European Radiology

, Volume 17, Issue 8, pp 2149–2159 | Cite as

Color Doppler, power Doppler and B-flow ultrasound in the assessment of ICA stenosis: Comparison with 64-MD-CT angiography

  • D. -A. ClevertEmail author
  • T. Johnson
  • E. M. Jung
  • D. -A. Clevert
  • P. M. Flach
  • T. I. Strautz
  • G. Ritter
  • M. T. Gallegos
  • R. Kubale
  • C. Becker
  • M. Reiser


The purpose of this study is to investigate the diagnostic potential of color-coded Doppler sonography (CCDS), power-Doppler (PD) and B-flow ultrasound in assessing the degree of extracranial internal carotid artery (ICA) stenosis in comparison to CT-angiography (MD-CTA). Thirty-two consecutive patients referred for CTA with 41 ICA-stenoses were included in this prospective study. MD-CTA was performed using a 64 row scanner with a CTDIvol of 13.1 mGy/cm. In CTA, CCDS, PD and B-flow, the degree of stenosis was evaluated by the minimal intrastenotic diameter in comparison to the poststenotic diameter. Two radiologists performed a quantitative evaluation of the stenoses in consensus blinded to the results of ultrasound. These were correlated to CTA, CCDS, PD and B-flow, intraoperative findings and clinical follow-up. Grading of the stenoses in B-flow ultrasound outperformed the other techniques in terms of accuracy with a correlation coefficient to CTA of 0.88, while PD and CCDS measurements yield coefficients of 0.74 and 0.70. Bland-Altman analysis additionally shows a very little bias of the three US methods between 0.5 and 3.2 %. There is excellent correlation (coefficient 0.88, CI 0.77–0.93) with 64-MD-CTA and B-flow ultrasound in terms of accuracy for intrastenotic and poststenotic diameter. Duplex sonography is useful for screening purposes.


Internal carotid artery Multidetector CT angiography Color-coded Doppler sonography Power Doppler B-flow ultrasound 


  1. 1.
    North American Symptomatic Carotid Endarterectomy Trial Collaborators (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med 325:445–452CrossRefGoogle Scholar
  2. 2.
    European Carotid Surgery Trialists Collaborative Group (1995) Risk of stroke in the distribution of an asymptomatic carotid artery. Lancet 345:445–453Google Scholar
  3. 3.
    Hetzel A, Eckenweber B, Trummer B, Wernz M, Schumacher M, von Reutern G (1998) Colour-coded duplex sonography of preocclusive carotid stenoses. Eur J Ultrasound 8:183–191PubMedCrossRefGoogle Scholar
  4. 4.
    Mead GE, Lewis SC, Wardlaw JM (2000) Variability in Doppler ultrasound influences referral of patients for carotid surgery. Eur J Ultrasound 12:137–143PubMedCrossRefGoogle Scholar
  5. 5.
    Schminke U, Motsch L, Hilker l, Kessler C (2000) Three-dimensional ultrasound observation of carotid artery plaque ulceration. Stroke 31:1651–1655PubMedGoogle Scholar
  6. 6.
    Fürst G, Saleh A, Wenserski F, Malms J, Cohnen M, Aulich A, Neumann-Haefelin T, Schroeter M, Steinmetz H, Sitzer M (1999) Reliability and validity of noninvasive imaging of internal carotid artery pseudo-occlusion. Stroke 30:1444–1449PubMedGoogle Scholar
  7. 7.
    Polak JF (2001) Carotid ultrasound. Radiol Clin North Am 39:569–589PubMedCrossRefGoogle Scholar
  8. 8.
    Saloner D (1998) Determinants of image appearance in contrast-enhanced magnetic resonance angiography. A review. Invest Radiol 33:488–495PubMedCrossRefGoogle Scholar
  9. 9.
    Krinsky GA, Kaminer E, Lee VS, Rofsky NM, Weinreb JC (1998) The effects of apnea on timing examinations for optimization of gadolinium-enhanced MRA of the thoracic aorta and arch vessels. J Comput Assist Tomogr 22:677–681PubMedCrossRefGoogle Scholar
  10. 10.
    Executive Committee for the Asymptomatic Carotid Artherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. J Am Med Ass 273:1421–1428CrossRefGoogle Scholar
  11. 11.
    Moore WS, Barnett HJM, Beebe H (1995) Guidelines for carotid endarterectomy. Circulation 91:556–579Google Scholar
  12. 12.
    Polak JF, Shemnski I, O’Leary DH, Lefkowitz D, Price TR, Savage PJ, Brant WE, Reid C (1998) Hypoechoic plaque at US of the carotid artery: an independent risk factor for incedent stroke in adults aged 65 years or older. Cardiovascular Health Study. Radiology 209:288–289Google Scholar
  13. 13.
    Jung EM, Kubale R, Clevert D-A, Lutz R, Rupp N (2002) B-Flow and contrast-medium-enhanced power Doppler (Optison®)-preoperative diagnosis of high grade stenosis of the internal carotid artery. Fortschr Röntgenstr 174:62–69CrossRefGoogle Scholar
  14. 14.
    Eckstein HH, Winter R, Eichbaum M, Klemm K, Schumacher H, Dorfler A, Schulte K, Neuwith A, Grass W, Schnabel P, Allenberg JR (2001) Grading of internal carotid artery stenosis: validation of Doppler/duplex ultrasound criteria and angiography against endarterctomy specimen. Eur J vasc Endovasc Surg 21:301–310PubMedCrossRefGoogle Scholar
  15. 15.
    Bonig L, Weder B, Schott D, Keel A, Nguyen T, Zaunbauer W (2000) Prediction of angiographic carotid artery stenosis indexes by colour Doppler-assisted duplex imaging. A critical appraisal of the parameters used. Eur J Neurol 7:183–190PubMedCrossRefGoogle Scholar
  16. 16.
    Lee VS, Hertzberg BS, Workman MJ, Smith TP, Kliewer MA, DeLong DM, Carroll BA (2000) Variability of Doppler US measurements along the common carotid artery: effects on estimates of internal carotid arterial stenosis in patients with angiographically proved disease. Radiology 214:387–392PubMedGoogle Scholar
  17. 17.
    Remonda L, Senn P, Barth A, Arnold M, Lövblad K-O, Schroth G (2002) Contrast -Enhanced 3 D MR Angiography of carotid artery: comparison with conventional digital subtraction angiography. AJNR 13:213–219Google Scholar
  18. 18.
    Yuan C, Mitsumori LM, Beach KW, Maravilla KR (2001) Carotid atherosclerotic plaque: noninvasive MR characterization and identification of vulnerable lesions. Radiology 221:285–299PubMedCrossRefGoogle Scholar
  19. 19.
    Flohr T, Stierstorfer K, Bruder H, Simon J, Schaller S (2002) New technical developments in multislice CT. Fortschr Röntgenstr 174:839–845CrossRefGoogle Scholar
  20. 20.
    Lell M, Wildberger JE, Heuschmid M, Flohr T, Stierstorfer K, Fellner FA, Lang W, Bautz WA, Baum U (2002) CT-angiography of the carotid artery: First results with a novel 16-slice-spiral-CT scanner. Fortschr Röntgenstr 174:1165–1169CrossRefGoogle Scholar
  21. 21.
    Arning C (2001) Perivascular tissue vibrations: a criterium for high-grade stenoses of the internal carotid artery. Ultraschall in Med 22:62–65CrossRefGoogle Scholar
  22. 22.
    Spencer E, Sheafor D, Hertzberg B, Bowie JD, Nelson R, Caroll B, Kliewer M (2001) Nonstenotic internal carotid arteries: Effects of age and blood pressure at the time of scanning on Doppler US velocity measurements. Radiology 220:174–178PubMedGoogle Scholar
  23. 23.
    Horrow MM, Stassi J, Shurman A, Brody J, Kirby CL, Rosenberg HL (2000) The limitations of carotid sonography: interpretive and technology-related errors. AJR 174:189–194PubMedGoogle Scholar
  24. 24.
    Arbeille P, Bouin-Pineau MH, Herault S (1999) Accuracy of the main Doppler methods for evaluating the degree of carotid stenoses (continuous wave, pulsed wave and color Doppler). Ultrasound Med Biol 25:65–73PubMedCrossRefGoogle Scholar
  25. 25.
    Weskott H-P (2000) B-flow-a new method for detecting blood flow. Ultraschall in Med 21:59–65CrossRefGoogle Scholar
  26. 26.
    Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, Carroll BA, Eliasziw M, Gocke J, Hertzberg BS, Katanik S, Needleman L, Pellerito J, Pollak JF, Rholl KS, Wooster DL, Zierler E (2003) Carotis artery stenosis : grey-scale and Doppler US diagnosis-society of radiologists in ultrasound consensus conference. Radiology 229:340–346PubMedCrossRefGoogle Scholar
  27. 27.
    Droste DW, Jürgens R, Nabavi DG, Schuierer G, Weber S, Ringelstein E (1999) Echocontrast-enhanced ultrasound of extracranial internal carotid artery high-grade stenosis and occlusion. Stroke 30:2302–2306PubMedGoogle Scholar
  28. 28.
    Claudon M, Winninger D, Briancon S, Pesque P (2001) Power Doppler US: evaluation of the morphology of stenoses with a flow phantom. Radiology 218:109–117PubMedGoogle Scholar
  29. 29.
    Sabeti S, Schillinger M, Mlekusch W, Nachtmann T, Lang W, Ahmadi R, Minear E (2004) Contralateral high-grade carotid artery stenosis or occlusion is not associated with increased risk for poor neurologic outcome after elective carotid stent placement. Radiology 2:70–76CrossRefGoogle Scholar
  30. 30.
    Umemura A, Yamada K (2001) B-mode flow imaging of the carotid artery. Stroke 32:2055–2057PubMedGoogle Scholar
  31. 31.
    Connors JJ, Sacks D, Becker GJ, Barr JD (2003) Carotid artery angioplasty and stent placement: quality improvement guidelines to ensure stroke risk reduction. J Vasc Interv Radiol 14:1095–1097PubMedCrossRefGoogle Scholar
  32. 32.
    Müller M, Ciccotti R, Reiche W, Hagen T (2001) Comparison of color-flow Doppler scanning, power Doppler scanning, and frequency shift for assessment of carotid artery stenosis. J Vasc Surg 34:1090–1095PubMedCrossRefGoogle Scholar
  33. 33.
    Yurdakul M, Tola M, Cumhur T (2004) B-flow imaging of internal carotid artery stenosis: comparison with power Doppler imaging and digital subtraction angiography. J Clin ultrasound 32:243–248PubMedCrossRefGoogle Scholar
  34. 34.
    Schmidt P, Sliwka U, Simon SG, Noth J (1998) High-grade stenosis of the internal carotid artery assessed by color and power Doppler imaging. J Clin Ultrasound 26:85–89PubMedCrossRefGoogle Scholar
  35. 35.
    Steinke W, Ries S, Artemis N, Schwartz A, Hennerici M (1997) Power Doppler imaging of carotid artery stenosis. Comparison with color Doppler flow imaging and angiography. Stroke 28:1981–1987PubMedGoogle Scholar
  36. 36.
    Weskott H-P (1997) Amplitude Doppler US: Slow blood flow detection level tested with a flow phantom. Radiology 202:125–130PubMedGoogle Scholar
  37. 37.
    Bucek RA, Reiter M, Koppensteiner I, Ahmadi R, Minar E, Lammer J (2002) B-flow evaluation of carotid arterial stenosis: initial experience. Radiology 225:295–299PubMedCrossRefGoogle Scholar
  38. 38.
    Clevert D-A, Rupp N, Reiser M, Jung EM (2005) Improved diagnosis of vascular dissection by ultrasound B-flow: a comparison with color-coded Doppler and power Doppler sonography. Eur Radiol 15:342–347PubMedCrossRefGoogle Scholar
  39. 39.
    Arning C, Hammer E, Kortmann H, Hahm H, Müller-Jensen A, Lachenmayer L (2003) Quantifying stenosis of the internal carotid artery: which ultrasound criteria are relevant. Ultraschall Med 24:233–238PubMedCrossRefGoogle Scholar
  40. 40.
    Long A, Lepoutre A, Corbillon E, Branchereau A (2002) Critical review of non- or minimally invasive methods (duplex ultrasonography, MR- and CT-angiography) for evaluating stenosis of the proximal internal carotid artery. Eur J Vasc Endovasc Surg 24:43–52PubMedCrossRefGoogle Scholar
  41. 41.
    Birchall D, Zaman A, Hacker J, Davies G, Mendelow D (2006) Analysis of haemodynamic disturbance in the atherosclerotic carotid artery using computational fluid dynamics. Eur Radiol 10:1–10 JanGoogle Scholar
  42. 42.
    Flor N, Sardanelli F, Soldi S, Franceschelli G, Missiroli C, De Paoli F, Cornalba G (2006) Unknown internal carotid artery atherosclerotic stenoses detected with biphasic multidetector computed tomography for head and neck cancer. Eur Radiol 16(4):866–871. Epub 2005 Dec 1 AprPubMedCrossRefGoogle Scholar
  43. 43.
    Zhang Z, Berg M, Ikonen A, Kononen M, Kalviainen R, Manninen H, Vanninen R (2005) Carotid stenosis degree in CT angiography: assessment based on luminal area versus luminal diameter measurements. Eur Radiol 15 (11):2359–2365. Epub 2005 Jun 14 NovPubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • D. -A. Clevert
    • 1
    Email author
  • T. Johnson
    • 1
  • E. M. Jung
    • 2
  • D. -A. Clevert
    • 3
  • P. M. Flach
    • 1
  • T. I. Strautz
    • 1
  • G. Ritter
    • 4
  • M. T. Gallegos
    • 4
  • R. Kubale
    • 5
  • C. Becker
    • 1
  • M. Reiser
    • 1
  1. 1.Department of Clinical RadiologyUniversity of Munich-Grosshadern CampusMunichGermany
  2. 2.Department of Diagnostic and Interventional RadiologyKlinikum PassauPassauGermany
  3. 3.Department of Electrical Engineering and Computer ScienceTechnische UniversityBerlinGermany
  4. 4.Department of Mathematics and Computer ScienceUniversity of PassauPassauGermany
  5. 5.Department of Diagnostic RadiologyPirmasensGermany

Personalised recommendations