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A Methodological Approach to Non-invasive Assessments of Vascular Function and Morphology
Published on: February 7, 2015
Is Doppler ultrasound sufficient as the sole investigation before carotid endarterectomy?
C Lovelock1, P Mitchell, J Brown
1Department of Neurology, Royal Melbourne Hospital and University of Melbourne, Royal Parade, Melbourne, Australia.
Insights
Doppler ultrasound (DU) alone misses significant intracranial disease in nearly a third of patients undergoing carotid endarterectomy (CE) assessment. Identifying this high-risk group enables more aggressive stroke prevention strategies.
Area of Science:
- Vascular Neurology
- Diagnostic Imaging
- Cerebrovascular Disease
Background:
- Carotid endarterectomy (CE) candidates often undergo screening with Doppler ultrasound (DU) of extracranial carotid arteries.
- This approach may miss critical intracranial disease, increasing stroke and mortality risk.
- Angiography is frequently recommended post-DU for comprehensive assessment.
Purpose of the Study:
- To determine the proportion of CE candidates where intracranial disease detection could alter management.
- To evaluate the diagnostic yield of angiography following DU screening in this population.
Main Methods:
- Review of carotid angiograms from 111 CE candidates previously screened with DU.
- Neuroradiologists identified intracranial stenoses (>50%), aneurysms, and non-atherosclerotic lesions.
- Demographic and epidemiological data were collected.
Main Results:
- Nearly a third (29%) of patients had significant intracranial stenoses.
- Over half of intracranial lesions were tandem, occurring distal to extracranial stenoses.
- Aneurysms were identified in 4.5% of cases.
Conclusions:
- Doppler ultrasound alone is insufficient for detecting significant intracranial disease in a substantial portion of CE candidates.
- Failure to identify intracranial pathology places patients at high risk for stroke.
- Detecting intracranial disease facilitates tailored, aggressive stroke prevention therapies.
Background And Aims:
Doppler ultrasound (DU) of the extracranial carotid arteries has been advocated as the sole imaging modality in carotid endarterectomy (CE) candidates. However this approach fails to identify patients with potentially significant intracranial disease, at high risk of stroke and death. Therefore, many stroke clinicians recommend angiography after screening DU. We aimed to identify the proportion of cases referred for CE in whom the identification of intracranial disease could have altered management.
Methods:
Two neuroradiologists, blinded to the clinical history, reviewed the films of 111 CE candidates, predominantly of Caucasian background, who had undergone carotid angiography after screening DU. Intracranial stenoses >50% luminal diameter, incidental aneurysms and non-atherosclerotic lesions were documented. Demographic and epidemiological data were collected.
Results:
Of the 111 patients, 87 had >50% extracranial stenoses although two thirds were asymptomatic. Intracranial stenotic lesions were recorded in 29% of patients. Over half of these were tandem lesions, distal to an extracranial stenosis. Aneurysms were found in 4.5% of patients.
Conclusions:
DU alone would have failed to detect significant intracranial disease in nearly a third of cases. These patients are at high risk of stroke. The identification of this group allows more aggressive stroke prevention therapy.
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