Carotid Stenosis Evaluation Note

Date/Time: [Date and time of evaluation]

Service: [Vascular Surgery / Neurosurgery / Interventional Cardiology / Neurology]

Encounter Type: [Clinic visit / Inpatient consult / Pre-op evaluation]

Consult Request Time: [Consult request time] (Include only if inpatient consult)

Referring Clinician: [Referring clinician name and service]

Reason for Consult: [Reason for evaluation]

Data Sources: [Patient interview / Family or caregiver / Chart review / Outside records / Outside imaging] (List all sources used)

Limitations: [Limitations in obtaining history and how information was obtained] (Include only if history limited by aphasia, dementia, intubation, sedation, or telemedicine)

Chief Concern

[Single-sentence clinical question combining presentation with evaluation goal] (Examples: "Evaluate carotid stenosis found on duplex; determine need for intervention" or "Post-TIA with ipsilateral carotid stenosis—assess CEA vs CAS vs medical therapy")

Carotid-Specific History

Symptom Status: [Symptomatic / Asymptomatic / Unknown]

• (If symptomatic) Index cerebrovascular event: [TIA / Non-disabling ischemic stroke / Amaurosis fugax] | Date/Time: [Date and time] | Duration: [Duration] | Deficits: [Motor, sensory, speech, or vision deficits] | Current status: [Resolved / Persistent] | Laterality vs stenosis: [Ipsilateral / Contralateral / Uncertain] | Symptomatic window: [Within 6 months / Beyond 6 months]
• (If history not obtainable from patient) History source: [Source and method used to determine symptom status]

Prior cerebrovascular events: [Prior TIA or stroke with dates, deficits, and residuals; state "None" if none]

Prior carotid interventions: [CEA / CAS / TCAR with side, date, complications, and restenosis status; state "None" if none]

Other vascular disease: [CAD / PAD / AAA with pertinent details; state "None" if none]

Risk factors: Hypertension [Yes / No]; Diabetes [Type and control status]; Hyperlipidemia [Yes / No]; Tobacco [Current / Former / Never, pack-years]; CKD [Stage and eGFR]; Atrial fibrillation [Yes / No]; Prior neck radiation or surgery [Yes / No]; Contrast allergy [Yes / No, reaction type if yes]

Functional status and life expectancy: [Functional baseline, ADLs, frailty assessment, life expectancy considerations] (Include when relevant to intervention decision)

Current Medical Therapy

• Antiplatelet: [Agent, dose] (State "None" with reason if not on therapy)
• Anticoagulation: [Agent, dose, indication] (State "None" if not applicable)
• Statin therapy: [Agent, dose, intensity: High / Moderate / Low] (State "None" with reason if not on therapy)
• Antihypertensives: [List with doses]
• Diabetes medications: [List with doses]
• Recent labs: LDL [Value and date]; A1c [Value and date] (Include if available)

Therapy Optimization Assessment:

• High-intensity statin: [On / Not on / Contraindicated / Intolerant] (Include reason if not on therapy)
• Antiplatelet: [On / Not on / Contraindicated / Intolerant] (Include reason if not on therapy)
• Tobacco cessation: [Current / Former / Never] (If current, document counseling provided)
• Blood pressure control: [At goal / Above goal / Labile]
• Diabetes control: [At goal / Above goal / Not applicable]

Physical Examination

• Vitals: BP [Value]; HR [Value]; O2 sat [Value]
• Neurologic exam: Mental status [Findings]; Speech [Findings]; Cranial nerves [Findings]; Motor [Strength and drift]; Sensory [Findings]; Coordination [Findings]; Gait [Findings] (Explicitly document any baseline deficits)
• NIHSS: [Score] performed by [Name and role] (Include if performed for symptomatic patients; otherwise state "Not performed")
• Vascular exam: Carotid bruits [Present / Absent]; Peripheral pulses [Radial, femoral, DP, PT with quality]
• Cardiac: Rhythm [Regular / Irregular]; Murmurs [Present / Absent]
• Exam limitations: [Describe limitations] (Include only if exam limited by telemedicine or patient factors)

Diagnostic Imaging

(Repeat block for each study; state whether images personally reviewed or report only)

• Study: [Duplex ultrasound / CTA neck / MRA neck / Catheter angiography] | Date: [Date] | Facility: [Internal / External] | Review: [Images personally reviewed / Report only]

  • (If Duplex) PSV [Value]; EDV [Value]; ICA/CCA ratio [Value]; Stenosis category [<50% / 50–69% / 70–99% / Near-occlusion / Occluded]; Plaque characteristics [Calcified / Ulcerated / Echolucent / Heterogeneous]; Study limitations [Describe if present]
  • (If CTA/MRA) Stenosis severity [Percent and side]; Aortic arch type [I / II / III / Bovine]; Great vessel anatomy [Describe tortuosity and variants]; Intracranial findings [Stenosis, occlusion, or other]; Access considerations [Describe if relevant]
  • (If Angiography) Lesion morphology [Describe]; Percent stenosis [Value and method]; Collateral flow [Describe]; Access route [Describe]
  • Key impression: [Concise summary of actionable findings]

Imaging synthesis: [Reconciliation of discordant findings with rationale for preferred measurement] (Include only if multiple studies show different results)

Pertinent labs: Creatinine/eGFR [Values and date]; Lipids [Values and date]; Cardiac testing [EKG, echo, or stress results if obtained]

Assessment

1. Primary problem: [Left / Right / Bilateral] carotid artery stenosis — [Symptomatic / Asymptomatic] (If symptomatic: [Event type] on [Date]) with [Stenosis percent or category] based on [Modality and date]. Competing etiologies considered: [Cardioembolic / Intracranial atherosclerosis / Small vessel disease / None identified].
2. Secondary problems affecting management: [Bleeding risk considerations / Cardiac disease / CKD / Hostile neck / Contrast allergy / Anatomic constraints / Risk factor optimization needs] (List those materially affecting decisions)

Plan

Indication Statement: Patient [meets / does not meet] criteria for carotid revascularization because [patient-specific rationale linking symptom status, stenosis severity, timing, anatomy, and comorbid risks]. (Do not infer candidacy; state explicitly)

Procedure Selection Rationale

• [CEA / CAS / TCAR / Medical therapy] is favored because [anatomy, age, comorbidities, prior procedures, neck factors, access considerations, patient preference].
• Not a candidate for [CEA / CAS / TCAR] due to [explicit limiting factor]. (Include only if applicable)

Shared Decision-Making

(Required when CAS or TCAR is considered; otherwise state "Not applicable — CEA or medical therapy only")

• Options discussed: [CEA / CAS / TCAR / Optimal medical therapy]
• Patient-specific risks and benefits discussed: [Stroke / Death / MI / Cranial nerve injury / Bleeding / Restenosis / Contrast nephropathy / Access complications]
• Patient values and preferences: [Patient-specific content]
• Joint decision: [Proceed with specified procedure / Defer intervention / Medical therapy preferred] with rationale

Procedural Planning

(Include if intervention planned)

• Timing: [Urgent within 48 hours / Early within 2 weeks / Elective] (For symptomatic patients, document rationale for timing)
• Antiplatelet plan: [Agents, loading strategy, peri- and post-procedure duration]
• Statin optimization: [Adjustments needed]
• Anticoagulation management: [Hold / Bridge / Continue with specifics]
• Pre-operative testing: [Labs, EKG, echo, stress testing, additional imaging as needed]
• Renal protection: [Hydration, contrast minimization strategy] (Include if CKD or contrast allergy)
• Disposition: [Admit / Outpatient scheduling] with coordination plan

Surveillance Plan

• (If no intervention) Duplex surveillance: [Interval, e.g., every 6–12 months]; Symptom-triggered return precautions: [New neurologic symptoms, visual changes]
• (If post-intervention) Baseline post-procedure duplex: [Timing]; Ongoing surveillance: [Schedule]; Re-evaluation thresholds: [Velocity or stenosis changes that would prompt action]

Follow-Up and Coordination

• Follow-up: [Timeframe] with [Clinic or service]
• Return precautions: New focal neurologic deficits, monocular vision loss, sudden severe headache, chest pain, or dyspnea

CMS Documentation for CAS/TCAR

(Include only if CAS or TCAR planned)

• Neurologic assessment: [Documented above / Not yet completed — plan to obtain]
• Imaging sequence: [Duplex and cross-sectional imaging documented / Pending: specify study needed]
• Shared decision-making: [Documented above]