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there is no doubt that carotid bruits are important in the diagnosis of carotid disease. 56 57 a carotid bruit with hemodynamic significance is associated with increased stroke risk and 58 59 imparts a significant risk for cerebrovascular occlusion. in a prospective study of risk factors in patients with neurologic events, the relative risk for ipsilateral stroke was 7.1 and for contralateral stroke was 0.4 for patients with carotid bruits in comparison with those without bruits 60 (class iii). a bruit that is intermittently heard during periods of rest is the best test for hemodynamic significance. a carotid bruit heard only with exertion, for example, may represent intermittent stenosis because of turbulence or high blood flow, but it is less likely to be truly hemodynamically significant. the optimal test for hemodynamically significant bruits is performed during phonation in the valsalva maneuver, which increases blood pressure in the internal carotid artery causing flow through the most narrow lesion in the carotid artery, thus leading to an audible bruit. the valsalva maneuver also brings stenosis and turbulence to the attention of the clinician and raises the possibility of poststenotic dilatation. bruits that remain audible after application of the valsalva maneuver suggest that the stenosis is flow limiting; an audible bruit persists if the stenosis is severe. 61 in a prospective study of carotid bruits, the carotid bruit was present in 60% of patients with carotid stenosis of at least 70% 63 (class iia). however, carotid bruits can be absent in up to 10% of patients with carotid stenosis of 80% or more 64 65 66 (class iib).

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