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Utility of noninvasive studies in the evaluation of patients with carotid artery disease

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Abstract

Endarterectomy reduces the risk of stroke in selected patients with carotid artery stenosis, and the benefit is related to the degree of stenosis. Although the randomized trials demonstrating this benefit measured the degree of stenosis with conventional catheter angiography, many physicians are relying on noninvasive tests to select patients for surgery. Technologic advancement in this area is outpacing the availability of quality data supporting the clinical utility of the newer noninvasive tests.

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References and Recommended Reading

  1. Aronow WS, Ahn C, Kronzon I, Gutstein H: Association of left ventricular hypertrophy and chronic atrial fibrillation with the incidence of new thromboembolic stroke in 2,384 older persons. Am J Cardiol 1999, 84:468–469.

    Article  PubMed  CAS  Google Scholar 

  2. Hankey GJ, Warlow CP: Symptomatic carotid ischaemic events: safest and most cost effective way of selecting patients for angiography, before carotid endarterectomy. BMJ 1990, 300:1485–1491.

    PubMed  CAS  Google Scholar 

  3. Pessin MS, Duncan GW, Mohr JP, Poskanzer DC: Clinical and angiographic features of carotid transient ischemic attacks. N Engl J Med 1977, 296:358–362.

    Article  PubMed  CAS  Google Scholar 

  4. North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991, 325:445–453.

    Article  Google Scholar 

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

    Article  Google Scholar 

  6. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study: Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995, 273:1421–1428.

    Article  Google Scholar 

  7. Barnett HJ, Taylor DW, Eliasziw M, et al.: Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998, 339:1415–1425.

    Article  PubMed  CAS  Google Scholar 

  8. Dawson DL, Roseberry CA, Fujitani RM: Preoperative testing before carotid endarterectomy: a survey of vascular surgeons’ attitudes. Ann Vasc Surg 1997, 11:264–272.

    Article  PubMed  CAS  Google Scholar 

  9. Kuntz KM, Skillman JJ, Whittemore AD, Kent KC: Carotid endarterectomy in asymptomatic patients—is contrast angiography necessary? A morbidity analysis. J Vasc Surg 1995, 22:706–714.

    Article  PubMed  CAS  Google Scholar 

  10. Castaldo JE: Is carotid endarterectomy appropriate for asymptomatic stenosis? Yes. Arch Neurol 1999, 56:877–879. This paper debates the issue of operating on patients in whom the modest benefit is dependent on surgical and angiographic risk.

    Article  PubMed  CAS  Google Scholar 

  11. Chaturvedi S: Is carotid endarterectomy appropriate for asymptomatic stenosis? No. Archives of Neurology 1999, 56:879–881. This paper is the counterpoint to Castaldo [10], and debates the issue of operating on patients in whom the modest benefit dependent on surgical and angiographic risk.

    Article  PubMed  CAS  Google Scholar 

  12. Barnett HJ, Meldrum HE, Eliasziw M: The dilemma of surgical treatment for patients with asymptomatic carotid disease. Ann Intern Med 1995, 123:723–725.

    PubMed  CAS  Google Scholar 

  13. Benavente O, Moher D, Pham B: Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis. BMJ 1998, 317:1477–1480.

    PubMed  CAS  Google Scholar 

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

    PubMed  CAS  Google Scholar 

  15. Goldstein LB, McCrory DC, Landsman PB, et al.: Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms. Stroke 1994, 25:1116–1121.

    PubMed  CAS  Google Scholar 

  16. Mackey WC, O’Donnell TF Jr, Callow AD: Carotid endarterectomy in patients with intracranial vascular disease: short-term risk and long-term outcome. J Vasc Surg 1989, 10:432–438.

    Article  PubMed  CAS  Google Scholar 

  17. Kappelle LJ, Eliasziw M, Fox AJ, Sharpe BL, Barnett HJ: Importance of intracranial atherosclerotic disease in patients with symptomatic stenosis of the internal carotid artery. The North American Symptomatic Carotid Endarterectomy Trail. Stroke 1999, 30:282–286.

    PubMed  CAS  Google Scholar 

  18. Sundt TM, Sandok BA, Whisnant JP: Carotid endarterectomy. Complications and preoperative assessment of risk. Mayo Clin Proc 1975, 50:301–306.

    PubMed  CAS  Google Scholar 

  19. McCrory DC, Goldstein LB, Samsa GP, et al.: Predicting complications of carotid endarterectomy. Stroke 1993, 24:1285–1291.

    PubMed  CAS  Google Scholar 

  20. Dion JE, Gates PC, et al.: Clinical events following neuroangiography: a prospective study. Stroke 1987, 18:997–1004.

    PubMed  CAS  Google Scholar 

  21. Earnest FT, Forbes G, Sandok BA, et al.: Complications of cerebral angiography: prospective assessment of risk. Am J Roentgenol 1984, 142:247–253.

    Google Scholar 

  22. Hankey G, Warlow C, Sellar R: Cerebral angiographic risk in mild cerebrovascular disease. Stroke 1990, 21:209–222.

    PubMed  CAS  Google Scholar 

  23. Davies KN, Humphrey PR: Complications of cerebral angiography in patients with symptomatic carotid territory ischaemia screened by carotid ultrasound. J Neurol Neurosurg Psychiatry 1993, 56:967–972.

    Article  PubMed  CAS  Google Scholar 

  24. Waugh JR, Sacharias N: Arteriographic compliations in the DSA era. Radiology 1992, 182:243–246.

    PubMed  CAS  Google Scholar 

  25. Johnston DC, Chapman KM, Goldstein LB: Low rate of complications of cerebral angiography in routine clinical practice. Neurology 2001, in press. Demonstrates that the risk of important complications from the gold standard test is modest and lower than previously reported.

  26. Grzyska U, Freitag J, Zeumer H: Selective cerebral intraarterial DSA. Complication rate and control of risk factors. Neuroradiology 1990, 32:296–299.

    Article  PubMed  CAS  Google Scholar 

  27. Hankey GJ, Warlow CP, Molyneux AJ: Complications of cerebral angiography for patients with mild carotid territory ischaemia being considered for carotid endarterectomy. J Neurol Neurosurg Psychiatry 1990, 53:542–548.

    PubMed  CAS  Google Scholar 

  28. Heiserman JE, Dean BL, Hodak JA, et al.: Neurologic complications of cerebral angiography. Am J Neuroradiol 1994, 15:1401–1407.

    PubMed  CAS  Google Scholar 

  29. Lustgarten JH, Solomon RA, Quest DO, Khanjdi AG, Mohr JP: Carotid endarterectomy after noninvasive evaluation by duplex ultrasonography and magnetic resonance angiography. Neurosurgery 1994, 34:612–618.

    Article  PubMed  CAS  Google Scholar 

  30. Reid MC, Lachs MS, Feinstein AR: Use of methodological standards in diagnostic test research. Getting better but still not good. JAMA 1995, 274:645–651.

    Article  PubMed  CAS  Google Scholar 

  31. Rothwell PM, Pendlebury ST, Wardlaw J, Warlow CP: Critical appraisal of the design and reporting of studies of imaging and measurement of carotid stenosis. Stroke 2000, 31:1444–1450. Demonstrates that research in this area is frequently of inadequate methodology to be reliable when assessing the operating characteristics of noninvasive tests.

    PubMed  CAS  Google Scholar 

  32. Johnston DC, Goldstein LB, Matchar DB: Diagnostic testing of the carotid arteries. In Common Diagnostic Tests, edn 3. Edited by Garber A, Sox H: 2000 In Press;

  33. Bragoni M, Feldmann E, Wilterdink J: The evaluation of symptomatic carotid artery disease. A survey of specialty practices in Rhode Island. J Neuroimaging 1996, 6:184–188.

    PubMed  CAS  Google Scholar 

  34. Alexandrov AV, Vital D, Brodie DS, Hamilton P, Grotta JC: Grading carotid stenosis with ultrasound. An interlaboratory comparison. Stroke 1997, 28:1208–1210.

    PubMed  CAS  Google Scholar 

  35. Elgersma OE, van Leersum M, Buijs PC, et al.: Changes over time in optimal duplex threshold for the identification of patients eligible for carotid endarterectomy. Stroke 1998, 29:2352–2356.

    PubMed  CAS  Google Scholar 

  36. Moneta GL, Edwards JM, Chitwood RW, et al.: Correlation of North American Symptomatic Carotid Endarterectomy Trial (NASCET) angiographic definition of 70% to 99% internal carotid artery stenosis with duplex scanning. J Vasc Surg 1993, 17:152–157.

    Article  PubMed  CAS  Google Scholar 

  37. Howard GC, Baker WH: A multicenter validation study of doppler ultrasound versus angiography. J Stroke Cerebrovasc Dis 1991, 1:166–173.

    Article  Google Scholar 

  38. Howard G, Baker WH, Chambless LE, et al.: An approach for the use of Doppler ultrasound as a screening tool for hemodynamically significant stenosis (despite heterogeneity of Doppler performance). A multicenter experience. Asymptomatic Carotid Atherosclerosis Study Investigators. Stroke 1996, 27:1951–1957.

    PubMed  CAS  Google Scholar 

  39. Hamper UM, DeJong MR, Caskey CI, Sheth S: Power Doppler imaging: clinical experience and correlation with color Doppler US and other imaging modalities. Radiographics 1997, 17:499–513.

    PubMed  CAS  Google Scholar 

  40. Griewing B, Morgenstern C, Driesner F, et al.: Cerebrovascular disease assessed by color-flow and power Doppler ultrasonography. Comparison with digital subtraction angiography in internal carotid artery stenosis. Stroke 1996, 27:95–100.

    PubMed  CAS  Google Scholar 

  41. Greenes RA, Begg CB: Assessment of diagnostic technologies. Methodology for unbiased estimation from samples of selectively verified patients. Invest Radiol 1985, 20:751–756.

    Article  PubMed  CAS  Google Scholar 

  42. Golledge J, Ellis M, Sabharwal T, et al.: Selection of patients for carotid endarterectomy. J Vasc Surg 1999, 30:122–130.

    Article  PubMed  CAS  Google Scholar 

  43. Jackson MR, Chang AS, Robles HA, et al.: Determination of 60% or greater carotid stenosis: a prospective comparison of magnetic resonance angiography and duplex ultrasound with conventional angiography. Ann Vasc Surg 1998, 12:236–243.

    Article  PubMed  CAS  Google Scholar 

  44. Huston J, Nichols DA, Luetmer PH, et al.: MR angiographic and sonographic indications for endarterectomy. AJNR 1998, 19:309–315.

    PubMed  CAS  Google Scholar 

  45. Johnston DC, Goldstein LB: Clinical carotid endarterectomy decision making: Noninvasive vascular imaging versus angiography. Neurology 2001, 56:1009–1015. Highlights the importance of knowledge of local capabilities for noninvasive diagnostic testing of the carotids and suggests caution when relying on a single noninvasive test to select patients for endarterectomy.

    PubMed  CAS  Google Scholar 

  46. Norris JW, Rothwell PM: Noninvasive carotid imaging to select patients for endarterectomy: is it really safer than conventional angiography? Neurology 2001, 56:990–991. Corresponding editorial to Johnston and Goldstein [45].

    PubMed  CAS  Google Scholar 

  47. Edelman RR: Basic principles of magnetic resonance angiography. Cardiovasc Intervent Radiol 1992, 15:3–13.

    PubMed  CAS  Google Scholar 

  48. Brant-Zawadzki M, Gillan G: Extracranial carotid magnetic resonance angiography. Cardiovasc Intervent Radiol 1992, 15:82–90.

    PubMed  CAS  Google Scholar 

  49. Brant-Zawadzki M, Heiserman JE: The roles of MR angiography, CT angiography, and sonography in vascular imaging of the head and neck. AJNR 1997, 18:1820–1825.

    PubMed  CAS  Google Scholar 

  50. Rofsky NM, Adelman MA: Gadolinium-enhanced MR angiography of the carotid arteries: a small step, a giant leap? Radiology 1998, 209:31–34.

    PubMed  CAS  Google Scholar 

  51. Friese S, Krapf H, Fetter M, et al.: Ultrasonography and contrast-enhanced MRA in ICA-stenosis: is conventional angiography obsolete? J Neurol 2001, 248:506–513. An otherwise well-performed study that does not compare the tests with the gold standard, which is a requirement of sound methodology.

    Article  PubMed  CAS  Google Scholar 

  52. Patel MR, Kuntz KM, Klufas RA, et al.: Preoperative assessment of the carotid bifurcation. Can magnetic resonance angiography and duplex ultrasonography replace contrast arteriography? Stroke 1995, 26:1753–1758.

    PubMed  CAS  Google Scholar 

  53. Young GR, Humphrey PR, Shaw MD, et al.: Comparison of magnetic resonance angiography, duplex ultrasound, and digital subtraction angiography in assessment of extracranial internal carotid artery stenosis. J Neurol Neurosurg Psychiatry 1994, 57:1466–1478.

    PubMed  CAS  Google Scholar 

  54. Pan XM, Saloner D, Reilly LM, et al.: Assessment of carotid artery stenosis by ultrasonography, conventional angiography, and magnetic resonance angiography: correlation with ex vivo measurement of plaque stenosis. J Vasc Surg 1995, 21:82–88.

    Article  PubMed  CAS  Google Scholar 

  55. Liberopoulos K, Kaponis A, Kokkinis K, et al.: Comparative study of magnetic resonance angiography, digital subtraction angiography, duplex ultrasound examination with surgical and histological findings of atherosclerotic carotid bifurcation disease. Int Angiol 1996, 15:131–137.

    PubMed  CAS  Google Scholar 

  56. Anderson CM, Lee RE, Levin DL, de la Torre Alonso S, Saloner D: Measurement of internal carotid artery stenosis from source MR angiograms. Radiology 1994, 193:219–226.

    PubMed  CAS  Google Scholar 

  57. Kent KC, Kuntz KM, Patel MR, et al.: Perioperative imaging strategies for carotid endarterectomy. An analysis of morbidity and cost-effectiveness in symptomatic patients. JAMA 1995, 274:888–893.

    Article  PubMed  CAS  Google Scholar 

  58. Magarelli N, Scarabino T, Simeone AL, et al.: Carotid stenosis: a comparison between MR and spiral CT angiography. Neuroradiology 1998, 40:367–373.

    Article  PubMed  CAS  Google Scholar 

  59. Patel ST, Kuntz KM, Kent KC: Is routine duplex ultrasound surveillance after carotid endarterectomy cost-effective? Surgery 1998, 124:343–351.

    PubMed  CAS  Google Scholar 

  60. Remonda L, Heid O, Schroth G: Carotid artery stenosis, occlusion, and pseudo-occlusion: first-pass, gadoliniumenhanced, three-dimensional MR angiography—preliminary study. Radiology 1998, 209:95–102.

    PubMed  CAS  Google Scholar 

  61. Saloner D: Determinants of image appearance in contrastenhanced magnetic resonance angiography. A review. Invest Radiol 1998, 33:488–495.

    Article  PubMed  CAS  Google Scholar 

  62. Sardanelli F, Zandrino F, Parodi RC, De Caro G: MR angiography of internal carotid arteries: breath-hold Gd-enhanced 3D fast imaging with steady-state precession versus unenhanced 2D and 3D time-of-flight techniques. J Computer Assisted Tomography 1999, 22:208–215.

    Article  Google Scholar 

  63. Serfaty JM, Chirossel P, Chevallier JM, et al.: Accuracy of three-dimensional gadolinium-enhanced MR angiography in the assessment of extracranial carotid artery disease. Am J Roentgenol 2000, 175:455–463. A technical study and one of the few evaluating contrast magnetic resonance angiography in a larger cohort.

    CAS  Google Scholar 

  64. Johnston DC, Goldstein LB: Contrast-enhanced MRA of the carotid arteries: Utility in routine clinical practice. In 26th International Stroke Conference; 2001 January 2001; Ft. Lauderdale, Florida: Stroke 2001, 328-c.

  65. Sameshima T, Futami S, Morita Y, et al.: Clinical usefulness of and problems with three-dimensional CT angiography for the evaluation of arteriosclerotic stenosis of the carotid artery: comparison with conventional angiography, MRA, and ultrasound sonography. Surg Neurol 1999, 51:301–308. Highlights some of the weaknesses of the techniques.

    Article  PubMed  CAS  Google Scholar 

  66. Cinat M, Lane CT, Pham H, et al.: Helical CT angiography in the preoperative evaluation of carotid artery stenosis. J Vasc Surg 1998, 28:290–300.

    Article  PubMed  CAS  Google Scholar 

  67. Anderson GB, Ashforth R, Steinke DE, Ferdinandy R, Findlay JM: CT angiography for the detection and characterization of carotid artery bifurcation disease. Stroke 2000, 31:2168–2174. One of the few well-performed studies on computed tomographic angiography highlighting some of the strengths and weaknesses of the technique.

    PubMed  CAS  Google Scholar 

  68. Binaghi S, Maedera P, Uskéa A, et al.: Three-dimensional computed tomography angiography and magnetic resonance angiography of carotid bifurcation stenosis. Eur Neurol 2001, 46:25–34.

    Article  PubMed  CAS  Google Scholar 

  69. Randoux B, Marro B, Koskas F, et al.: Carotid artery stenosis: prospective comparison of CT, three-dimensional gadolinium-enhanced MR, and conventional angiography. Radiology 2001, 220:179–185.

    PubMed  CAS  Google Scholar 

  70. Biller J, Feinberg WM, Castaldo JE, et al.: Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1998, 29:554–562. Familiarity with these guidelines is important for clinicians making these decisions in this area.

    PubMed  CAS  Google Scholar 

  71. Whitty CJ, Sudlow CL, Warlow CP: Investigating individual subjects and screening populations for asymptomatic carotid stenosis can be harmful. J Neurol Neurosurg Psychiatry 1998, 64:619–623. An interesting perspective on screening for carotid stensosis in asymptomatic patients.

    PubMed  CAS  Google Scholar 

  72. Lee TT, Solomon NA, Heidenreich PA, Oehlert J, Garber AM: Cost-effectiveness of screening for carotid stenosis in asymptomatic persons. Ann Intern Med 1997, 126:337–346.

    PubMed  CAS  Google Scholar 

  73. Obuchowski NA, Modic MT, Magdinec M, Masaryk TJ: Assessment of the efficacy of noninvasive screening for patients with asymptomatic neck bruits. Stroke 1997, 28:1330–1339.

    PubMed  CAS  Google Scholar 

  74. Yin D, Carpenter JP: Cost-effectiveness of screening for asymptomatic carotid stenosis. J Vasc Surg 1998, 27:245–255.

    Article  PubMed  CAS  Google Scholar 

  75. Cronenwett JL, Birkmeyer JD, Nackman GB, et al.: Costeffectiveness of carotid endarterectomy in asymptomatic patients. J Vasc Surg 1997, 25:298–309.

    Article  PubMed  CAS  Google Scholar 

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  1. Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, 1081 Burrard Street, Room 2369 Providence Wing, V6Z 1Y6, Vancouver, British Columbia, Canada

    Dean C. C. Johnston MD, MHSc & Larry B. Goldstein MD

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  1. Dean C. C. Johnston MD, MHSc
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  2. Larry B. Goldstein MD
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Johnston, D.C.C., Goldstein, L.B. Utility of noninvasive studies in the evaluation of patients with carotid artery disease. Curr Neurol Neurosci Rep 2, 25–30 (2002). https://doi.org/10.1007/s11910-002-0049-7

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