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Musialek P, Bonati LH, Bulbulia R, Halliday A, Bock B, Capoccia L, Eckstein HH, Grunwald IQ, Lip PL, Monteiro A, Paraskevas KI, Podlasek A, Rantner B, Rosenfield K, Siddiqui AH, Sillesen H, Van Herzeele I, Guzik TJ, Mazzolai L, Aboyans V, Lip GYH. Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases. Cardiovasc Res 2025; 121:13-43. [PMID: 37632337 DOI: 10.1093/cvr/cvad135] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023] Open
Abstract
Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded the knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (i) establishing a unified knowledge foundation and (ii) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailors personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promoting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management including statins, novel lipid-lowering and antithrombotic strategies, and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multi-morbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for inter-disciplinary collaboration and prioritized patient-centric decision-making.
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Affiliation(s)
- Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, St. John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland
| | | | - Richard Bulbulia
- Medical Research Council Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | | | - Laura Capoccia
- Department of Surgery 'Paride Stefanini', Policlinico Umberto I, 'Sapienza' University of Rome, Rome, Italy
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Iris Q Grunwald
- Department of Radiology, Ninewells Hospital, University of Dundee, Dundee, UK
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, University of Dundee, Dundee, UK
| | | | - Andre Monteiro
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | | | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, University of Dundee, Dundee, UK
- Division of Radiological and Imaging Sciences, University of Nottingham, Nottingham, UK
| | - Barbara Rantner
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Campus Grosshadern, Munich, Germany
| | | | - Adnan H Siddiqui
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, and Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Henrik Sillesen
- Department of Vascular Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Tomasz J Guzik
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Internal Medicine, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Lucia Mazzolai
- Department of Angiology, University Hospital Lausanne, Lausanne, Switzerland
| | - Victor Aboyans
- Department of Cardiology, CHRU Dupuytren Limoges, Limoges, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Daolio RM, Zanin LFS, Flumignan CDQ, Cassola N, Guedes Neto HJ, Santos JEM, Amorim JE, Nakano LCU, Flumignan RLG. Accuracy of duplex ultrasonography versus angiotomography for the diagnosis of extracranial internal carotid stenosis. Rev Col Bras Cir 2024; 51:e20243632. [PMID: 38896635 PMCID: PMC11185060 DOI: 10.1590/0100-6991e-20243632-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/09/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Internal carotid artery (ICA) stenosis causes about 15% of ischemic strokes. Duplex ultrasonography (DUS) is the first line of investigation of ICA stenosis, but its accuracy varies in the literature and it is usual to complement the study with another more accurate exam when faced with significant stenosis. There is a lack of studies that compare DUS with angiotomography (CTA) in the present literature. METHODS we performed an accuracy study, which compared DUS to CTA of patients in a tertiary hospital with a maximum interval of three months between tests. Patients were selected retrospectively, and two independent and certified vascular surgeons evaluated each image in a masked manner. When there was discordance, a third evaluator was summoned. We evaluated the diagnostic accuracy of ICA stenosis of 50-94% and 70-94%. RESULTS we included 45 patients and 84 arteries after inclusion and exclusion criteria applied. For the 50-94% stenosis range, DUS accuracy was 69%, sensitivity 89%, and specificity 63%. For the 70-94% stenosis range, DUS accuracy was 84%, sensitivity 61%, and specificity 93%. There was discordance between CTA evaluators with a change from clinical to surgical management in at least 37.5% of the conflicting reports. CONCLUSION DUS had an accuracy of 69% for stenoses of 50-94% and 84% for stenoses of 70-94% of the ICA. The CTA analysis depended directly on the evaluator with a change in clinical conduct in more than 37% of cases.
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Affiliation(s)
- Raul Muffato Daolio
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Luiz Fernando Santetti Zanin
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | | | - Nicolle Cassola
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Henrique Jorge Guedes Neto
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | | | - Jorge Eduardo Amorim
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Luís Carlos Uta Nakano
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
| | - Ronald Luiz Gomes Flumignan
- - Universidade Federal de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia Vascular e Endovascular - São Paulo - SP - Brasil
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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 360] [Impact Index Per Article: 180.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Svoboda N, Bradac O, Mandys V, Netuka D, Benes V. Diagnostic accuracy of DSA in carotid artery stenosis: a comparison between stenosis measured on carotid endarterectomy specimens and DSA in 644 cases. Acta Neurochir (Wien) 2022; 164:3197-3202. [PMID: 35945355 DOI: 10.1007/s00701-022-05332-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/15/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE DSA (digital subtraction angiography) is the gold standard for measuring carotid artery stenosis (CS). Yet, the correlation between DSA and stenosis is not well documented. MATERIAL AND METHODS We compared CS as measured by DSA to carotid artery specimens obtained from carotid endarterectomy surgery. Patients were divided into three groups according to NASCET criteria (North American Symptomatic Carotid Endarterectomy Trial): stenosis of 30-49% (mild), stenosis of 50-69% (moderate), and stenosis of 70-99% (severe). RESULTS This prospective cohort study involved 644 patients. The mean stenosis in the mild stenosis group (n = 128 patients) was 54% ECST (European Carotid Surgery Trial), 40% NASCET, and 72% ESs (endarterectomy specimens). The mean absolute difference between ECST and NASCET was 14%. The mean stenosis in the moderate stenosis group (n = 347 patients) was 66% ECST, 60% NASCET, and 77% ES. The mean absolute difference between ECST and NASCET was 6%. The mean stenosis in the severe group (n = 169 patients) was 80% ECST, 76% NASCET, and 79% ES. No significant correlation coefficients were found between DSA and ES methods. In the mild group, the CC was 0.16 (ESCT) and 0.13 (NASCET); in the moderate group, the CC was 0.05 (ESCT) and 0.01 (NASCET); and in the severe group, the CC was 0.23 (ESCT) and 0.10 (NASCET). For all groups combined, CC was 0.22 for the ECST and 0.20 for the NASCET method. CONCLUSION The relationship between DSA and ES methods to measure CS is almost random. This lack of a relationship between the DSA and ES techniques questions the validity of current DSA-based guidelines.
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Affiliation(s)
- Norbert Svoboda
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, U Vojenské nemocnice 1200/2, Prague 6, 16000, Czech Republic.
| | - Ondrej Bradac
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, U Vojenské nemocnice 1200/2, Prague 6, 16000, Czech Republic
| | - Vaclav Mandys
- Department of Pathology, Third Faculty of Medicine - Charles University, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, U Vojenské nemocnice 1200/2, Prague 6, 16000, Czech Republic
| | - Vladimir Benes
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, U Vojenské nemocnice 1200/2, Prague 6, 16000, Czech Republic
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Cassola N, Baptista-Silva JC, Nakano LC, Flumignan CD, Sesso R, Vasconcelos V, Carvas Junior N, Flumignan RL. Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments. Cochrane Database Syst Rev 2022; 7:CD013172. [PMID: 35815652 PMCID: PMC9272405 DOI: 10.1002/14651858.cd013172.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Carotid artery stenosis is an important cause of stroke and transient ischemic attack. Correctly and rapidly identifying patients with symptomatic carotid artery stenosis is essential for adequate treatment with early cerebral revascularization. Doubts about the diagnostic value regarding the accuracy of duplex ultrasound (DUS) and the possibility of using DUS as the single diagnostic test before carotid revascularization are still debated. OBJECTIVES To estimate the accuracy of DUS in individuals with symptomatic carotid stenosis verified by either digital subtraction angiography (DSA), computed tomography angiography (CTA), or magnetic resonance angiography (MRA). SEARCH METHODS We searched CRDTAS, CENTRAL, MEDLINE (Ovid), Embase (Ovid), ISI Web of Science, HTA, DARE, and LILACS up to 15 February 2021. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data. SELECTION CRITERIA We included studies assessing DUS accuracy against an acceptable reference standard (DSA, MRA, or CTA) in symptomatic patients. We considered the classification of carotid stenosis with DUS defined with validated duplex velocity criteria, and the NASCET criteria for carotid stenosis measures on DSA, MRA, and CTA. We excluded studies that included < 70% of symptomatic patients; the time between the index test and the reference standard was longer than four weeks or not described, or that presented no objective criteria to estimate carotid stenosis. DATA COLLECTION AND ANALYSIS The review authors independently screened articles, extracted data, and assessed the risk of bias and applicability concerns using the QUADAS-2 domain list. We extracted data with an effort to complete a 2 × 2 table (true positives, true negatives, false positives, and false negatives) for each of the different categories of carotid stenosis and reference standards. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where meta-analysis was possible, we used a bivariate meta-analysis model. MAIN RESULTS We identified 25,087 unique studies, of which 22 were deemed eligible for inclusion (4957 carotid arteries). The risk of bias varied considerably across the studies, and studies were generally of moderate to low quality. We narratively described the results without meta-analysis in seven studies in which the criteria used to determine stenosis were too different from the duplex velocity criteria proposed in our protocol or studies that provided insufficient data to complete a 2 × 2 table for at least in one category of stenosis. Nine studies (2770 carotid arteries) presented DUS versus DSA results for 70% to 99% carotid artery stenosis, and two (685 carotid arteries) presented results from DUS versus CTA in this category. Seven studies presented results for occlusion with DSA as the reference standard and three with CTA as the reference standard. Five studies compared DUS versus DSA for 50% to 99% carotid artery stenosis. Only one study presented results from 50% to 69% carotid artery stenosis. For DUS versus DSA, for < 50% carotid artery stenosis, the summary sensitivity was 0.63 (95% confidence interval [CI] 0.48 to 0.76) and the summary specificity was 0.99 (95% CI 0.96 to 0.99); for the 50% to 69% range, only one study was included and meta-analysis not performed; for the 50% to 99% range, the summary sensitivity was 0.97 (95% CI 0.95 to 0.98) and the summary specificity was 0.70 (95% CI 0.67 to 0.73); for the 70% to 99% range, the summary sensitivity was 0.85 (95% CI 0.77 to 0.91) and the summary specificity was 0.98 (95% CI 0.74 to 0.90); for occlusion, the summary sensitivity was 0.91 (95% CI 0.81 to 0.97) and the summary specificity was 0.95 (95% CI 0.76 to 0.99). For sensitivity analyses, excluding studies in which participants were selected based on the presence of occlusion on DUS had an impact on specificity: 0.98 (95% CI 0.97 to 0.99). For DUS versus CTA, we found two studies in the range of 70% to 99%; the sensitivity varied from 0.57 to 0.94 and the specificity varied from 0.87 to 0.98. For occlusion, the summary sensitivity was 0.95 (95% CI 0.80 to 0.99) and the summary specificity was 0.91 (95% CI 0.09 to 0.99). For DUS versus MRA, there was one study with results for 50% to 99% carotid artery stenosis, with a sensitivity of 0.88 (95% CI 0.70 to 0.98) and specificity of 0.60 (95% CI 0.15 to 0.95); in the 70% to 99% range, two studies were included, with sensitivity that varied from 0.54 to 0.99 and specificity that varied from 0.78 to 0.89. We could perform only a few of the proposed sensitivity analyses because of the small number of studies included. AUTHORS' CONCLUSIONS This review provides evidence that the diagnostic accuracy of DUS is high, especially at discriminating between the presence or absence of significant carotid artery stenosis (< 50% or 50% to 99%). This evidence, plus its less invasive nature, supports the early use of DUS for the detection of carotid artery stenosis. The accuracy for 70% to 99% carotid artery stenosis and occlusion is high. Clinicians should exercise caution when using DUS as the single preoperative diagnostic method, and the limitations should be considered. There was little evidence of the accuracy of DUS when compared with CTA or MRA. The results of this review should be interpreted with caution because they are based on studies of low methodological quality, mainly due to the patient selection method. Methodological problems in participant inclusion criteria from the studies discussed above apparently influenced an overestimated estimate of prevalence values. Most of the studies included failed to precisely describe inclusion criteria and previous testing. Future diagnostic accuracy studies should include direct comparisons of the various modalities of diagnostic tests (mainly DUS, CTA, and MRA) for carotid artery stenosis since DSA is no longer considered to be the best method for diagnosing carotid stenosis and less invasive tests are now used as reference standards in clinical practice. Also, for future studies, the participant inclusion criteria require careful attention.
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Affiliation(s)
- Nicolle Cassola
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ricardo Sesso
- Department of Medicine, Division of Nefrology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Nelson Carvas Junior
- Evidence-Based Health Post-Graduation Program, Universidade Federal de São Paulo; Cochrane Brazil; Department of Physiotherapy, Universidade Paulista, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Derbas LA, Patel KK, Muskula PR, Wang J, Gosch K, Fitridge R, Spertus JA, Smolderen KG. Variability in utilization of diagnostic imaging tests in patients with symptomatic peripheral artery disease. Int J Cardiol 2021; 330:200-206. [PMID: 33581177 DOI: 10.1016/j.ijcard.2021.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 12/20/2020] [Accepted: 02/05/2021] [Indexed: 01/09/2023]
Abstract
AIM Imaging can help guide management in peripheral arterial disease (PAD) with symptoms refractory to medical treatment. However, there are no set guidelines to determine when physicians should seek further imaging in patients with PAD for the assessment of new, persistent or worsening symptoms. This study describes the rates and variability in non-invasive and invasive imaging for patients presenting to vascular specialty clinics for symptomatic PAD. METHODS Patients (n=1,275) with a new PAD diagnosis or exacerbation of PAD symptoms were enrolled from 16 vascular clinics. Hierarchical logistic regression models were used to estimate the referral rates for 1) non-invasive and 2) invasive imaging tests, after adjusting for patient demographics, disease characteristics, PAQ summary score, PAD performance measures and country. Median Odds Ratios (MOR) were calculated to examine the variability across sites and providers. RESULTS Mean ABI was 0.67 ± 0.19. There were 690 (54.1%) patients who had imaging, of which 62 (9.0%) had invasive imaging. Imaging rates ranged from 8.6% to 98.6% across sites. The MOR for use of imaging for site was 3.36 (p < 0.001) and provider 3.49 (p < 0.001). The variability was explained primarily by (R2 = 29%) country followed by patient-level factors, provider and lastly site (R2 = 17%, 14%, and 13%, respectively). CONCLUSION There is wide variation in the use of imaging for patients presenting with new onset or recent exacerbations of their PAD. Country, followed by provider and site, were most strongly associated with this variability after adjusting for patient characteristics.
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Affiliation(s)
| | - Krishna K Patel
- University of Missouri Kansas City, Kansas City, MO, USA; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | - Jingyan Wang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Robert Fitridge
- The University of Adelaide, The Queen Elizabeth Hospital, Woodville, Australia
| | - John A Spertus
- University of Missouri Kansas City, Kansas City, MO, USA; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Kim G Smolderen
- Yale School of Medicine, Department of Internal Medicine, Vascular Medicine Outcomes Program, Cardiovascular Medicine Section, New Haven, CT, USA.
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Conventional Angiography in the Assessment of Recently Symptomatic Patients with Ipsilateral Carotid Stenosis. J Stroke Cerebrovasc Dis 2021; 30:105487. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 11/15/2022] Open
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Soun JE, Song JW, Romero JM, Schaefer PW. Central Nervous System Vasculopathies. Radiol Clin North Am 2019; 57:1117-1131. [DOI: 10.1016/j.rcl.2019.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Juliano AF, Policeni B, Agarwal V, Burns J, Bykowski J, Harvey HB, Hoang JK, Hunt CH, Kennedy TA, Moonis G, Pannell JS, Parsons MS, Powers WJ, Rosenow JM, Schroeder JW, Slavin K, Whitehead MT, Corey AS. ACR Appropriateness Criteria ® Ataxia. J Am Coll Radiol 2019; 16:S44-S56. [PMID: 31054758 DOI: 10.1016/j.jacr.2019.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 01/14/2023]
Abstract
Ataxia can result from an abnormality in the cerebellum, spinal cord, peripheral nerves, and/or vestibular system. Pathology involving the brain, such as infarct or hydrocephalus, can also present with ataxia as part of the symptom constitution, or result in symptoms that mimic ataxia. Clinical evaluation by history and careful neurological examination is important to help with lesion localization, and helps determine where imaging should be focused. In the setting of trauma with the area of suspicion in the brain, a head CT without intravenous contrast is the preferred initial imaging choice. If vascular injury is suspected, CTA of the neck can be helpful. When the area of suspicion is in the spine, CT or MRI of the spine can be considered to assess for bony or soft-tissue injury, respectively. In the setting of ataxia unrelated to recent trauma, MRI is the preferred imaging modality, tailored to assess the brain or spine depending on the area of suspected pathology. The use of intravenous contrast is generally helpful. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Amy F Juliano
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.
| | - Bruno Policeni
- Panel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Vikas Agarwal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | - Jenny K Hoang
- Duke University Medical Center, Durham, North Carolina
| | | | | | - Gul Moonis
- Columbia University Medical Center, New York, New York
| | - Jeffrey S Pannell
- University of California San Diego Medical Center, San Diego, California
| | | | - William J Powers
- University of North Carolina School of Medicine, Chapel Hill, North Carolina; American Academy of Neurology
| | - Joshua M Rosenow
- Northwestern University Feinberg School of Medicine, Chicago, Illinois; neurosurgical consultant
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Forjoe T, Asad Rahi M. Systematic review of preoperative carotid duplex ultrasound compared with computed tomography carotid angiography for carotid endarterectomy. Ann R Coll Surg Engl 2019; 101:141-149. [PMID: 30767557 PMCID: PMC6400905 DOI: 10.1308/rcsann.2019.0010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2018] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION We reviewed the literature for preoperative computed tomography carotid angiography and/or carotid duplex to determine their respective sensitivity and specificity in assessing the degree of carotid stenosis. We aimed to identify whether one imaging modality can accurately identify critical stenosis in patients presenting with transient ischaemic attack or symptoms of a cerebrovascular accident requiring carotid endarterectomy. METHODS Systematic search of MEDLINE, Embase, Cochrane database of systematic reviews, all Evidence-Based Medicine Reviews (Cochrane Database of Systematic Reviews, ACP Journal club, Database of Abstracts of Reviews of Effects, Cochrane Clinical Answers, Cochrane Controlled Trials Register, Cochrane Methodology Register, Health Technology Assessment and NHS Economic Evaluation Database) for primary studies relating to computed tomography carotid angiography (CTA) and/or carotid duplex ultrasound (CDU). Studies included were published between 1990 and 2018 and focused on practice in the UK, Europe and North America. RESULTS The sensitivity and specificity of CTA and CDU are comparable. CDU is safe and readily available in the clinical environment hence its use in the initial preoperative assessment of carotid stenosis. CDU is an adequate imaging modality for determining stenosis greater than 70%; sensitivity and specificity are improved when the criteria for determining greater than 70% stenosis are adjusted. Vascular laboratories opting to use duplex as their sole imaging modality should assess the sensitivity and specificity of their own duplex procedure before altering practice to preoperative single imaging for patients. CONCLUSIONS The sensitivity and specificity of CTA (90.6% and 93%, respectively) and CDU (92.3% and 89%, respectively) are comparable. Both are dependent on criteria used in vascular laboratories. CDU sensitivity and specificity was improved to 98.7% and 94.1%, respectively, where peak systolic velocity and end diastolic velocity were assessed. Either modality can be used to determine greater than 70% stenosis, although a secondary imaging modality may be required for cases of greater than 50% stenosis.
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Affiliation(s)
- T Forjoe
- Manchester Medical School, Manchester, UK
| | - M Asad Rahi
- Regional Vascular Centre, Royal Preston Hospital, Preston, UK
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12
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Comparison of Measurement and Grading of Carotid Stenosis with Computed Tomography Angiography and Doppler Ultrasound. Ann Vasc Surg 2018. [PMID: 29522870 DOI: 10.1016/j.avsg.2018.01.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Doppler ultrasound (DUS) and computed tomography angiography (CTA) are the most commonly used imaging modalities for carotid disease. The aim of this study was to test the accuracy and reproducibility of CTA-derived measurements of carotid stenosis and compare them with those obtained by DUS. METHODS Images of 100 carotid arteries of patients who underwent carotid DUS at our unit and CTA of the carotids within a 28-day period were identified retrospectively from multidisciplinary team meeting records. CTAs were assessed by 2 investigators, each using a manual and a semi-automated method. With both methods, the degree of stenosis was calculated using the North American Symptomatic Carotid Endarterectomy Trial equation and graded as mild (0-49%), moderate (50-69%), or severe (70-99%). Cohen's kappa and specificity and sensitivity for ≥50% stenosis were calculated. RESULTS The interobserver agreement was moderate (κ 0.407, weighted-κ 0.517) for the manual method and good (κ 0.786, weighted-κ 0.842) for the semi-automated method. Using DUS as the gold standard, the semi-automated method had greater sensitivity (75%) and specificity (91%) in detecting clinically significant carotid artery stenosis (≥50%) than the manual one (63% and 86%, respectively). Agreement between DUS and the semi-automated method of CTA reporting was moderate (κ 0.453, 95% confidence interval [CI]: 0.320-0.586, weighted-κ 0.598, 95% CI: 0.486-0.710), whereas DUS and the manual method of CTA reporting had only fair agreement (κ 0.344, 95% CI: 0.209-0.478, weighted-κ 0.446, 95% CI: 0.315-0.577). CONCLUSIONS CTA tends to underestimate the degree of stenosis when compared with DUS. The semi-automated method of CTA reporting has greater reproducibility and greater agreement with DUS. These findings have practical implications when CTA is used to measure the degree of carotid stenosis in clinical practice.
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Amsalem Y, Porat L, Javitt MC, Sprecher E, Telman G. Internal carotid artery dissection among younger and older patients with acute ischemic stroke. Int J Neurosci 2017; 128:337-341. [DOI: 10.1080/00207454.2017.1381607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Yakov Amsalem
- Department of Radiology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - L. Porat
- Department of Radiology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - M. C. Javitt
- Department of Radiology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - Elliot Sprecher
- Department of Neurology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
| | - Gregory Telman
- Department of Neurology, Rambam Health Care Campus and Technion Faculty of Medicine, Haifa, Israel
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Alagoz AN, Acar BA, Acar T, Karacan A, Demiryürek BE. Relationship Between Carotid Stenosis and Infarct Volume in Ischemic Stroke Patients. Med Sci Monit 2016; 22:4954-4959. [PMID: 27984560 PMCID: PMC5189723 DOI: 10.12659/msm.898112] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Stroke is a serious health problem all over the world. Ischemia causes 85% of strokes and 75% of these ischemic strokes occur within the area supplied by the internal carotid artery (ICA). Material/Methods This study included 47 acute stroke patients who were in the large-artery atherosclerosis group according to Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and who had an infarct in the area supplied by the internal carotid artery. We sought to determine whether there was a significant correlation between the infarct volume of the patients as measured by diffusion-weighted magnetic resonance imaging (DW MRI), their National Institutes of Health Stroke Scale (NIHSS), and degree of carotid stenosis as identified by carotid computed tomography angiography (CTA). Results A significant correlation was observed between the percentage of carotid artery stenosis and infarct volume (p<0.001). In addition, there was a significant positive correlation between the NIHSS and infarct volume; the correlation was of moderate strength (r=0.366, p=0.001). Conclusions Our findings indicate that the percentage of carotid artery stenosis could be useful in predicting the infarct volume of the stroke.
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Affiliation(s)
| | | | - Türkan Acar
- Department of Neurology, Sakarya University, Faculty of Medicine, Sakarya, Turkey
| | - Alper Karacan
- Department of Radiology, Sakarya University, Faculty of Medicine, Sakarya, Turkey
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Barlinn K, Floegel T, Kitzler HH, Kepplinger J, Siepmann T, Pallesen LP, Bodechtel U, Reichmann H, Alexandrov AV, Puetz V. Multi-parametric ultrasound criteria for internal carotid artery disease-comparison with CT angiography. Neuroradiology 2016; 58:845-51. [PMID: 27230916 DOI: 10.1007/s00234-016-1706-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 05/16/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The German Society of Ultrasound in Medicine (known by its acronym DEGUM) recently proposed a novel multi-parametric ultrasound approach for comprehensive and accurate assessment of extracranial internal carotid artery (ICA) steno-occlusive disease. We determined the agreement between duplex ultrasonography (DUS) interpreted by the DEGUM criteria and CT angiography (CTA) for grading of extracranial ICA steno-occlusive disease. METHODS Consecutive patients with acute cerebral ischemia underwent DUS and CTA. Internal carotid artery stenosis was graded according to the DEGUM-recommended criteria for DUS. Independent readers manually performed North American Symptomatic Carotid Endarterectomy Trial-type measurements on axial CTA source images. Both modalities were compared using Spearman's correlation and Bland-Altman analyses. RESULTS A total of 303 acute cerebral ischemia patients (mean age, 72 ± 12 years; 58 % men; median baseline National Institutes of Health Stroke Scale score, 4 [interquartile range 7]) provided 593 DUS and CTA vessel pairs for comparison. There was a positive correlation between DUS and CTA (r s = 0.783, p < 0.001) with mean difference in degree of stenosis measurement of 3.57 %. Bland-Altman analysis further revealed widely varying differences (95 % limits of agreement -29.26 to 22.84) between the two modalities. CONCLUSION Although the novel DEGUM criteria showed overall good agreement between DUS and CTA across all stenosis ranges, potential for wide incongruence with CTA underscores the need for local laboratory validation to avoid false screening results.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Thomas Floegel
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.,Department of Neuroradiology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hagen H Kitzler
- Department of Neuroradiology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Jessica Kepplinger
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ulf Bodechtel
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Andrei V Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Pizzolato R, Romero JM. Neurosonology and noninvasive imaging of the carotid arteries. HANDBOOK OF CLINICAL NEUROLOGY 2016; 135:165-191. [PMID: 27432665 DOI: 10.1016/b978-0-444-53485-9.00009-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In this chapter, we review imaging of the extracranial carotid arteries and the indications for noninvasive carotid artery evaluation, measuring the degree of arterial stenosis and plaque morphology. We also analyze the types of noninvasive imaging, including carotid duplex ultrasound, transcranial Doppler, magnetic resonance angiography, and computer tomography angiography. We look at each of these modalities, briefly discussing techniques, benefits, limitations, and sources of error. Furthermore, we discuss the apparent accuracy and the need for multimodality imaging. Finally, an imaging algorithm for the evaluation of the extracranial carotid arteries is proposed, which is in routine use at our hospital.
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Affiliation(s)
- Raffaella Pizzolato
- Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Javier M Romero
- Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Darlington M, Gueret P, Laissy JP, Pierucci AF, Maoulida H, Quelen C, Niarra R, Chatellier G, Durand-Zaleski I. Cost-effectiveness of computed tomography coronary angiography versus conventional invasive coronary angiography. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2015; 16:647-655. [PMID: 24990117 DOI: 10.1007/s10198-014-0616-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 06/03/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To determine the costs and cost-effectiveness of a diagnostic strategy including computed tomography coronary angiography (CTCA) in comparison with invasive conventional coronary angiography (CA) for the detection of significant coronary artery disease from the point of view of the healthcare provider. METHODS The average cost per CTCA was determined via a micro-costing method in four French hospitals, and the cost of CA was taken from the 2011 French National Cost Study that collects data at the patient level from a sample of 51 public or not-for-profit hospitals. RESULTS The average cost of CTCA was estimated to be 180<euro> (95 % CI 162-206<euro>) based on the use of a 64-slice CT scanner active for 10 h per day. The average cost of CA was estimated to be 1,378<euro> (95 % CI 1,126-1,670<euro>). The incremental cost-effectiveness ratio of CA for all patients over a strategy including CTCA triage in the intermediate risk group, no imaging test in the low risk group, and CA in the high risk group, was estimated to be 6,380<euro> (95 % CI 4,714-8,965<euro>) for each additional correctly classified patient. This strategy correctly classifies 95.3 % (95 % CI 94.4-96.2) of all patients in the population studied. CONCLUSIONS A strategy of CTCA triage in the intermediate-risk group, no imaging test in the low-risk group, and CA in the high-risk group, has good diagnostic accuracy and could significantly cut costs. Medium-term and long-term outcomes need to be evaluated in patients with coronary stenosis potentially misclassified by CTCA due to false negative examinations.
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Affiliation(s)
- Meryl Darlington
- URC Eco IdF, Paris Health Economics and Health Services Research Unit, AP-HP, Hôtel Dieu, 1 Place du Parvis Notre Dame, 75004, Paris, France,
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Sussman ES, Kellner CP, Mergeche JL, Bruce SS, McDowell MM, Heyer EJ, Connolly ES. Radiographic absence of the posterior communicating arteries and the prediction of cognitive dysfunction after carotid endarterectomy. J Neurosurg 2014; 121:593-8. [PMID: 24995780 DOI: 10.3171/2014.5.jns131736] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Approximately 25% of patients exhibit cognitive dysfunction 24 hours after carotid endarterectomy (CEA). One of the purported mechanisms of early cognitive dysfunction (eCD) is hypoperfusion due to inadequate collateral circulation during cross-clamping of the carotid artery. The authors assessed whether poor collateral circulation within the circle of Willis, as determined by preoperative CT angiography (CTA) or MR angiography (MRA), could predict eCD. METHODS Patients who underwent CEA after preoperative MRA or CTA imaging and full neuropsychometric evaluation were included in this study (n = 42); 4 patients were excluded due to intraoperative electroencephalographic changes and subsequent shunt placement. Thirty-eight patients were included in the statistical analyses. Patients were stratified according to posterior communicating artery (PCoA) status (radiographic visualization of at least 1 PCoA vs of no PCoAs). Variables with p < 0.20 in univariate analyses were included in a stepwise multivariate logistic regression model to identify predictors of eCD after CEA. RESULTS Overall, 23.7% of patients exhibited eCD. In the final multivariate logistic regression model, radiographic absence of both PCoAs was the only independent predictor of eCD (OR 9.64, 95% CI 1.43-64.92, p = 0.02). CONCLUSIONS The absence of both PCoAs on preoperative radiographic imaging is predictive of eCD after CEA. This finding supports the evidence for an underlying ischemic etiology of eCD. Larger studies are justified to verify the findings of this study. Clinical trial registration no.: NCT00597883 ( http://www.clinicaltrials.gov ).
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Vujković Z, Miljković S, Đajić V, Račić D, Mavija S, Dragić S. Ultrasonographic assessment of collateral cerebral circulation in patient with internal carotid artery occlusion. SCRIPTA MEDICA 2014. [DOI: 10.5937/scrimed1402087v] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Carnicelli AP, Stone JJ, Doyle A, Chowdhry AK, Mix D, Ellis J, Gillespie DL, Chandra A. Cross-sectional area for the calculation of carotid artery stenosis on computed tomographic angiography. J Vasc Surg 2013; 58:659-65. [DOI: 10.1016/j.jvs.2013.02.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 12/05/2012] [Accepted: 02/12/2013] [Indexed: 11/24/2022]
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ten Kate GL, van Dijk AC, van den Oord SC, Hussain B, Verhagen HJ, Sijbrands EJ, van der Steen AF, van der Lugt A, Schinkel AF. Usefulness of contrast-enhanced ultrasound for detection of carotid plaque ulceration in patients with symptomatic carotid atherosclerosis. Am J Cardiol 2013; 112:292-8. [PMID: 23587280 DOI: 10.1016/j.amjcard.2013.03.028] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 03/14/2013] [Accepted: 03/14/2013] [Indexed: 10/26/2022]
Abstract
Previous data have indicated that carotid plaque ulceration is a strong predictor of cerebrovascular events. Standard ultrasound and color Doppler ultrasound (CDUS) scans have poor diagnostic accuracy for the detection of carotid plaque ulceration. The aim of the present prospective study was to assess the value of contrast-enhanced ultrasound (CEUS) scans for the detection of carotid plaque ulceration. The Institutional Ethics Committee approved the study protocol, and all patients provided informed consent. The patients had symptomatic stenosis of the internal carotid artery and underwent carotid computed tomographic angiography as part of their clinical evaluation. All patients underwent a CDUS examination in conjunction with CEUS. Carotid plaque ulceration was defined as the presence of ≥1 disruptions in the plaque-lumen border ≥1 × 1 mm. Carotid computed tomographic angiography was used as reference technique. The study population consisted of 20 patients (mean age 64 ± 9 years, 80% men), and 39 carotid arteries were included in the present analysis. Computed tomographic angiography demonstrated that the plaque surface was smooth in 15 (38%), irregular in 7 (18%) and ulcerated in 17 (44%) carotid arteries. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CDUS for the detection of ulceration was 29%, 73%, 54%, 46%, and 57%, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CEUS for the detection of ulceration was 88%, 59%, 72%, 63%, and 87%, respectively. CEUS had superior sensitivity and diagnostic accuracy for the assessment of carotid plaque ulceration compared with CDUS. CEUS improved the intrareader and inter-reader variability for the assessment of carotid plaque ulceration compared with CDUS. In conclusion, CEUS could be an additional method for the detection of carotid plaque ulceration. The role of CDUS for the assessment of carotid plaque ulceration seems limited.
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Qu H, Yang M. Early imaging characteristics of 62 cases of cerebral venous sinus thrombosis. Exp Ther Med 2012; 5:233-236. [PMID: 23251274 PMCID: PMC3523955 DOI: 10.3892/etm.2012.796] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/04/2012] [Indexed: 01/31/2023] Open
Abstract
This study aimed to evaluate the early imaging characteristics of cerebral venous sinus thrombosis (CVST). A retrospective analysis was conducted of the clinical and imaging data of 62 patients with CVST diagnosed by magnetic resonance imaging (MRI) and/or digital subtraction angiography (DSA). In the 62 cases, MRI (1.5 T MRI) and magnetic resonance venography (MRV) examinations were conducted for 56 cases, and 54 of these were definitely diagnosed as CVST cases. Their MRI manifestations presented punctiform and sheet-like hemorrhagic cerebral infarction and extensive brain edema while partial cases presented cerebral ventricle dilation. In addition, MRI, MRV and DSA examinations were conducted synchronously for 2l cases. Among the 20 patients whose MRI and MRV examinations were positive, 19 cases were positive by DSA examination and the coincidence rate of the two was 95.00%. The clinical manifestations of CVST lack specificity. MRI combined with MRV examination is the preferred method of diagnosing CVST.
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Affiliation(s)
- Hui Qu
- Department of Neurology, Beijing Tiantan Hospital, Affiliated Hospital of Capital University of Medical Sciences, Beijing 100050
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Shenoy AU, Aljutaili M, Stollenwerk B. Limited economic evidence of carotid artery stenosis diagnosis and treatment: a systematic review. Eur J Vasc Endovasc Surg 2012; 44:505-13. [PMID: 22995752 DOI: 10.1016/j.ejvs.2012.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 08/26/2012] [Indexed: 10/27/2022]
Abstract
UNLABELLED The objective of this article is to assess the availability and validity of economic evaluations of carotid artery stenosis (CS) diagnosis and treatment. DESIGN Systematic review of economic evaluations of the diagnosis and treatment of CS. METHODS Systematic review of full economic evaluations published in Medline and Google Scholar up until 28 February 2012. Based on economic checklists (Evers and Philips), the identified studies were classified as high, medium, or low quality. RESULTS Twenty-three evaluations were identified. The study quality ranged from 26% to 84% of all achievable points (Evers). Seven studies were of high, eight of medium and eight of low quality. No comparison was made between carotid angioplasty and stenting (CAS) and best medical treatment (BMT). For subjects with severe stenosis, comparisons of carotid endarterectomy (CEA) and BMT were also missing. Three of five studies dealing with pre-operative imaging found that duplex Doppler ultrasound (US) was cost-effective compared with carotid angiogram (AG). CONCLUSIONS There is a huge lack of high-quality studies and of studies that confirm published results. Also, for a given study quality, the most cost-effective treatment strategy is still unknown in some cases ('CAS' vs. 'BMT', 'US combined with magnetic resonance angiography supplemented with AG' vs. 'US combined with computer tomography angiography').
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Affiliation(s)
- A U Shenoy
- Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Neuherberg, Germany
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Accuracy of digital subtraction angiography, computed tomography angiography, and magnetic resonance angiography in grading of carotid artery stenosis in comparison with actual measurement in an in vitro model. Ann Vasc Surg 2012; 26:338-43. [PMID: 22285345 DOI: 10.1016/j.avsg.2011.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 11/07/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate the accuracy of digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) in grading of carotid stenosis compared with actual measurement in an in vitro model. METHODS Various grades of stenosis were created by adhering different amounts of silicone rubber sealant onto the inner wall of clear, radiolucent tubes. After DSA, CTA, and MRA, the tubes were transected with 1-mm interval through the plaques. The cross-sectional areas were digitally photographed, and the percentage of area reduction of every single slide was measured with ImageJ planimetric software. The maximum actual area reduction (AAR) stenosis of each tube was recorded. The differences among DSA, CTA, MRA, and AAR were compared statistically using paired Student t test. RESULTS Overall, CTA and MRA significantly underestimated the degrees of stenosis compared with AAR (P = 0.001 and P = 0.0009, respectively), and no significant difference was found between DSA and AAR (P = 0.40). In the subgroup with stenosis of <70%, there was no significant difference between DSA, CTA, and MRA versus AAR (P = 0.18, P = 0.16, and P = 0.08, respectively). In the subgroup with severe stenosis of >70%, CTA and MRA significantly underestimated the stenosis versus AAR (P = 0.004, and P = 0.007 respectively), and DSA significantly overestimated the stenosis (P = 0.0007). CONCLUSIONS This in vitro model study demonstrated that CTA and MRA underestimate the lesions in severe stenosis of >70%. DSA tends to overestimate the disease. The accuracy of DSA is affected by plaque morphology, such as mountain-shaped lesions.
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Zavanone C, Ragone E, Samson Y. Concordance rates of Doppler ultrasound and CT angiography in the grading of carotid artery stenosis: a systematic literature review. J Neurol 2011; 259:1015-8. [PMID: 22064974 DOI: 10.1007/s00415-011-6265-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 09/22/2011] [Accepted: 09/22/2011] [Indexed: 11/26/2022]
Abstract
Physicians have been increasingly relying on noninvasive imaging methods to grade carotid stenosis. The accuracy of Doppler ultrasound (DUS) and CT angiography (CTA) versus intra-arterial angiography (IA) has been assessed in many studies and at least two meta-analyses. Here, we performed a systematic review of studies that compared DUS to CTA. In a PubMed review of the literature from 2000 to 2009, we found 12 studies that compared DUS and CTA-based grading of carotid stenosis. Only 4 of them included at least 20 patients and provided data to classify the diseased arteries into the following categories: mild, moderate or severe NASCET stenosis or occlusion. We extracted 431 arteries from 244 patients (range per study: 48-164). It was not possible to distinguish symptomatic from asymptomatic stenoses. Nearly half arteries had severe stenosis (46% based on DUS and 43% based on CTA). The weighted kappa was 0.85 (95% CI 0.76-0.94), and the accuracy was 0.78. When the arteries were classified into medical and potentially surgical groups, the kappa was 0.76 (95% CI 0.70-0.83), and the accuracy was 0.89. Overall, 17% of the stenoses classified as medical based on DUS were reclassified as surgical based on CTA and 14% of the stenoses classified as medical based on CTA were reclassified as surgical based on DUS. The sparse available data comparing DUS and CTA suggest that the grading of a carotid stenosis as medical or potentially surgical remains uncertain in a relatively high proportion of patients.
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Affiliation(s)
- Chiara Zavanone
- AP-HP Urgences Cérébro-Vasculaires, Groupe Hospitalier Pitié-Salpêtrière, Université Pierre et Marie Curie Paris VI, Paris Universitas, 47-83 Boulevard de l'Hôpital, 75013 Paris, France.
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Young KC, Benesch CG. Transesophageal echocardiography screening in subjects with a first cerebrovascular ischemic event. J Stroke Cerebrovasc Dis 2011; 20:503-9. [PMID: 20813548 PMCID: PMC2997382 DOI: 10.1016/j.jstrokecerebrovasdis.2010.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 03/02/2010] [Accepted: 03/09/2010] [Indexed: 11/25/2022] Open
Abstract
Our goal was to develop decision guides to predict the presence of a high-risk source of embolus and to predict a change in management following transesophageal echocardiography (TEE) in subjects who present with a first cerebral ischemic event. We conducted a retrospective review of subjects age ≥18 years who underwent TEE after a first ischemic event and were admitted to our stroke service between 2004 and 2007 (n = 287). A high-risk source of embolus and a change in clinical management (including medication changes or subsequent testing) were analyzed as separate endpoints, using multivariate techniques and receiver operating characteristic curves. We found that 14.3% of the subjects had a high-risk source, and an additional 61.3% had a potential (or low-risk) source of embolus. Increasing age and no history of diabetes mellitus were independently associated with a high-risk source of embolus. TEE would be recommended for nondiabetic individuals age ≥66 years (sensitivity, 68%; specificity, 76%). The area under the curve (AUC) for detecting a high-risk source was 0.773. TEE results changed medications or clinical management in 30.3% of the subjects. Current smokers were less likely to undergo a change in management. The AUC was uninformative (0.56) for predicting changes in management. Subjects presenting with a first ischemic event age ≥66 years may benefit from TEE. Although changes in management occurred in at least 30% of our cohort, no factors that predicted a change in management better than chance alone could be identified.
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Affiliation(s)
- Kate C Young
- Department of Neurology, University of Rochester Medical Center, 575 Elmwood Ave., Rochester, NY 14620, USA.
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Kılıçkap G, Ergun E, Başbay E, Koşar P, Kosar U. Carotid stenosis evaluation by 64-slice CTA: comparison of NASCET, ECST and CC grading methods. Int J Cardiovasc Imaging 2011; 28:1257-66. [DOI: 10.1007/s10554-011-9939-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 08/04/2011] [Indexed: 11/30/2022]
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Angiographic Reversed Flow Ratio as an Indicator of High-Grade Internal Carotid Stenosis. J Vasc Interv Radiol 2011; 22:1083-8. [DOI: 10.1016/j.jvir.2010.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 05/13/2010] [Accepted: 12/05/2010] [Indexed: 11/24/2022] Open
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Abstract
Advances in stroke treatment have mirrored advances in vascular imaging. Understanding and advances in reperfusion therapies were made possible by improvements in computed tomographic angiography, magnetic resonance angiography, neurovascular ultrasound, and renewed interest in catheter angiography. As technology allows better noninvasive vascular diagnosis, digital subtraction angiography (the remaining gold standard for vascular imaging) is increasingly used for rescue procedures and elective interventions. This review will examine specific advantages and disadvantages of different vascular imaging modalities as related to stroke diagnosis.
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Affiliation(s)
- Kristian Barlinn
- Comprehensive Stroke Center, University of Alabama at Birmingham Hospital, Birmingham, AL 35249 USA
- Dresden University Stroke Center, University of Technology Dresden, 01307 Dresden, Germany
| | - Andrei V. Alexandrov
- Comprehensive Stroke Center, University of Alabama at Birmingham Hospital, Birmingham, AL 35249 USA
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Bannas P, Finck-Wedel AK, Buhk JH, Bley TA, Koops A, Kooijman H, Beil FU, Adam G, Weber C. Comparison of whole body MR angiography at 1.5 and 3 Tesla in patients with hereditary hyperlipidemia. Acta Radiol 2011; 52:547-53. [PMID: 21498295 DOI: 10.1258/ar.2011.100404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients suffering from hereditary hyperlipidemia have a high risk for premature cardiovascular disease and death as a consequence of accelerated atherosclerosis. PURPOSE To prospectively and intra-individually compare image quality and detectability of stenoses in contrast enhanced whole-body MRA (WBMRA) at 1.5 and 3 Tesla (T) in patients with hereditary hyperlipidemia. MATERIAL AND METHODS Twenty-seven patients with hereditary hyperlipidemia received a 1.5 and 3 T gadopentetate dimeglumine contrast-enhanced WBMRA. Twenty-three defined arterial segments were analyzed regarding depiction of target vessels and image quality according to a 5-point-scale ('not evaluable' to 'excellent'). Wilcoxon matched pair test was performed for comparison. Forty-three defined arterial segments were analyzed for the degree of stenosis (0%, 1-49%, 50-99% and 100%) as well as vessel alterations such as aneurysms. Chi-square test was performed for comparison. RESULTS 1.5 T and 3 T scans yielded WBMRA with diagnostic quality in all patients. In seven of 23 arterial segments (30.4%) image quality was rated significantly higher at 3 T, whereas there was no significant difference in the remaining 16 segments between WBMRA at 1.5 T and 3 T. All relevant stenoses (n = 5), occlusions (n = 6), and aneurysms (n = 3) were evaluated similarly at both field strengths. CONCLUSION WBMRA can be performed at 1.5 T and 3 T with diagnostic image quality. Image quality was significantly higher at 3 T than at 1.5 T in only 30.4% of the arterial segments. In order to effectively take advantage of the higher field strength, further optimization of sequence parameters and injection protocols for WBMRA at 3 T is necessary.
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Affiliation(s)
- Peter Bannas
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg
| | | | - Jan-Hendrik Buhk
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg
| | - Thorsten Alexander Bley
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg
| | - Andreas Koops
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg
| | | | - Frank-Ulrich Beil
- Department of Internal Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg
| | - Christoph Weber
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg
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Nonent M, Ben Salem D, Serfaty JM, Buthion V, Pasco-Papon A, Rotaru C, Bressollette L, Papon X, Pachai C, Fortrat JO, Gouny P, Badra A, Berge J, Le Bras Y, Cottier JP, Gauvrit JY, Douek P. Overestimation of moderate carotid stenosis assessed by both Doppler US and contrast enhanced 3D-MR angiography in the CARMEDAS study. J Neuroradiol 2010; 38:148-55. [PMID: 20728218 DOI: 10.1016/j.neurad.2010.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 05/01/2010] [Accepted: 05/20/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate the agreement and diagnostic accuracy of Contrast enhanced magnetic resonance angiography (CE-MRA), Doppler ultrasound (DUS) and Digital subtraction angiography (DSA) in the assessment of carotid stenosis. METHODS DUS, CE-MRA and DSA were performed in 56 patients included in the Carotide-angiographie par résonance magnétique-échographie-doppler-angioscanner (CARMEDAS) multicenter study with a carotid stenosis ≥ 50%. Three readers evaluated stenoses on CE-MRA and DSA (NASCET criteria). Velocities criteria were used for stenosis estimation on DUS. RESULTS CE-MRA had a sensitivity and specificity of 96-98% and 66-83% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 94% and 76-84% respectively for carotid stenoses ≥ 70%. The interobserver agreement of CE-MRA was excellent, except for moderate stenoses (50-69%). DUS had a sensitivity and specificity of 88 and 75% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 83 and 86% respectively for carotid stenoses ≥ 70%. Combined concordant CE-MRA and DUS had a sensitivity and specificity of 100 and 85-90% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 96-100% and 80-87% respectively for carotid stenoses ≥ 70%. The positive predictive value of the association CE-MRA and DUS for carotid stenoses ≥ 70% is calculated between 77 and 82% while the negative predictive value is calculated between 97 and 100%. CE-MRA and DUS have concordant findings in 63-72%, and the overestimations cases were recorded only for carotid stenosis ≤ 69%. CONCLUSION Combined DUS-CE-MRA is excellent for evaluation of severe stenosis but remains debatable in moderate stenosis (50-69%) due to the risk of overestimations.
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Affiliation(s)
- M Nonent
- Department of Radiology, University Hospital Center, hôpital de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest cedex, France
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Powell SE. Use of multi-detector computed tomographic angiography in the diagnosis of a parapharyngeal aneurysm in a 6-week-old foal. Equine Vet J 2010; 42:270-3. [PMID: 20486985 DOI: 10.2746/042516409x481132] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Multidetector-row computed tomographic contrast angiography (MDCTA) is routinely employed to investigate vascular masses in human patients but, to date, the use of this technique to investigate an aneurysmal mass has not been reported in an equine case. The potential of MDCTA to investigate a right-sided parapharyngeal mass in a 6-week-old Thoroughbred foal was therefore investigated. A 4-slice helical computed tomography scanner was used on a superficial, firm, ovoid mass yielding arterial blood on fine needle aspiration. MDCTA enabled identification of the vessels involved thus assisting in forming a diagnosis based on the morphology of the lesion and aided surgical planning. Histology confirmed the presence of mural thrombus and calcification within the smooth muscle wall consistent with a true aneurysm. MDCTA provided additional information to conventional imaging in this case of vascular masses of the head and neck. The technique therefore has the potential to improve diagnosis and assist in the management of such lesions.
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Affiliation(s)
- S E Powell
- Rossdales Equine Diagnostic Centre, Cotton End Road, Exning, Suffolk CB8 7NN, UK
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Puchner S, Popovic M, Wolf F, Reiter M, Lammer J, Bucek RA. Multidetector CTA in the Quantification of Internal Carotid Artery Stenosis: Value of Different Reformation Techniques and Axial Source Images Compared With Selective Carotid Arteriography. J Endovasc Ther 2009; 16:336-42. [DOI: 10.1583/08-2636.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Babiarz LS, Romero JM, Murphy EK, Brobeck B, Schaefer PW, González RG, Lev MH. Contrast-enhanced MR angiography is not more accurate than unenhanced 2D time-of-flight MR angiography for determining > or = 70% internal carotid artery stenosis. AJNR Am J Neuroradiol 2009; 30:761-8. [PMID: 19164440 DOI: 10.3174/ajnr.a1464] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Internal carotid artery (ICA) atheromatous disease is an important cause of ischemic stroke, and endarterectomy or stent placement is typically indicated for symptomatic patients with > or = 70% stenosis. Our purpose was to compare contrast-enhanced MR angiography (CE-MRA) with unenhanced 2D time-of-flight MR angiography (2D TOF MRA) in detecting hemodynamically significant ICA stenosis, by using CT angiography (CTA) as the reference standard. MATERIALS AND METHODS This was an institutional review board-approved retrospective study. We identified 177 consecutive patients (354 ICAs) who received correlative CE-MRA, 2D TOF MRA, and CTA. Two neuroradiologists blinded to the CTA data graded the degree of ICA stenosis according to a 5-point scale. Additionally, luminal signal-intensity characteristics including 1) signal intensity drop-out, 2) distal-vessel narrowing, and 3) distal-vessel signal-intensity reduction were recorded. MRA results were correlated with those of CTA, and receiver-operating-characteristic (ROC) curves were constructed. RESULTS On CTA, there were 55 ICAs with and 299 without > or = 70% stenosis. CE-MRA was 84% sensitive and 96% specific for detecting > or = 70% stenosis; 2D TOF MRA was 80% sensitive and 95% specific. The area under the ROC curve was 0.97 for CE-MRA and 0.95 for 2D TOF MRA (P = .51, not significant). For both MRA studies, each of the luminal signal-intensity characteristics had high specificity (> 98%) but poor-to-mild sensitivity (35%-66%) in detecting > or = 70% stenosis. CONCLUSIONS Although it is established that CE-MRA more accurately delineates neurovascular anatomy than does unenhanced 2D TOF MRA, the administration of gadolinium did not offer a significant advantage in distinguishing surgically treatable ICA stenosis. This conclusion may be important in patients with contraindications to gadolinium.
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Affiliation(s)
- L S Babiarz
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. 02114, USA
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van Helvoort-Postulart D, Dirksen CD, Kessels AGH, van Engelshoven JMA, Myriam Hunink MG. A comparison between willingness to pay and willingness to give up time. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2009; 10:81-91. [PMID: 18437436 DOI: 10.1007/s10198-008-0105-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 04/02/2008] [Indexed: 05/26/2023]
Abstract
We compared the willingness-to-pay and willingness to give up time methods to assess preferences for digital subtraction angiography (DSA), computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Respondents were hypertensive patients suspected of having renal artery stenosis. Data were gathered using telephone interviews. Both the willingness-to-pay and willingness to give up time methods revealed that patients preferred CTA to MRA in order to avoid DSA. The agreement between willingness-to-pay and willingness to give up time responses was high (kappa 0.65-0.85). The willingness-to-pay method yielded relatively more protest answers (12%) as compared to willingness to give up time (2%). So, our results provided evidence for the comparability of willingness to pay and willingness to give up time. The high percentage of protest answers on the willingness-to-pay questions raises questions with respect to the application of the willingness-to-pay method in a broad decision-making context. On the other hand, the strength of willingness-to-pay is that the method directly arrives at a monetary measure well founded in economic theory, whereas the willingness to give up time method requires conversion to monetary units.
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Jaff MR, Goldmakher GV, Lev MH, Romero JM. Imaging of the carotid arteries: the role of duplex ultrasonography, magnetic resonance arteriography, and computerized tomographic arteriography. Vasc Med 2009; 13:281-92. [PMID: 18940905 DOI: 10.1177/1358863x08091971] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Stenosis of the internal carotid artery represents a major cause of stroke, with atherosclerosis representing the major pathophysiology of this stenosis. It is estimated that over 700,000 Americans suffer a stroke annually. A prompt and accurate diagnosis of carotid artery disease is critical when planning a therapeutic strategy. Physical examination is inaccurate in determining the presence and severity of carotid artery disease. Therefore, reliable imaging tests which offer little risk to the patient are required.
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Affiliation(s)
- Michael R Jaff
- Section of Vascular Medicine, Division of Cardiovascular Medicine and the Division of Vascular/Endovascular Surgery, The Massachusetts General Hospital Vascular Center, Boston 02114, USA.
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Makaryus AN, Phillips LM, Wright P, Freeman J, Green SJ, Ong L, Marchant D. Mandatory diagnostic angiography for carotid artery stenosis prior to carotid artery intervention. J Interv Cardiol 2008; 22:16-21. [PMID: 18973511 DOI: 10.1111/j.1540-8183.2008.00404.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Revascularization is an important strategy for reducing stroke risk in patients with severe carotid atherosclerosis. Magnetic resonance angiography (MRA) and/or carotid ultrasound have traditionally been used as the only diagnostic modalities prior to revascularization. Patients undergoing CEA frequently have no further assessments of carotid anatomy prior to surgery. Evaluation with carotid ultrasound and MRA can often overestimate the degree of stenosis. We sought to determine if noninvasive imaging was sufficient for determining whether a patient should be referred for carotid intervention. METHODS We performed an analysis of 101 patients referred for carotid artery stenting (CAS). All patients had previously been evaluated with carotid ultrasound and 94% had undergone MRA as well. We sought to determine if noninvasive diagnostic imaging for carotid stenosis was sufficient to determine the necessity for endovascular intervention. RESULTS Of the 101 patients referred for carotid intervention, 36 (36%) were shown to have <70% stenoses and did not require intervention. Of those who had significant disease, 49 (75%) underwent successful CAS, 15 (23%) underwent CEA, and 1 patient was treated medically for a total occlusion. Three of the 36 patients not requiring carotid intervention were found to have subclavian stenosis. Two (4%) of the patients undergoing CAS and 4 (27%) of the patients undergoing CEA had minor complications. No patients suffered a major stroke, MI, or death at follow-up. CONCLUSION This analysis demonstrates that 36% of patients referred for endovascular intervention based on noninvasive imaging did not meet criteria by angiography. This emphasizes the need for carotid angiography prior to carotid intervention.
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Affiliation(s)
- Amgad N Makaryus
- North Shore University Hospital, Manhasset, New York, New York 11030, USA
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Runck F, Steiner RP, Bautz WA, Lell MM. MR imaging: influence of imaging technique and postprocessing on measurement of internal carotid artery stenosis. AJNR Am J Neuroradiol 2008; 29:1736-42. [PMID: 18635618 DOI: 10.3174/ajnr.a1179] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE MR angiography (MRA) is increasingly used as an alternative to digital subtraction angiography (DSA) to evaluate internal carotid artery (ICA) stenosis. Because MRA is not standardized in data acquisition and postprocessing, we sought to evaluate the effects of different acquisition techniques (time-of-flight MRA [TOF-MRA]) and contrast-enhanced MRA [CE-MRA]) and postprocessing methods (maximum intensity projection [MIP], multiplanar reformation [MPR], and volume-rendering on stenosis grading. MATERIALS AND METHODS Fifty patients (33 men, 17 women) with symptomatic ICA stenosis were examined at 1.5T. Two imaging techniques and 3 postprocessing methods resulted in 6 image datasets per patient. Two readers independently evaluated ICA stenosis according to the North American Symptomatic Carotid Endarterectomy Trial criteria. Interobserver variability was calculated with the Pearson correlation coefficient and simultaneous confidence intervals (CI). The relationship of the values of ICA stenosis between the techniques was assessed by means of simultaneous 95% Tukey CI. RESULTS Interobserver agreement was high. Higher concordance was found for postprocessing techniques with TOF- than with CE-MRA; the mean difference between TOF-MPR and TOF-MIP was 0.4% (95% CI, -2.9%-3.8%). Stenosis values for CE-MPR differed significantly from those of CE volume-rendering (7.2%; 95% CI, 3.9%-10.6%). CONCLUSION Stenosis grading was found to be independent of the postprocessing technique except for comparison of CE-MPR with CE volume-rendering, with the volume-rendering technique resulting in higher stenosis values. MPR seems to be best-suited for measurement of ICA stenosis. Parameter setting is critical with volume-rendering, in which stenosis values were consistently higher compared with the other methods.
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Affiliation(s)
- F Runck
- Department of Radiology and Neuroradiology, Klinikum Augsburg, Augsburg, Germany.
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Debrey SM, Yu H, Lynch JK, Lövblad KO, Wright VL, Janket SJD, Baird AE. Diagnostic Accuracy of Magnetic Resonance Angiography for Internal Carotid Artery Disease. Stroke 2008; 39:2237-48. [DOI: 10.1161/strokeaha.107.509877] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sarah M. Debrey
- From the Stroke Neuroscience Unit (S.M.D., V.L.W., H.Y., J.K.L., A.E.B.), National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, MD; and Boston University School of Dental Medicine (S.J.J.), Boston, Mass, USA and HUG Hôpital Cantonal, Geneva, Switzerland
| | - Hua Yu
- From the Stroke Neuroscience Unit (S.M.D., V.L.W., H.Y., J.K.L., A.E.B.), National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, MD; and Boston University School of Dental Medicine (S.J.J.), Boston, Mass, USA and HUG Hôpital Cantonal, Geneva, Switzerland
| | - John K. Lynch
- From the Stroke Neuroscience Unit (S.M.D., V.L.W., H.Y., J.K.L., A.E.B.), National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, MD; and Boston University School of Dental Medicine (S.J.J.), Boston, Mass, USA and HUG Hôpital Cantonal, Geneva, Switzerland
| | - Karl-Olof Lövblad
- From the Stroke Neuroscience Unit (S.M.D., V.L.W., H.Y., J.K.L., A.E.B.), National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, MD; and Boston University School of Dental Medicine (S.J.J.), Boston, Mass, USA and HUG Hôpital Cantonal, Geneva, Switzerland
| | - Violet L. Wright
- From the Stroke Neuroscience Unit (S.M.D., V.L.W., H.Y., J.K.L., A.E.B.), National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, MD; and Boston University School of Dental Medicine (S.J.J.), Boston, Mass, USA and HUG Hôpital Cantonal, Geneva, Switzerland
| | - Sok-Ja D. Janket
- From the Stroke Neuroscience Unit (S.M.D., V.L.W., H.Y., J.K.L., A.E.B.), National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, MD; and Boston University School of Dental Medicine (S.J.J.), Boston, Mass, USA and HUG Hôpital Cantonal, Geneva, Switzerland
| | - Alison E. Baird
- From the Stroke Neuroscience Unit (S.M.D., V.L.W., H.Y., J.K.L., A.E.B.), National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, MD; and Boston University School of Dental Medicine (S.J.J.), Boston, Mass, USA and HUG Hôpital Cantonal, Geneva, Switzerland
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Shaalan WE, Wahlgren CM, Desai T, Piano G, Skelly C, Bassiouny HS. Reappraisal of velocity criteria for carotid bulb/internal carotid artery stenosis utilizing high-resolution B-mode ultrasound validated with computed tomography angiography. J Vasc Surg 2008; 48:104-12; discussion 112-3. [PMID: 18486416 DOI: 10.1016/j.jvs.2008.02.068] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 02/25/2008] [Accepted: 02/29/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Reliability of the most commonly used duplex ultrasound (DUS) velocity thresholds for internal carotid artery (ICA) stenosis has been questioned since these thresholds were developed using less precise methods to grade stenosis severity based on angiography. In this study, maximum percent diameter carotid bulb ICA stenosis (European Carotid Surgery Trial [ECST] method) was objectively measured using high resolution B-mode DUS validated with computed tomography angiography (CTA) and used to determine optimum velocity thresholds for > or =50% and > or =80% bulb internal carotid artery stenosis (ICA). METHODS B-mode DUS and CTA images of 74 bulb ICA stenoses were compared to validate accuracy of the DUS measurements. In 337 mild, moderate, and severe bulb ICA stenoses (n = 232 patients), the minimal residual lumen and the maximum outer bulb/proximal ICA diameter were determined on longitudinal and transverse images. This in contrast to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method using normal distal ICA lumen diameter as the denominator. Severe calcified carotid segments and patients with contralateral occlusion were excluded. In each study, the highest peak systolic (PSV) and end-diastolic (EDV) velocities as well as ICA/common carotid artery (CCA) ratio were recorded. Using receiver operating characteristic (ROC) analysis, the optimum threshold for each hemodynamic parameter was determined to predict > or =50% (n = 281) and > or =80% (n = 62) bulb ICA stenosis. RESULTS Patients mean age was 74 +/- 8 years; 49% females. Clinical risk factors for atherosclerosis included coronary artery disease (40%), diabetes mellitus (32%), hypertension (70%), smoking (34%), and hypercholesterolemia (49%). Thirty-three percent of carotid lesions (n = 110) presented with ischemic cerebrovascular symptoms and 67% (n = 227) were asymptomatic. There was an excellent agreement between B-mode DUS and CTA (r = 0.9, P = .002). The inter/intraobserver agreement (kappa) for B-mode imaging measurements were 0.8 and 0.9, respectively, and for CTA measurements 0.8 and 0.9, respectively. When both PSV of > or =155 cm/s and ICA/CCA ratio of > or =2 were combined for the detection of > or =50% bulb ICA stenosis, a positive predictive value (PPV) of 97% and an accuracy of 82% were obtained. For a > or =80% bulb ICA stenosis, an EDV of > or =140 cm/s, a PSV of > or =370 cm/s and an ICA/CCA ratio of > or =6 had acceptable probability values. CONCLUSION Compared with established velocity thresholds commonly applied in practice, a substantially higher PSV (155 vs 125 cm/s) was more accurate for detecting > or =50% bulb/ICA stenosis. In combination, a PSV of > or =155 cm/s and an ICA/CCA ratio of > or =2 have excellent predictive value for this stenosis category. For > or =80% bulb ICA stenosis (NASCET 60% stenosis), an EDV of 140 cm/s, a PSV of > or =370 cm/s, and an ICA/CCA ratio of > or =6 are equally reliable and do not indicate any major change from the established criteria. Current DUS > or =50% bulb ICA stenosis criteria appear to overestimate carotid bifurcation disease and may predispose patients with asymptomatic carotid disease to untoward costly diagnostic imaging and intervention.
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Affiliation(s)
- Wael E Shaalan
- Section of Vascular Surgery, Department of Surgery, University of Chicago, ChicagoIL, USA
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42
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Abstract
Carotid imaging is key to effective secondary stroke prevention. It is commonly performed, but is a rather specialist procedure requiring regular practice to maintain acceptable accuracy. Previously the domain of the neuroradiologist, noninvasive carotid imaging is now widely practiced in general departments where specialist knowledge of anatomy and intracranial disorders may be less available. Noninvasive imaging is largely replacing intraarterial angiography in the assessment of carotid stenosis in most centres because the accuracy is perceived to be sufficient. However, effective stroke prevention needs to be delivered rapidly, guided by imaging tests that are used with an understanding of their limitations and accuracy. This review will discuss currently available imaging methods, their advantages and disadvantages, difficulties in determining their accuracy, current estimates of accuracy and gaps in knowledge.
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Affiliation(s)
- Joanna M Wardlaw
- Division of Clinical Neurosciences, Western General Hospital, Crewe Rd, Edinburgh, EH4 2XU, UK
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Brown DL, Hoffman SN, Jacobs TL, Gruis KL, Johnson SL, Chernew ME. CT angiography is cost-effective for confirmation of internal carotid artery occlusions. J Neuroimaging 2008; 18:355-9. [PMID: 18321251 DOI: 10.1111/j.1552-6569.2007.00216.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE While sensitive to internal carotid artery (ICA) occlusion, carotid ultrasound can produce false-positive results. CT angiography (CTA) has a high specificity for ICA occlusion and is safer and cheaper than catheter angiography, although less accurate. We determined the cost-effectiveness of CTA versus catheter angiography for confirming an ICA occlusion first suggested by carotid ultrasound. METHODS A Markov decision-analytic model was constructed to estimate the cost-effectiveness of CTA compared with catheter angiography in a hypothetical cohort of symptomatic patients with a screening examination consistent with an ICA occlusion. Costs in 2004 dollars were estimated from Medicare reimbursement. Effectiveness was measured in quality-adjusted life years. RESULTS The 2-year cost in the CTA scenario was $9,178, and for catheter angiography, $11,531, consistent with a $2,353 cost-savings per person for CTA. CTA resulted in accrual of 1.83 quality-adjusted life years while catheter angiography resulted in 1.82 quality-adjusted life years. CTA was less costly and marginally more effective than catheter angiography. In sensitivity analyses, when CTA sensitivity and specificity were allowed to vary across a plausible range, CTA remained cost-effective. CONCLUSIONS After screening examination has suggested an ICA occlusion, confirmatory testing with CTA provides similar effectiveness to catheter angiography and is less costly.
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Affiliation(s)
- Devin L Brown
- Stroke Program, University of Michigan, Ann Arbor, MI 48109-5855, USA.
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Schellinger PD, Richter G, Köhrmann M, Dörfler A. Noninvasive Angiography (Magnetic Resonance and Computed Tomography) in the Diagnosis of Ischemic Cerebrovascular Disease. Cerebrovasc Dis 2007; 24 Suppl 1:16-23. [DOI: 10.1159/000107375] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
Transient ischemic attack (TIA) is a precursor to ischemic stroke. At least half of patients with TIA have a new, small ischemic lesion demonstrable on magnetic resonance imaging using a diffusion weighted sequence. The risk of subsequent major stroke is 10-20% in the next 3 months with much of that risk front-loaded in the first week. Strategies to identify and treat high-risk patients need to be defined. The optimal treatment approach and the timing of interventions, both medical and surgical, remains unknown. In general, aspirin is the first line of treatment to prevent further stroke. Other antiplatelet agents such as clopidogrel alone or in combination with aspirin and the combination aspirin/extended-release dipyridamole may be administered. Endarterectomy or carotid stenting is of great benefit to patients with TIA secondary to stenosis in the extracranial carotid artery.
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Affiliation(s)
- Padmavathy N Sylaja
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Bucek RA, Puchner S, Haumer M, Reiter M, Minar E, Lammer J. CTA Quantification of Internal Carotid Artery Stenosis: Application of Luminal Area vs. Luminal Diameter Measurements and Assessment of Inter-observer Variability. J Neuroimaging 2007; 17:219-26. [PMID: 17608907 DOI: 10.1111/j.1552-6569.2007.00124.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE In contrast to digital subtraction angiography (DSAdia), computed tomography angiography (CTA) provides exact delineation of the perfused lumen in the axial plane, thus allowing luminal (CTAdia) as well as cross-sectional area (CTAarea) internal carotid artery stenosis (ICAS) assessment. The purposes of the present study were to correlate CTAdia and CTAarea with DSAdia and to assess the inter-observer variabilities of both CTA techniques. METHODS In a retrospective analysis, CTA images were reviewed by two observers and ICAS was assessed according to North American Symptomatic Carotid Endarterectomy Trial applying CTAdia and CTAarea. DSAdia was assessed by a third observer. RESULTS Based on 54 consecutive patients (40 males [74.1%] and 14 females [25.9%]; median age 73.3 years), ICAS percentages of CTAdia and CTAarea revealed significant correlations with DSAdia (r= 0.79-0.87, all P<.001) with median differences in the range of +8% to -6%. Inter-observer agreement was moderate for CTAdia (kappa= 0.60) and excellent for CTAarea (kappa= 0.86). Sensitivity of CTAarea for the detection of ICAS >70% was 100% for both observers, corresponding results for CTAdia were 97.1% and 71.4%, respectively, using DSAdia as the gold standard. CONCLUSION CTAarea assessment of ICAS correlates well with the results of DSAdia and provides an excellent sensitivity for the detection of ICAS >70% with superior inter-observer agreement compared to CTAdia.
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Affiliation(s)
- Robert A Bucek
- Department of Angiography and Interventional Radiology, Vienna Medical University, Vienna, Austria.
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Titi M, George C, Bhattacharya D, Rahi A, Woodhead PM, Stevenson WJ, Pillai A, Al-Khaffaf H. Comparison of carotid Doppler ultrasound and computerised tomographic angiography in the evaluation of carotid artery stenosis. Surgeon 2007; 5:132-6. [PMID: 17575665 DOI: 10.1016/s1479-666x(07)80039-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare results of carotid Doppler ultrasound (CDUS) and spiral computerised tomographic angiography (CTA) in patients with suspected carotid artery stenosis and to evaluate their combined effect on decision making for carotid endarterectomy (CEA). METHODS A total of 107 patients were studied. All of the patients had CDUS followed by CTA as a standard method of investigation. Data included the indications for investigation, stenosis degree measured in both modalities, in addition to difficulties and limitations faced while doing them. RESULTS Out of the 214 carotid scans performed, 187 scans were included in the comparison, while 27 scans were excluded due to inadequate data or imaging difficulties. The overall concordance between both CDUS and CTA was 79.1% (148/187) (95% CI 0.72-0.83). CDUS under-estimated and over-estimated the degree of stenosis in 26/187 (14%, 95% CI 0.09-0.19) and 13/187 (7%, 95% CI 0.04-0.12), respectively. When CTA was considered in conjunction with CDUS, the decision regarding operative treatment was changed in 29/187 cases (16%) (95% CI 0.11-0.21). CONCLUSIONS CDUS remains the first line non-invasive imaging for carotid artery stenosis. However, in cases where it is inconclusive, CTA is an excellent, reliable, minimally invasive, and outpatient alternative for patient selection for CEA.
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Affiliation(s)
- M Titi
- Vascular Department, Burnley General Hospital, East Lancashire Hospitals NHS Trust, UK
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Bucek RA, Puchner S, Kanitsar A, Rand T, Lammer J. Automated CTA Quantification of Internal Carotid Artery Stenosis:A Pilot Trial. J Endovasc Ther 2007; 14:70-6. [PMID: 17291142 DOI: 10.1583/06-1905.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the feasibility and accuracy of automated analysis software for use with multidetector computed tomographic angiography (CTA) in the exact grading of internal carotid artery stenosis. METHODS A retrospective pilot trial was performed using CTA datasets from 87 stenotic carotid arteries in 46 consecutive patients (34 men; median age 73.5 years) with known cerebrovascular disease. Internal carotid artery (ICA) stenosis was graded according to NASCET criteria by 2 experienced vascular radiologists in consensus using axial source images as well as curved planar reformations and digital subtraction angiography (DSA). These results were then compared to those obtained from the automated CTA analysis software and the results of manually adapted automated CTA analysis. RESULTS Measurements from automated CTA analysis as well as manually adapted automated CTA analysis correlated significantly to those of axial/reformatted CTA and DSA (r=0.53 and r=0.82, r=0.58 and 0.70, respectively, all p<0.05). Compared to axial/reformatted CTA measurements, automated CTA analysis had a median difference of -16%, while manually adapted automated CTA had a difference of -10%. Corresponding differences in a comparison with DSA were +4% and -2%, respectively. Circumferential calcification or kinking of the ICA origin did not significantly interfere with these differences (all p>0.05). Sensitivities for the detection of ICA stenosis >70% by manually adapted automated CTA analysis and automated measurement were 44.2% and 34.9%, respectively, versus axial/reformatted CTA. Compared with DSA as the gold standard, the sensitivities were 54.2% and 62.5%, respectively. Specificities for both methods and gold standards all exceeded 90%. CONCLUSION Commercially available automated CTA analysis is a feasible tool, but sensitivities are still not sufficient for clinical application.
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Affiliation(s)
- Robert A Bucek
- Department of Angiography and Interventional Radiology, Medical University Vienna, Austria.
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Lell M, Fellner C, Baum U, Hothorn T, Steiner R, Lang W, Bautz W, Fellner FA. Evaluation of carotid artery stenosis with multisection CT and MR imaging: influence of imaging modality and postprocessing. AJNR Am J Neuroradiol 2007; 28:104-10. [PMID: 17213434 PMCID: PMC8134121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND PURPOSE We prospectively evaluated the influence of different imaging techniques (time-of-flight MR angiography [TOF-MRA], contrast-enhanced MR angiography [CE-MRA], multisection CT angiography [CTA]) and postprocessing methods (maximum intensity projection [MIP], multiplanar reformation [MPR]) on carotid artery stenosis grading. MATERIALS AND METHODS Fifty patients (34 men, 16 women) with symptomatic stenosis of the internal carotid artery were examined with a 16-section spiral CT and a 1.5T MR unit. Two MRA techniques were applied: 3D-TOF and CE-MRA. MPR was used for postprocessing with all modalities; MIP was used only with MRA. Four readers measured and calculated the percentage diameter stenosis independently according to NASCET criteria. The Wilcoxon test was used to measure interobserver variability, and the Friedman test was used to test the null-hypothesis of equality of the modalities. RESULTS The hypothesis for global equality was rejected (P < .001). TOF-MRA and CTA assessed with MPR showed the highest concordance (difference, 0.6%; confidence interval [CI], -3.0, 4.3%), and CE-MRA with MIP and CTA showed the lowest concordance in stenosis grading (difference, 7.0%; CI, 3.4, 10.6%). MPR resulted in lower degrees of stenosis than MIP for both MRA sequences, although not statistically significant (CE, -3.0%; CI, -6.6, 0.6%; TOF, -2.2%; CI, -5.8, 1.4%). When only studies with good or excellent image quality were considered, the differences decreased, but the trends remained. CONCLUSION Stenosis grading is dependent on the examination method and postprocessing technique. CTA and TOF-MRA evaluated with MPR revealed highest concordance.
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Affiliation(s)
- M Lell
- Institute of Diagnostic Radiology, University Erlangen-Nuremberg, Erlangen, Germany.
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Abstract
Computed tomography angiography (CTA) is a rapidly developing technology with great potential. This is particularly true for evaluating neurovascular disease. Clinical stroke because of atherosclerotic disease of the carotid and vertebral arteries is a common examination indication; areas of stenosis, and soft and calcified plaque along the entire vessel, not only at the carotid bifurcation, permit a full assessment of the patient's disease process. Other diseases including dissection, trauma, intracranial stenosis, thrombosis, and aneurysms can be readily diagnosed. Although duplex ultrasound may be a first line examination in many patients, both magnetic resonance angiography (MRA) and CTA offer distinct advantages over it. CTA and MRA are both highly accurate but CTA has several key advantages. CTA has been advanced by the development of improved multidetector CT (MDCT) and workstations that postprocess the data. Methods to obtain quality CTA images and to rapidly analyze the data for abnormalities are the subject of this chapter. In addition, evolving techniques in future CT scanners and workstations, and developing methods of vulnerable plaque and CT perfusion imaging are discussed.
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Affiliation(s)
- David S Enterline
- Division of Neuroradiology, Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA.
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