Directed Neurological Examination

The carotid artery should be palpated gently for the presence and the intensity of the impulse. The artery should be auscultated for a bruit. However, a bruit is not always indicative of carotid artery stenosis. In addition, the absence of a bruit does not rule out carotid stenosis. A vertebral artery bruit can be auscultated over the posterior upper cervical region. The temporal region, the orbits, and the mastoid region are good locations to auscultate cranial bruits, as in the case of arteriovenous malformations or aneurysms. Attention should be paid to the scalp, looking for prominence, or tenderness of the superficial temporal artery that may be seen with temporal arteritis. Bounding pulsation of the superficial temporal or the supraorbital arteries may be seen with internal carotid occlusive disease owing to increased collateral flow through the external carotid artery. Necrosis of the scalp can be seen with temporal arteritis.

Attention should be paid to the ocular globe, looking for scleral injection, dilated ocular and orbital vessels, pulsating exophthalmos, chemosis, or ophthalmoplegia that can be seen with carotid-cavernous fistulas. A dilated funduscopic examination can demonstrate the ocular manifestations of carotid vascular disease, including hypoperfusion or venous stasis retinopathy, anterior ischemic optic neuropathy, retinal infarctions, and rubeosis iridis. There may be evidence of microemboli such as bright orange-yellow, refractile, or Hollenhorst plaques; white platelet-fibrin intra-arterial plugs; or gray-white nonrefractile calcific emboli.

A careful auscultation of the heart should focus on the detection of structural lesions or rhythm disturbances. The aorta and peripheral pulses should be palpated and auscultated to provide clues to underlying peripheral atherosclerosis.

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