Clinical evaluation of stenosis of the carotid bifurcation with magnetic resonance angiographic techniques

Magnetic Resonance Angiography and Duplex Scanning Concordance in Detecting Severe Carotid Stenosis

In this meta-analysis, the authors examine published studies on the consistency (homogeneity) of study outcomes of magnetic resonance angiography (MRA), conventional angiography (XRA), and duplex ultrasound (DU) scanning in assessment of the degree of carotid artery disease.

The sensitivity, specificity, and accuracy of the MRA as a noninvasive diagnostic test are exceptional. Given an adequate two-dimensional time-of-flight (2D-TOF) study, it provides a robust test for the evaluation of carotid stenosis. The authors conclude from this meta-analysis that MRA is at least as accurate as DU in a selected group of patients. The question of superiority for all patients with suspected carotid artery disease is not, however, answered by this meta-analysis. Another question not answered is the question of DU/MRA-XRA concordance/discordance. If DU and MRA were concordant across all, rather than a selected group of patients, would the clinical decision tree be in favor of elimination of XRA? The cost for a DU scan is approximately one third of the cost of an MRA and, from an economic point of view, one could not argue the use of MRA over DU. However, as MRA technology and accuracy improve and when the cost of MRA approaches that of DU, MRA may replace DU as a screening method.

Clearly, a consecutive series of all patients suspected of having carotid artery disease needs to be evaluated by use of the best available diagnostic technologies. A comprehensive protocol would include an evaluation of the sources of difficulties in conducting these tests.

Use of magnetic resonance angiography to select candidates with recently symptomatic carotid stenosis for surgery: systematic review

OBJECTIVE

To determine if sufficient evidence exists to support the use of magnetic resonance angiography as a means of selecting patients with recently symptomatic high grade carotid stenosis for surgery.

DESIGN

Systematic review of published research on the diagnostic performance of magnetic resonance angiography, 1990-9.

MAIN OUTCOME MEASURES

Performance characteristics of diagnostic test.

RESULTS

126 potentially relevant articles were identified, but many articles failed to examine the performance of magnetic resonance angiography as a diagnostic test at the surgical decision thresholds used in major clinical trials on endarterectomy. 26 articles were included in a meta-analysis that showed a maximal joint sensitivity and specificity of 99% (95% confidence interval 98% to 100%) for identifying 70-99% stenosis and 90% (81% to 99%) for identifying 50-99% stenosis. Only four articles evaluated contrast enhanced magnetic resonance angiography.

CONCLUSIONS

Magnetic resonance angiography is accurate for selecting patients for carotid endarterectomy at the surgical decision thresholds established in the major endarterectomy trials, but the evidence is not very robust because of the heterogeneity of the studies included. Research is needed to determine the diagnostic performance of the most recent developments in magnetic resonance angiography, including contrast enhanced techniques, as well as to assess the impact of magnetic resonance angiography on surgical decision making and outcomes.

Efficacy of MR Angiography in the Detection and Characterization of Occlusive Disease in the Vertebrobasilar System

PURPOSE

The purpose of this work was to determine the efficacy of MR angiography (MRA) in the detection and characterization of occlusive disease in the vertebrobasilar system.

METHOD

We retrospectively reviewed the posterior circulation registry of our institution to select 42 consecutive patients with posterior circulation ischemic symptoms who underwent both MRA and angiography. The extracranial vertebral arteries (ECVAs) were examined by two-dimensional time-of-flight MRA above the C6 level, and the intracranial vertebral arteries (ICVAs) and basilar arteries (BAs) were examined by three-dimensional time-of-flight MRA. Sixty-two ECVAs, 63 ICVAs, and 39 BAs were examined by the readers.

RESULTS

Occlusive disease was seen on angiography in 22 of the 42 patients. The sensitivity and specificity values for detection of lesions in 12 ECVA, 19 ICVA, and 12 BA abnormalities were as follows: ECVA, 92 and 96% for Reader A and 100 and 90% for Reader B; ICVA, 84 and 93% for Reader A and 74 and 82% for Reader B; and BA, 100 and 88% for Reader A and 100 and 78% for Reader B. For ICVA, the sensitivity of MRA was less than that of angiography because of lesions missed by the readers at the junctional area of the extra-and intracranial MRA. MRA accurately characterized 9 of the 12 (75%) ECVA, 10 of the 19 (43%) ICVA, and 11 of the 12 (92%) BA lesions.

CONCLUSION

MRA is an effective method for detection of occlusive lesions in the ECVAs and BAs. Clinically important lesions can be missed by MRA in the ICVA. MRA is more accurate in characterization of occlusive lesions in BAs than in ECVAs or ICVAs.

MR angiography in carotid stenosis: a comparison of three techniques

PURPOSE

To compare the accuracy of three different magnetic resonance angiography (MRA) techniques for studying steno-occlusive disease of carotid arteries.

METHODS

64 patients were evaluated with three MRA techniques- three-dimensional (3D) time-of-flight (TOF), two-dimensional (2D) TOF, and 3D Phase-Contrast (PC); the acquisition was in the axial plane, the volume included the carotid bifurcation. Digital subtraction angiography (DSA) was considered the 'gold standard'. The MRA images were reprojected with a maximum intensity pixel ray-tracing (MIP) algorithm. The three MRA techniques were blindly graded as normal, mildly stenotic (0-29%), moderately stenotic (30-49%), severely stenotic (70-99%), or occluded.

RESULTS

DSA provided 128 diagnostic judgments: 92 were negatives and 36 positives. 2D TOF was in agreement with angiography in 116 of 128 cases (90%), but overestimated the results in seven cases and underestimated in five cases. 3D TOF agreed with angiography in 125 of 128 cases (97%), with one overestimation and two under estimations. 3D PC was concordant in 116 of 128 cases (90%), overestimating in six cases, underestimating in six cases. The sensitivity, specificity and diagnostic accuracy for 2D TOF was, respectively 84%, 94%, and 92%, while for 3D TOF was 94%, 100%, and 98%, and for 3D PC 86%, 98%, and 95%. The comparison of the three different MRA techniques provided no statistically significant difference (Friedman test P < 0.05).

CONCLUSION

The high degree of diagnostic accuracy of MRA found in the study of the steno-occlusive disease of the carotid arteries confirms the high degree of reliability of this methodology carried out with the 3D TOF technique, compared to 2D TOF and 3D PC.

How should we estimate carotid stenosis using magnetic resonance angiography?

Our purpose was to assess the reproducibility of and differences between the most commonly used methods for assessing carotid artery stenosis using magnetic resonance angiography (MRA). We studied 55 patients who underwent axial three-dimensional time-of-flight MRA (1.5 T). Quantitative caliper measurements were performed from maximum intensity projection (MIP) and multiple planar reconstruction (MPR) images, according to the criteria of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST). The measurements were compared to each other and to visual interpretation, using conventional angiography as the reference. The measured percentage stenoses were higher on MRA than on digital subtraction angiography (DSA) using both NASCET (mean difference 1.9-3.0%) and ECST (6.3-6.7%) criteria. The kappa coefficients for the agreement between DSA and MRA were higher using the NASCET (0.61-0.76) than the ECST criteria (0.52-0.65). No statistically significant differences were found between measurements from MIP and MPR images. The ECST measurement criteria gave significantly higher percentage stenoses than the NASCET criteria (P < 0.001), this difference being more prominent on MRA (mean difference in diameter stenosis percentage 14.3-16.4%) than on DSA (7.6-11.2%) and most important with mild stenoses. The difference between visual interpretation and quantitative measurements on MRA was significant (P = 0.01-0.001). There were no statistically significant interobserver differences in the MRA film readings, either in visually estimated degrees of stenosis or stenosis measurements. Thus, the different criteria of the two multicentre trials led to significantly different results, especially in the assessment of mild stenosis, and these differences are more important with MRA than with DSA. Differences between the imaging modalities or the reconstruction programs seem less important.

Carotid artery stenosis: preoperative noninvasive evaluation in a community hospital

PURPOSE

The purpose of this study was to determine whether noninvasive evaluation with duplex ultrasonography and magnetic resonance angiography of patients with carotid artery stenosis can replace contrast angiography at our institution.

METHODS

This study consisted of a retrospective chart review of 40 patients (74 carotid arteries) in combination with a blinded reanalysis of original data. Contrast angiography was compared with duplex ultrasonography and magnetic resonance angiography. The overall diagnostic accuracy of duplex ultrasonography and magnetic resonance angiography was determined individually and concordantly in patients being evaluated for carotid artery stenosis.

RESULTS

The overall sensitivity of duplex ultrasonography was 88.5%, and the specificity was 91.7% (Spearman correlation coefficient = 0.8456; p < 0.001). For magnetic resonance angiography the sensitivity was 92.3%, and the specificity was 97.9% (Spearman correlation coefficient = 0.9086; p < 0.001). In the presence of concordance, the noninvasive studies exhibited a sensitivity of 100%, (correlation coefficient = 0.9661; kappa value = 0.9655). No occlusions or severe lesions were missed by both studies. In only one vessel (1.52%) was a false-positive concordance noted.

CONCLUSIONS

Carotid endarterectomy may be undertaken with a high degree of confidence that the operation will be appropriate if the noninvasive evaluations are concordant. In the absence of concordance of the noninvasive studies, contrast angiography should be considered.

Comparison of magnetic resonance angiography, duplex ultrasound, and digital subtraction angiography in assessment of extracranial internal carotid artery stenosis

The results of a prospective study comparing ultrasound, intra-arterial digital subtraction angiography, and magnetic resonance angiography in the assessment of the degree of extracranial internal carotid artery stenosis are reported in patients with symptoms of recent carotid territory ischaemia. A total of 70 patients and 137 vessels were examined by all three techniques. The results obtained by each technique were reported blind. The mean difference (SD) for the comparison of magnetic resonance angiography and digital subtraction angiography was -0.7 (14)%, for ultrasound and digital subtraction angiography 3.1 (15)%, and for magnetic resonance angiography and ultrasound -3.8 (15)%. The level of agreement was greater for the more tightly stenosed vessels. With the assumption that the results of the digital subtraction angiogram reflect the true situation, the sensitivity and specificity in the detection of > or = 30% stenoses were 93% and 82% with ultrasound and 89% and 82% with magnetic resonance angiography; for stenoses > or = 70% 93% and 92% with ultrasound and 90% and 95% with magnetic resonance angiography; and for stenoses of 70-99% 89% and 93% with ultrasound and 86% and 93% with magnetic resonance angiography. For occlusion the values were 93% and 99% with ultrasound and 80% and 99% with magnetic resonance angiography. Increased sensitivity and specificity were obtained when analysis was confined to those vessels in which ultrasound and magnetic resonance angiography were in agreement over classification. It is thus possible to accurately categorize the degree of stenosis of the extracranial internal carotid artery from a combination of ultrasound and magnetic resonance angiography. The adoption of this combination for the investigation of patients before carotid endarterectomy removes the risk associated with conventional angiography and represents an important advance in the management of carotid stenosis.

Blinded-reader comparison of magnetic resonance angiography and duplex ultrasonography for carotid artery bifurcation stenosis

BACKGROUND AND PURPOSE

We compared two-dimensional time-of-flight magnetic resonance angiography (MRA) and duplex ultrasonography with arteriography for the detection of 70% to 99% stenoses at the carotid artery bifurcation (ie, surgical disease according to findings of the North American Carotid Endarterectomy Trial).

METHODS

Three blinded readers independently measured stenoses on MRA in 73 vessels from 38 patients. Duplex ultrasonography was available in 66 vessels from 35 of these patients, and blinded reading was performed by one reader. Comparison was made to arteriography.

RESULTS

Magnetic resonance angiography demonstrated a sensitivity of 92.4%, specificity of 74.5%, and negative predictive value of 95.8% for 70% to 99% stenoses. Interobserver agreement was high (kappa = 0.91). Absence of signal at stenoses with evidence of distal flow usually, but not always, corresponded to surgical disease. Duplex ultrasonography demonstrated a sensitivity of 81.0%, specificity of 82.2%, and negative predictive value of 90.2% for surgical disease. There was no significant difference between MRA and duplex ultrasonography for the sensitivity or specificity in detecting 70% to 99% stenoses (P > .1, exact form of the McNemar test). MRA had no false positives or false negatives for complete occlusions of the carotid artery, whereas duplex ultrasonography missed one occlusion and falsely called two patent vessels occluded. In seven cases, both MRA and duplex ultrasonography overestimated stenoses to miscategorize them as surgical disease.

CONCLUSIONS

Although the sensitivity and specificity of MRA and duplex ultrasonography are not significantly different for distinguishing surgical and nonsurgical degrees of stenosis at the carotid bifurcation, MRA has some advantages that may make it the screening test of choice. Concordant MRA and duplex ultrasonography for surgical disease does not necessarily obviate the need for catheter arteriography.

Between-method correlation in quantifying internal carotid stenosis

BACKGROUND AND PURPOSE

The degree of internal carotid stenosis has emerged as the most important predictor of ischemic stroke in extracranial carotid artery disease. The purpose of this study was to assess the validity of the noninvasive techniques for quantifying internal carotid stenosis with respect to the accepted standard of intra-arterial angiography.

METHODS

We measured the maximum percentage reduction in luminal diameter on the intra-arterial digital subtraction angiograms of 56 symptomatic patients with extracranial internal carotid stenosis (n = 77) or occlusion (n = 20). These data were compared with independent measurements based on continuous-wave Doppler ultrasonography, pulsed-wave Doppler spectrum analysis, color Doppler-assisted duplex imaging, and magnetic resonance angiography.

RESULTS

Correlations with intra-arterial angiography were equally strong (r > .90) for magnetic resonance angiography, continuous-wave Doppler, and color duplex analysis. Positive and negative predictive values for (therapeutically relevant) 70% to 99% stenosis were higher for continuous-wave Doppler (.82, .97) and color duplex (.84, .98) than for magnetic resonance angiography (.79, .81). Also, accuracy in quantifying high-grade stenosis was better for both of these ultrasonographic techniques, mainly due to the frequent occurrence of a "flow gap" on the magnetic resonance angiograms. Continuous-wave Doppler and magnetic resonance angiography, but not color duplex, failed to detect slow residual arterial flow in one and two cases of symptomatic "pseudo-occlusion" of the internal carotid, respectively.

CONCLUSIONS

(1) Several noninvasive methods compare well with intra-arterial angiography in identifying and quantifying high-grade internal carotid stenosis; (2) the use of these noninvasive methods may suffice for treatment decisions; and (3) because residual between-method disagreement is partly explained by principles of physics, the validity of continuous-wave Doppler and color duplex in quantifying 60% to 99% stenosis is likely to be underestimated by correlation with intra-arterial angiography.

Magnetic resonance angiography of vascular lesions causing neuro-ophthalmic deficits

Magnetic resonance angiography (MRA) is a noninvasive, rapidly evolving technique for imaging the intra- and extracranial carotid and vertebrobasilar circulations. It may in some circumstances obviate conventional angiography and the accompanying risks associated with catheterization and contrast injection. MRA exploits the different physical properties between moving protons and stationary tissue to yield flow sensitive data in the form of anatomic images or velocity and flow measurements. Since patients with various vascular disorders may present exclusively with ophthalmologic signs and symptoms, it is expected that MRA will become more frequently utilized by ophthalmologists. The exact role of MRA in the workup of vascular disorders remains to be more precisely defined, pending the performance of additional well-controlled standardized studies. At present, MRA is utilized to complement the conventional spin-echo studies of patients with arterial and venous occlusion, vascular malformations, intracranial aneurysms, and neoplastic vascular invasion. With further refinements, it is expected that MRA will become a standard diagnostic tool for the evaluation of patients with vascular disorders.

Surgical decisions on the basis of magnetic resonance angiography of the carotid arteries

The recent demonstration of the efficacy of carotid endarterectomy in certain patients emphasizes the advantages of having a noninvasive, accurate means of evaluating the carotid arteries. Advances in magnetic resonance (MR) angiography now allow accurate depiction of the carotid arteries that may be adequate for surgical planning in many cases. This report examines the accuracy of MR angiography compared with that of conventional angiography in symptomatic patients undergoing carotid endarterectomy and compares them with surgical findings. Twenty-one carotid arteries in 20 patients were treated surgically for severe stenosis or occlusion. Preoperatively, all patients had both MR and conventional angiograms, which were interpreted on a five-grade scale by two independent neuroradiologists who were unaware of the patient's clinical history. The two studies were highly correlated, particularly in the case of severe stenosis and occlusion. There were no false-negative MR studies that missed surgically significant lesions. In two cases, MR angiography overestimated the stenosis by one grade. On MR angiography, surgically significant stenosis appears as focal areas of signal intensity loss at the level of stenosis with reappearance of the signal distally. If the distal signal intensity does not reappear, the artery is likely to be occluded. In symptomatic patients, MR angiograms that demonstrate a flow-void gap with distal reappearance at a site consistent with the symptoms may be adequate as the sole preoperative study. Three patients who underwent carotid endarterectomy on this basis are presented. The factors that contribute to artifactual and overestimated stenosis are reviewed.

New magnetic resonance techniques for evaluating cerebrovascular disease

Magnetic resonance (MR) imaging of acute stroke has made important contributions to diagnosis. Several novel MR technologies, now in preclinical and clinical development, will contribute to stroke diagnosis and perhaps help to guide therapy. MR angiography is the most clinically advanced new MR technology and offers the clinician a method to image noninvasively the extra- and intracranial vasculature. Diffusion-weighted MR imaging can demonstrate ischemic lesions quantitatively within minutes of onset in experimental stroke models, and human application is proceeding. Perfusion MR studies can reveal the presence or absence of cerebral perfusion in specific arterial territories. MR spectroscopy can assess tissue metabolites in vivo and reveal changes in these metabolites associated with ischemic injury. The combination of these new MR techniques should provide a plethora of information about the extent of ischemic lesions, associated vascular and perfusion deficits, and metabolic consequences. This information will afford the clinician the opportunity to assess and subtype ischemic stroke patients more rapidly and could be used to monitor therapeutic responses.