial and intracranial vascular disease depends upon:

• Location of the problem
• Severity of symptoms
• Person's age and medical history

Medication and lifestyle changes

Extracranial and intracranial vascular disease can sometimes be prevented, though not reversed, by several lifestyle changes. To address atherosclerosis, people may be advised to:

• Quit smoking
• Eat a low-fat and low-cholesterol diet
• Exercise
• Lose weight

This can help lower blood pressure and cholesterol, which in turn can slow the buildup of plaque in the arteries.

Along with lifestyle changes, medications are usually the most frequently recommended treatment. Common prescriptions include:

• Drugs that lower cholesterol and blood pressure
• Antiplatelet and anticoagulant drugs to prevent blood clots from forming

Carotid endarterectomy

When stenosis severely restricts an artery, or a person has already suffered a stroke, an open surgical approach may be indicated.

A carotid endarterectomy consists of a small linear incision in the neck followed by dissection and localization of the carotid artery.

The artery is opened and all the “calcified fat” (atheroma) is removed from the artery to:

• Reestablish blood flow 
• Reduce chance of strokes

Brain waves are monitored during surgery to make sure the brain is receiving enough blood throughout the procedure.

Angioplasty and stenting

Angioplasty involves inserting a thin tube called a catheter into an artery in the groin or leg and threading the catheter up to the affected artery

A small balloon at the end of the catheter is inflated at the blocked area, flattening the plaque buildup against the artery wall and widening the artery so blood flow is restored.

The procedure may be followed by stenting, which inserts a wire mesh tube called a stent into the artery to hold it open in the long term.