“In a few minutes you can find out what your stroke risk is.” Dr. Bogdan Rotaru, MedLife: when is carotid Doppler useful and what does 50% stenosis mean
Stroke, one of the main causes of death and disability in Romania, according to national statisticscan be prevented. A non-invasive, quick and risk-free method visualizes the blood vessels that reach the brain and can assess the degree of stroke risk. It is the carotid Doppler ultrasound that can provide clues about the risk of a dangerous vascular event. “In a few minutes I can get an idea if there is a problem and how big the risk is,” he points out Dr. Bogdan Rotaruneurologist primary doctor, with competence in electromyography and ultrasound, within Favorite MedLife hyperclinics. Unlike the evaluation of the coronary arteries, which requires invasive investigations, in the case of the carotid screening is much more accessible and can be helpful in determining the next steps: from monitoring and treatment to referral to vascular surgery, in significant stenoses.
Dr. Rotaru frequently sees patients in the office who come for a cardiovascular or neurological “check-up”, sent by cardiologists and family doctors, but also people who go directly to the neurologist for headaches or after an episode that scared them: a numbness on one side of the face, a hand they couldn't move for several tens of minutes, a short speech disorder or blurred vision. Such symptoms, even if they disappear on their own in a short period of time, should not be overlooked. “It's good to have them investigated by a neurologist”, says Dr. Rotaru, because they can be signs of a transient ischemic attack (TIA), that is, a “mini-stroke” in which the circulation is temporarily interrupted, without leaving significant sequelae, but which can herald a major event.
What Carotid Doppler Sees: How Blood Vessels Age
In these situations, carotid Doppler becomes essential: it can show whether one of the carotid arteries – the main blood vessels that “feed” the brain – is narrowed by an atheromatous plaque and how unstable that plaque is. “The percentage of stenosis also matters, the appearance of the plaque also matters,” explains Dr. Rotaru. Some plaques evolve slowly, are more calcified and more stable. Others are “softer”, they develop quickly and have a greater risk of breaking. And if a fragment breaks off, it can travel through the bloodstream and block an artery in the brain, resulting in a stroke.
Doppler ultrasound uses ultrasound to evaluate the blood vessels – arteries and veins. In neurology, the main interest is the arteries that bring blood to the brain: the carotid and the vertebral arteries, “two on each side,” explains Dr. Rotaru.
With age, but also depending on genetic inheritance and lifestyle, the walls of these arteries can thicken and deposits called atheromatous plaques can appear. In the general perception, they are associated with an increased level of cholesterol, but the doctor qualifies: “Atheroma plaques have a more complex structure. They also contain cholesterol, but cholesterol is not the main problem, there are others: high blood pressure, smoking, diabetes, sedentary lifestyle and genetic factors.”
What does “stenosis 50%” mean“
On the ultrasound report, the patient often sees a percentage: 10%, 30%, 55%, 70%. “If the plaque is small, the percentage becomes insignificant, it's 10%-20%. But from 50% up it starts to be relevant”, says the neurologist.
A stenosis of 50%-60% can mean, for a good part of patients, periodic monitoring and correct treatment for risk factors – blood pressure, cholesterol, diabetes, smoking. For others, especially when the plaque looks unstable, vascular surgery may be necessary.
Doctor Bogdan Rotaru gives the example of a patient who had a transient numbness for two hours, and the evaluation showed a plate with stenosis of approximately 55%, but with a suspicious, “soft” appearance. In such cases, revascularization is sometimes discussed—that is, an intervention to reduce the risk of that plaque sending more emboli (clots) to the brain.
What's next after Doppler: treatment, monitoring, sometimes surgery
Echodoppler can be recommended as a screening for people at risk – smokers, hypertensives, diabetics, those with very high cholesterol or with a family history of heart attack or stroke at a young age. “It is not a routine investigation for everyone”, emphasizes Dr. Rotaru, but it becomes useful after 40 years, especially when the risk factors accumulate.
If the doctor identifies atheroma plaques, the next steps are not the same for all patients. For small stenoses, the recommendation is usually to change the modifiable factors and treat: blood pressure control, cholesterol lowering, smoking cessation, more exercise, weight loss when appropriate. For large stenoses or high-risk plaques, the patient can be referred to vascular surgery, where there are two major options: classic and endovascular intervention.
“The classic variant means that the artery is opened at the neck level, the atheroma plaque is removed and a synthetic patch is placed. The endovascular variant is an intervention through a catheter, with the installation of a stent inside the vessel”, explains the doctor. Which option is better? “Both have advantages and disadvantages, one is not necessarily better.” The choice depends on the patient profile and perioperative risks: a patient with a high anesthetic risk may better tolerate the endovascular procedure, but this comes with the need for more intensive antithrombotic treatment after the intervention.
What can be changed by changing the lifestyle
One of the most common questions from patients is whether lifestyle changes can reduce atheroma plaque. “Unfortunately, the stenosis is not decreasing,” says Dr. Rotaru. But the good news is that, in conscientious patients, it can stabilize. “People who were conscientious to stop smoking, to follow their correct treatment, stabilized the plaque for many years. I had patients who, year after year, came for check-ups and in whom we found a stabilization of the stenosis without having any cerebral ischemic event.”
Periodic control is an essential part of prevention, the doctor insists, because stenosis can progress “in silence”. A patient who postpones check-ups may find out, after a few years, that he has moved into a much higher risk category. “A lady who I had told to come annually came after five years and the stenosis had increased significantly”, says Dr. Rotaru. “She was already in another risk category and she should have been much more careful.”
Manifestations that should send emergency patients to the hospital are: numbness on one side of the body, slurred speech, weakness in a limb or persistent vision problems. “We don't waste time if we have such symptoms, we call an ambulance!” In ischemic stroke today there are methods to dissolve or extract the clot in emergency centers – treatments that depend critically on time.
Headaches are not specific in either stroke or brain tumors
One of the biggest fears Dr. Bogdan Rotaru encounters in his office is the connection between headaches and a possible stroke or a possible brain tumor. “Many strokes do not cause headaches,” says Dr. Rotaru. The pain appears rather when the intracranial pressure increases, in hemorrhages or cerebral edema – already serious situations. More often, the symptoms are “dumb”: slowed speech, half of the face “fallen”, a hand we can no longer move normally, a “black” area in the field of vision.
Even in the case of brain tumors, headaches are not common. “The probability that the manifestation of a tumor is the headache is extremely small,” reassures Dr. Rotaru. “In 98%-99% of cases, a headache is not caused by a stroke, an aneurysm, or a tumor. It has much more common causes, fortunately.”
However, there are situations in which the headache must be evaluated: when it is unlike anything the person has had before, when it is very severe or when it is associated with neurological signs – persistent numbness, speech disorders, weakness, changes in vision.
Genetic testing can guide prevention in neurology
People with a family history of Alzheimer's dementia, stroke or aneurysm at a young age, as well as those with known risk factors, have the opportunity to assess their risk through the genetic tests currently available. Whether it is mutations at the level of known genes with a strong impact, or the polygenic risk score (mutations at the level of several genes, with a small impact, but which, cumulatively, increase the risk of a condition), genetic testing is a tool that provides a picture of the individual status and can be the starting point for a personalized prevention plan. “Genetic tests do not say that you will definitely get the disease or that you will not get it at all, but they place us somewhere compared to the average risk in the general population,” explains Dr. Rotaru.
In practice, says the neurologist, the challenge remains the same: to convince people to change their habits. Communication is essential: “You try to realize the level and personality of each person and communicate your message as close as possible to his level, so that the doctor and the patient form a team.”
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