Angiographic and pathologic correlates in carotid artery disease

Eighty-four consecutive intact atheromata from the carotid bifurcation were examined macroscopically and by standard microscopic techniques. Preoperative angiograms of these cases were reviewed by a single radiologist with special attention to detecting the presence of ulceration. Pathologic and angiographic findings were compared and correlated with the patient's clinical presentation. Macroscopic findings of ulceration were present in 43 cases (51%). Thirty-four specimens contained intramural hemorrhage and 27 showed evidence of mural thrombus. Mural thrombus was significantly associated with evidence of ulceration (p less than 0.01). Intramural hemorrhage was commonly associated with ulceration (25/34) but was also seen in nonulcerated plaques (p greater than 0.05). Angiographic diagnosis of ulceration was made in 54 cases (64%). While angiography identified 78% of macroscopic ulcers (34/43; p = 0.05), seven typical ulcerations were missed angiographically and there were 18 angiographic false positive results (18/54:33%). Macroscopic ulcerations were most common in patients with symptoms of hemispheric ischemia (p less than 0.1). The angiographic diagnosis of ulceration did not correlate with the patient's clinical presentation (i.e., hemispheric ischemia, nonhemispheric ischemia, or asymptomatic stenosis). These results support the thesis that macroscopic ulceration is an important cause of hemispheric ischemia. Angiography does not reliably predict the presence of macroscopic ulceration and this limitation should be kept in mind when patients with hemispheric symptoms are evaluated. Such patients should not be denied consideration for endarterectomy simply because the angiogram fails to demonstrate ulceration.