The role of carotid noninvasive tests in stroke prevention

The evaluation of carotid disease is now in turmoil. Part of the problem stems from uncertainty over old issues, such as the role of carotid endarterectomy in the treatment of asymptomatic patients with high-grade carotid stenosis. Part of the problem results from the recent increase in sensitivity of certain carotid noninvasive tests and uncertainty about their role in the rational evaluation of a patient with suspected carotid disease. Finally, at this point, we do not know the true natural history of severe carotid stenosis, plaque ulceration, or wall hemorrhage, although retrospective studies and histologic data imply that these factors increase an individual's risk of stroke. Physicians caring for patients with carotid atherosclerotic disease may find themselves in the unusual situation of having more information from a panel of noninvasive tests than they can analyze. The fault does not lie with noninvasive testing itself, of course, but with our previous dependence on arteriography for anatomic information and the difficulties inherent in obtaining natural history data about any disease process for which there is surgical therapy.