The asymptomatic carotid bruit--operate or not?

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Abstract
The question of how to manage the patient with an asymptomatic bruit is one which is still unsolved and the subject of considerable controversy. Asymptomatic bruits have been described in 3 different and perhaps somewhat unrelated contexts. First, there is the bruit heard over the carotid artery in a patient whose symptoms relate to the opposite carotid artery and in whom arteriography reveals bilateral disease. Second, there is the patient without cerebral ischemic symptoms who is about to undergo major thoracic or abdominal surgery for another reason and in whom unilateral or bilateral carotid bruit is detected on examination. Third, there is a group of patients, perhaps the largest of all, in whom bruits are detected on routine physical examination but who are otherwise in good health except possibly for a mild degree of hypertension. The indications as well as the contraindications for arterial reconstructive operations in patients with transient ischemic attacks, progressing stroke, or completed stroke have been reasonably well-defined. The risk-benefit ratio of prophylactic surgery for patients with asymptomatic carotid artery stenosis is unknown. Furthermore, the natural history of asymptomatic carotid artery stenosis is also unknown. A major controversy still exists with regard to indications even for angiography in individuals with asymptomatic carotid bruit. Some surgeons take the position that while it is not possible to make the asymptomatic patient feel better, it is certainly feasible to keep him or her from getting worse by preventing stroke. If one were sure that this statement was in all respects valid, then there would be no controversy, but none of the operated series thus far reported has been from controlled studies.

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