Skip to main content

Advertisement

SpringerLink
Log in

Magnetic resonance angiography, digital subtraction angiography and Doppler ultrasonography in detection of carotid artery stenosis: a comparison with findings from histological specimens

  • Experimental Research
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Patients' life expectancy, clinical symptomatology and the extent of carotid stenosis are the most important factors when deciding whether to perform carotid endarterectomy (CEA) in patients with carotid stenosis. Therefore, the accuracy of measuring carotid stenosis is of utmost importance.

Methods

Patients with internal carotid artery (ICA) stenosis were investigated by digital subtraction angiography (DSA), Doppler ultrasonography (DUS) and magnetic resonance angiography (MRA). Atherosclerotic plaque specimens were transversally cut into smaller segments and histologically processed. The slides were scanned and specimens showing maximal stenosis were determined; the minimal diameter and the diameter of the whole plaque were measured. DSA, DUS and MRA measurements were obtained in 103 patients. A comparison between preoperative and histological findings was performed. In addition, correlation coefficients were computed and tested.

Results

Results show a significant correlation for each of the diagnostic procedures. Mean differences in the whole cohort between preoperative measurements and the histological measurements are as follows: angiographic measurement of carotid stenosis underestimated histological measurement by 14.5% and MRA by 0.7%, but DUS overestimated by 6.6%. The results in severe stenosis (≥70%) are as follows: angiographic measurement underestimated the histological measurements by 2.3%, but MRA overestimated by 12.1% and DUS by 11.3%. The results in moderate stenosis (50–69%): angiographic measurement underestimated the histological measurements by 12.3%, but MRA overestimated by 0.2% and DUS by 7.2%. The results in mild stenosis (30–49%): angiographic measurement underestimated the histological measurements by 24.7% and MRA by 7.6%, but DUS overestimated by 3.3%.

Conclusions

Our study confirms that DSA underestimates moderate and mild ICA stenosis. DUS slightly overestimated moderate ICA stenosis and highly overestimated high-grade ICA stenosis. MRA proved to be accurate in detecting moderate ICA stenosis, but slightly underestimated mild stenosis and overestimated high-grade stenosis. The surgeon should be aware of these discrepancies when deciding whether to perform CEA in patients with ICA stenosis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Alexandrov AV, Bladin CF, Maggisano R, Norris JW (1993) Measuring carotid stenosis. Time for a reappraisal. Stroke 24:1292–1296

    CAS  PubMed  Google Scholar 

  2. Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 363:1491–1502

    Article  Google Scholar 

  3. Back MR, Rogers GA, Wilson JS, Johnson BL, Shames ML, Bandyk DF (2003) Magnetic resonance angiography minimizes need for arteriography after inadequate carotid duplex ultrasound scanning. J Vasc Surg 38(3):422–430

    Article  PubMed  Google Scholar 

  4. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, Thorpe KE, Meldrum HE, for the North American Symptomatic Carotid Endarterectomy Trial Collaborators (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 339:1415–1425

    Article  CAS  PubMed  Google Scholar 

  5. Beneš V, Netuka D, Mandys V, Vrabec M, Mohapl M, Beneš V Jr, Kramář F (2004) Comparison between degree of carotid stenosis observed at angiography and in histological examination. Acta Neurochir 146(7):671–677

    Article  Google Scholar 

  6. Borisch I, Horn M, Butz B, Zorger N, Draganski B, Hoelscher T, Bogdahn U, Link J (2003) Preoperative evaluation of carotid artery stenosis: comparison of contrast-enhanced MR angiography and duplex sonography with digital subtraction angiography. AJNR 24(6):1117–1122

    PubMed  Google Scholar 

  7. Elgersma OE, Wust AF, Buijs PC, van Der Graaf Y, Eikelboom BC, Mali WP (2000) Multidirectional depiction of internal carotid arterial stenosis: three-dimensional time-of-flight MR angiography versus rotational and conventional digital subtraction angiography. Radiology 216(2):511–516

    CAS  PubMed  Google Scholar 

  8. European Carotid Surgery Trialists' Collaborative Group (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351:1379–1387

    Article  Google Scholar 

  9. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid stenosis. JAMA 273:1421–1428

    Article  Google Scholar 

  10. Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, Carroll BA, Eliasziw M, Gocke J, Hertzberg BS, Katanick S, Needleman L, Pellerito J, Polak JF, Rholl KS, Wooster DL, Zierler RE (2003) Carotid artery stenosis: gray-scale and Doppler us diagnosis—society of radiologists in ultrasound consensus conference. Radiology 229(2):340–346

    Article  PubMed  Google Scholar 

  11. Landry A, Ainsworth C, Blake C, Spence JD, Fenster A (2007) Manual planimetric measurement of carotid plaque volume using three-dimensional ultrasound imaging. Med Phys 34(4):1496–1505

    Article  PubMed  Google Scholar 

  12. Ludwig M, Zielinski T, Schremmer D, Stumpe KO (2008) Reproducibility of 3-dimensional ultrasound readings of volume of carotid atherosclerotic plaque. Cardiovasc Ultrasound 26(6):42

    Article  Google Scholar 

  13. Nederkoorn PJ, Elgersma OE, Mali WP, Eikelboom BC, Kappelle LJ, van der Graaf Y (2002) Overestimation of carotid artery stenosis with magnetic resonance angiography. J Vasc Surg 36(4):806–813

    PubMed  Google Scholar 

  14. Netuka D, Beneš V, Mandys V, Hlasenská J, Burkert J, Beneš V Jr (2006) Accuracy of angiography and Doppler ultrasonography in the detection of carotid stenosis: a histopathological study of 123 cases. Acta Neurochir 148(5):511–520

    Article  CAS  Google Scholar 

  15. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ (2004) Carotid endarterectomy trialists collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 363:915–924

    Article  CAS  PubMed  Google Scholar 

  16. Rothwell PM, Warlow CP (2005) Timing of TIAs preceding stroke: time window for prevention is very short. Neurology 64(5):817–820

    PubMed  Google Scholar 

  17. Runck F, Steiner RP, Bautz WA, Lell MM (2008) MR imaging: influence of imaging technique and postprocessing on measurement of internal carotid artery stenosis. AJNR 29(9):1736–1742

    Article  CAS  PubMed  Google Scholar 

  18. Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T (2006) Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 37(2):577–617

    Article  PubMed  Google Scholar 

  19. Schenk EA, Bond MG, Aretz TH, Angelo JN, Choi HY, Rynalski T, Gustafson NF, Berson AS, Ricotta JJ, Goodison MW (1988) Multicenter validation study of real-time ultrasonography, arteriography, and pathology: pathologic evaluation of carotid endarterectomy specimens. Stroke 19:289–296

    CAS  PubMed  Google Scholar 

  20. Stejskal L, Kramář F, Ostrý S, Benes V, Mohapl M, Limberk B (2007) Experience of 500 cases of neurophysiological monitoring in carotid endarterectomy. Acta Neurochir 149(7):681–688

    Article  CAS  Google Scholar 

  21. U-King-Im JM, Graves MJ, Cross JJ, Higgins NJ, Wat J, Trivedi RA, Tang T, Howarth SP, Kirkpatrick PJ, Antoun NM, Gillard JH (2007) Internal carotid artery stenosis: accuracy of subjective visual impression for evaluation with digital subtraction angiography and contrast-enhanced MR angiography. Radiology 244(1):213–222

    Article  PubMed  Google Scholar 

  22. Wasserman BA, Wityk RJ, Trout HH 3rd, Virmani R (2005) Low-grade carotid stenosis: looking beyond the lumen with MRI. Stroke 36(11):2504–2513

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The study was supported by grant: IGA NR 9435-3.

We are indebted to Lenka Bernardová for technical support.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, First Faculty of Medicine, Central Military Hospital, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic

    David Netuka, Svatopluk Ostrý, Ondřej Bradáč & Vladimír Beneš

  2. Radiodiagnostic Unit, Central Military Hospital, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic

    Tomáš Belšán & František Charvát

  3. Department of Internal Medicine, First Faculty of Medicine, Central Military Hospital, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic

    David Ručka

  4. Institute of Pathology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Šrobárova 50, 100 34, Prague 10, Czech Republic

    Václav Mandys

Authors
  1. David Netuka
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Svatopluk Ostrý
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tomáš Belšán
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David Ručka
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Václav Mandys
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. František Charvát
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ondřej Bradáč
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Vladimír Beneš
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vladimír Beneš.

Additional information

This is an elegant publication from a most experienced carotid surgery team in Prague. The question asked is a compelling one, that is, what is the true accuracy of less invasive measures of carotid stenosis compared to the gold standard DSA and the actual histology. The method is sound and reproducible. The results are fascinating, in that DSA actually underestimates most carotid stenosis, MRA appears to correlate the best, and ultrasound, as known to every experienced carotid surgeon, can be inaccurate and is closely linked with technician expertise.

The results validate the use of alternate non catheter methods to assess carotid stenosis. It would be interesting to study CT angiography (our preferred method) with this same study design in the future. In addition, we point out that when there is any question of a postoperative neurological problem related to stenosis, occlusion, or false aneurysm (thankfully rare with our use of universal patch graft angioplasty), we now use CT angiography to image the repair, and have eliminated completely any need for postoperative DSA in our carotid practice.

Christopher Loftus

Philadelphia, USA

Rights and permissions

Reprints and permissions

About this article

Cite this article

Netuka, D., Ostrý, S., Belšán, T. et al. Magnetic resonance angiography, digital subtraction angiography and Doppler ultrasonography in detection of carotid artery stenosis: a comparison with findings from histological specimens. Acta Neurochir 152, 1215–1221 (2010). https://doi.org/10.1007/s00701-010-0645-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-010-0645-2

Keywords

Search

Navigation