Comparison between directional Doppler and angiography in the diagnosis of internal carotid artery disease

Directional Doppler examination (DD) with flow registration over the supraorbital and supratrochlear arteries and over the carotid artery in the neck was adopted to 99 carotid arteries in 56 patients without previous knowledge of angiography results, and thereafter DD and angiography findings were compared. On subgrouping of the angiography results into internal carotid artery (ICA) stenosis < 50 %, > 50 %, and occlusion, a correct diagnosis was obtained by DD on 90 vessels (91 %). All 11 ICA occlusions were correctly diagnosed by DD. The incorrect results obtained with DD were as follows: Four ICA stenosis < 50 % were classified as stenosis > 50 %; four stenosis > 50 % were classified as < 50 %; one stenosis > 50 % was classified as occlusion.
DD is a useful noninvasive screening method for the detection of occlusion and > 50 % stenosis of ICA.     

Bedside Emergency Transcranial Doppler Diagnosis of Severe Carotid Disease Using Orbital Window Examination

BACKGROUND: Identifying internal carotid artery (ICA) stenosis in the acute stroke setting can provide clinically useful information. Transcranial Doppler (TCD) through the orbital window is an easy test to perform and to track and identify different vessels. Previous TCD studies have suggested that a reversed ophthalmic artery (OA) flow is a useful collateral pattern to predict ICA disease. The authors sought to evaluate the TCD orbital window for predicting cervical ICA (cICA) stenosis in the setting of acute stroke and TIA. METHOD: Power M-mode/TCD was performed in acute stroke and transient ischemic attack patients at 2 institutions. Each orbital window depth was detected on M-mode and evaluated for the direction of flow and resistance pattern. Gold standard for comparison was carotid evaluation using carotid duplex, computed tomography angiogram, or conventional angiography. The assessment of cICA disease was categorized by degree of stenosis or occlusion. RESULTS: A total of 216 transorbital exams were performed in 117 patients. Twenty-five cICA occlusions and 8 critical cICA stenoses (>or=95%) were identified by gold standard imaging. Reversed OA flow at 50 to 60 mm depth revealed high specificity (100%; confidence interval [CI], 97.6%-100.0%) and good sensitivity (75%; CI, 53.3%-90.2%) for identifying cICA occlusion or critical stenosis (>or=95%). Low pulsatility index (<1.2) and mean flow velocity (<15 cm/s) discriminated critical severe ICA stenosis or occlusion when OA flow was anterograde with good sensitivity (87.2%) and specificity (95.2%). CONCLUSION: The reversed OA sign at 50 to 60 mm depth is very specific for identifying cICA occlusion or critical stenosis. When OA flow is anterograde, a low mean flow velocity or pulsatility index is also useful to identify cICA critical stenosis or occlusion.     

Carotid plaque features on angiography and asymptomatic cerebral microembolism

We studied 110 carotid arteries of 55 patients with unilateral or bilateral carotid stenosis diagnosed with selective angiography, by using Transcranial Doppler to detect high intensity transient signals (HITS) in the middle cerebral arteries (MCAs). HITS identified as embolic signals were prevalent ( P <0.05) in the MCAs on the same side as severe (70–99%) stenosis (22 of 51=43.1%) compared to moderate (30–69%) stenosis (5 of 37=13.5%). No HITS were observed in the MCA on the same side as normal control carotid arteries ( n =17) [occluded arteries ( n =5) were not considered]. HITS were more prevalent ( P <0.05) in the MCAs on the same side as ulcerated plaques (14 of 23=60.9%) compared to non-ulcerated plaques (13 of 65=20%), and all moderate stenoses producing HITS presented ulceration of the plaque. Ulcerated plaque groups showed a higher mean number of HITS than non-ulcerated plaque groups and no significant difference was noted between moderate and severe stenosis, between superficial or deep ulcerations and between ulcerations with flap or without flap. Therefore, severe carotid stenosis and moderate stenosis with plaque ulceration result in angiographic findings most frequently associated with HITS. Further studies are necessary to evaluate the clinical significance of this finding.     

Congenital External Carotid‐Internal Carotid Artery Anastomosis Diagnosed by MR Angiography

We present what we believe is the first report of external carotid‐internal carotid artery anastomosis, which forms a large arterial ring at the proximal cervical internal carotid artery (ICA). If the small channel of the proximal cervical ICA is occluded, the remaining large channel of the external carotid artery may be diagnosed as a nonbifurcating cervical carotid artery .     

Contrast M-Mode Power Doppler Ultrasound in the Detection of Right-to-Left Shunts: Utility of Submandibular Internal Carotid Artery Recording

Cardiac right-to-left shunts (RLSs) can be detected by echocardiography and transcranial Doppler ultrasound (TCD). In patients without adequate transtemporal bone windows, results may be obtained by insonating extracranial arteries; however, the sensitivity and practicality of this approach is unknown. In 34 patients evaluated with echocardiography for RLSs, 73 studies were performed with unilateral, simultaneous contrast TCD (cTCD) of the middle cerebral artery (MCA) and anterior cerebral artery (ACA) and submandibular power M-mode Doppler (PMD) ultrasound of the extracranial internal carotid artery (ecICA). The number of microbubble (MB) signals and their times of first appearance were determined. RLS volume was graded on 6 levels (I = trace, II = small, III = medium, IVa = large, IVb = shower, IVc = curtain) and compared between MCA and ecICA recordings. In 2 of 24 cTCD studies in 15 patients without evidence of RLSs on single-gated MCA monitoring, low-volume RLSs (grades I and II) were detected via ecICA insonation; in both, MB signatures were tracked in the ecICA, passing into the ipsilateral ACA. In 40 of 49 studies (26 patients) in which RLSs were demonstrated with single-gated MCA monitoring, more MBs were detected in the ecICA than the MCA, with either single-gated or M-mode images, with increases of 76.9% and 66.1%, respectively (P = .027). Compared to single-gated studies, M-mode technology detected nonsignificant increases in MB number in both the MCA and the ecICA (by 20.2% and 14.0%, respectively). Contrast PMD with cervical ICA recording is at least as sensitive and specific as the traditional MCA method in detecting RLSs; furthermore, this method seems to be more sensitive for low-volume RLSs (grades I-III) because of air MB decay (9.2%) and entry into the ipsilateral ACA (34.2%). This is in concordance with the increase of detected RLS grades observed in 32.7% of patients with echocardiography-documented RLSs. The authors therefore suggest the incorporation of ecICA PMD not only in patients with poor ultrasonic bone windows but also in every patient being evaluated for suspected RLSs.     

脑梗死患者的颅外颈动脉超声与CT血管造影的比较

目的:比较颈部超声检查与颈部CTA对颅外颈动脉硬化性狭窄斑块的敏感性。方法:对比分析我科住院的61例脑梗死患者的双侧颈总动脉、颈动脉分叉处、颈内动脉超声检查和CTA检查结果。结果:61例患者中,超声发现斑块110处,CTA发现斑块124处,两者对于颈动脉的斑块检出率差异无显著性意义,两者狭窄程度的一致性是55%,但CTA对颈动脉分叉处斑块敏感性高于超声波检查,对钙化斑更敏感。超声检查血管狭窄的程度高于颈部CTA的结果,超声未能显示椎动脉异常。结论:脑梗死患者的颈部CTA检查优于超声检查,特别适用于椎基底动脉供血不足患者。     

颈部血管多普勒超声、数字减影血管造影、磁共振血管成像在颈动脉狭窄检查中的对比研究

目的对比分析颈部彩色多普勒超声(CDUS)、数字减影血管造影(DSA)以及磁共振血管成像(MRA)在颈动脉狭窄度评估方面的差异。方法回顾性分析81例经DSA诊断为颈动脉狭窄患者的临床资料,将其CDUS和MRA的数据与DSA结果进行比较,评价各种影像学检查在颈动脉血管狭窄及斑块检出中的敏感度、特异度和符合率。结果以狭窄率30%、50%、70%分别为节点,MRA、CDUS与DSA 3种方法检出的敏感度分别为78%、85%、73%,特异度分别为99%、98%、96%,符合率分别为90%、92%、91%,阴性预测率分别为94%、93%、90%,阳性预测率分别为95%、96%、90%,阳性似然比分别为77.8、42.5、18.25。MRA与DSA比较,敏感度分别为65%、89%、79%,特异度分别为95%、96%、98%,准确度分别为85%、92%、93%,阴性预测率分别为94%、95%、93%,阳性预测率分别为90%、93%、94%,阳性似然比分别为13.0、21.5、9.5。结论诊断颈动脉狭窄病变时,MRA特异度高,与DSA检测结果一致性较好;MRA与DSA的一致性较CDUS强。     

Comparison of ultrasonography, CT angiography, and digital subtraction angiography in severe carotid stenoses

Digital subtraction angiography (DSA) is considered to be the 'gold standard' for confirmation of severe (70-99%) stenoses of internal carotid arteries (ICAs). However, it is associated with a risk of complications. The aim of this study was to assess the accuracy of ultrasonography (US), computed tomographic angiography (CTA), and their combined use for the detection and quantification of severe carotid stenoses, when compared with DSA. Severe ICA stenoses were diagnosed by US in a set of 29 patients. All patients also underwent CTA and DSA. Sensitivity, specificity, positive (PPV), negative predictive values (NPV), and Pearson's correlation coefficient were used in the evaluation of the percentage of stenosis results. Homogeneity chi2 test was applied when assessing statistical significance. Severe stenosis was diagnosed in 34 ICAs. Two ICAs with uninterpretable CTA finding were excluded. The number of ICAs with stenoses 70-99%/<70%- US 32/0; CTA 29/3; US + CTA 29/3; DSA 24/8. Pearson's correlation coefficient - US 0.601; CTA 0.725; US + CTA 0.773. Sensitivity/specificity/PPV/NPV - US 1.0/0.75/0.75/xxx; CTA 1.0/0.844/0.828/1.0; US + CTA 1.0/0.844/0.828/1.0. Homogeneity chi2 test results - US, P = 0.002; CTA, P = 0.098; US + CTAG, P = 0.098. US in combination with CTA can be used for relatively secure diagnostics of severe ICA stenoses. Thus, invasive DSA can be avoided in a substantial number of patients.     

A Broad Diagnostic Battery for Bedside Transcranial Doppler to Detect Flow Changes With Internal Carotid Artery Stenosis or Occlusion

BACKGROUND AND PURPOSE: The authors establish accuracy parameters of a broad diagnostic battery for bedside transcranial Doppler (TCD) to detect flow changes due to internal carotid artery (ICA) stenosis or occlusion. METHODS: The authors prospectively studied consecutive patients with stroke or transient ischemic attack referred for TCD. TCD was performed and interpreted at bedside using a standard insonation protocol. A broad diagnostic battery included major criteria: collateral flow signals, abnormal siphon or terminal carotid signals, and delayed systolic flow acceleration in the middle cerebral artery. Minor criteria included a unilateral decrease in pulsatility index (< or = 0.6 or < or = 70% of contralateral side), flow diversion signs, and compensatory velocity increase. Angiography or carotid duplex ultrasound (CDU) was used to grade the degree of carotid stenosis using North American criteria. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TCD findings were determined. RESULTS: Seven hundred and twenty patients underwent TCD, of whom 517 (256 men and 261 women) had angiography and/or CDU within 8.8 +/- 0.9 days. Age was 63.1 +/- 15.7 years. For a 70% to 99% carotid stenosis or occlusion, TCD had sensitivity of 79.4%, specificity of 86.2%, PPV of 57.0%, NPV of 94.8%, and accuracy of 84.7%. For a 50% to 99% carotid stenosis or occlusion, TCD had sensitivity of 67.5%, specificity of 83.9%, PPV of 54.5%, NPV of 90.0%, and accuracy of 81.6%. TCD detected intracranial carotid lesions with 84.9% accuracy and extracranial carotid lesions with 84.4% accuracy (sensitivity of 88% and 79%, specificity of 85% and 86%, PPV of 24% and 54%, and NPV of 99% and 95%, respectively). The prevalence of the ophthalmic artery flow reversal was 36.4% in patients with > or = 70% stenosis or occlusion. If present, this finding indicated a proximal ICA lesion location in 97% of these patients. CONCLUSIONS: In symptomatic patients, bedside TCD can accurately detect flow changes consistent with hemodynamically significant ICA obstruction; however, TCD should not be a substitute for direct carotid evaluation. Because TCD is sensitive and specific for a > or = 70% carotid stenosis or occlusion in both extracranial and intracranial carotid segments, it can be used as a complementary test to refine other imaging findings and detect tandem lesions.     

The Accuracy of Transcranial Doppler in the Diagnosis of Stenosis or Occlusion of the Terminal Internal Carotid Artery

BACKGROUND AND PURPOSE: Transcranial Doppler (TCD) can detect intracranial stenoses and occlusions that can help in the diagnosis and management of ischemic stroke. The accuracy parameters for lesions located in the terminal internal carotid artery (TICA) are less known, unlike other basal cerebral vessels. PATIENTS AND METHODS: The authors studied consecutive patients referred for TCD who underwent contrast angiography or magnetic resonance angiography. They calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and likelihood ratios. RESULTS: Forty-three patients had TCD and angiography: mean age was 57 +/- 20 years, and 65% were men. Twenty-two patients were diagnosed with TICA stenosis or occlusion on TCD underwent angiography. Four patients had abnormal TCD findings that were not confirmed by angiography. Two of 21 patients with normal TCD showed moderate (< 50%) stenosis of the TICA and cavernous segment of the internal carotid artery at angiography. Accuracy parameters for TCD were as follows: sensitivity = 90% (confidence interval [CI], 63%-96%), specificity = 83% (CI, 61%-94%), PPV = 82%, NPV = 86%, positive likelihood ratio = 5, and negative likelihood ratio = 0.17. CONCLUSIONS: TCD is a sensitive screening tool for the lesions in the TICA. Specificity is likely affected by a wide spectrum of the stenosis severity shown at angiography and time lags between the studies.     

Aberrant Ascending Pharyngeal Artery Mimicking a Partially Occluded Internal Carotid Artery

Doppler sonography has become a primary imaging modality for the diagnosis of carotid arterial stenosis. Carotid stenting for a severely stenotic but not completely occluded carotid artery is becoming an alternative to carotid endarterectomy in selected groups of patients. The authors discuss a case of complete occlusion of the internal carotid artery associated with an ipsilateral aberrant ascending pharyngeal artery originating from the proximal internal carotid artery, which mimicked a stenotic internal carotid artery on sonography. Meticulous Doppler sonographic examination may provide clues for this extraordinary condition, yet angiography is indicated for a definite diagnosis.     

The relationship between the carotid and coronary artery stenosis: a study based on angiography

ABSTRACT

Objective: Previous studies have demonstrated a strong association between carotid artery stenosis (CAS) and coronary artery stenosis disease (COAS). However, prior evaluated methods are non-invasive examinations. This study was aimed to access the relationship between CAS and COAS by the means of angiography.

Methods: This is a single-center, retrospectively reviewed study based on digital subtraction angiography (DSA) of carotid artery and coronary artery angiography (CAG). We collected a total of 231 patients undergoing DSA and CAG at the same-day between June 2013 and May 2015. The patients were stratified according to the degree of CAS and COAS, mild stenosis <50%, moderate stenosis 50–69%, severe stenosis 70–99%, occlusion 100%. The correlation of CAS with COAS, as well as the risk factors, was analyzed.

Results: A total of 231 patients was enrolled in this study, male 71.9% (166/231). The age ranges from 32 to 80, mean age 60.06 ± 9.98. Of these patients, 79 patients were severe CAS and 128 patients were severe COAS. Statistical analysis demonstrated that the independent risk factors of severe COAS ≥70%, were age, sex, previous cerebral infraction, coronary heart diseases, and coronary artery surgery. CAS was associated with COAS (Spearman r = 0.333, P < 0.01). The more serious the CAS, the more involved COAS (Kendall’s tab-b = 0.294, p < 0.01).

Conclusions: The DSA confirmed CAS was associated with CAG confirmed COAS. The heavier the CAS is, the more the number of the affected coronary artery.     

Doppler examination of the carotid arteries

The ability of Doppler ultrasound to detect extracranial carotid arterial disease was evaluated in 148 carotid arteries, examined also angio-graphically. A continuous wave, directional Doppler with zero-crossing meter was used. Doppler diagnosis was based on direct examination of the carotid bifurcation. Of four quantitative variables evaluated, only the end-diastolic ICA/CCA frequency ratio was found to be useful. In stenoses exceeding 75% a deranged Doppler recording was obtained. For stenoses ≥ 50% or occlusion sensitivity was 98.3%, specificity 96.6% and over-all accuracy 97.3% with the direct examination technique. Corresponding figures for an indirect Doppler test (frontal artery flow) were 45.8, 100% and 78.4%. Stenoses < 50% could not be separated from normal vessels. Direct Doppler examination with a zero-crossing detector is reliable, provided that the limitations of the frequency analysis are considered.     

Common Carotid Artery Agenesis: Duplex Ultrasonographic Findings

Background

Agenesis of the common carotid artery (CCA) resulting in separation of the origin of the external carotid artery (ECA) and internal carotid artery (ICA) from the aortic arch is rare. Fewer than 25 cases have been reported, and correlative ultrasound data were available for only 1 of them.

Case Report

A 52-year-old woman visited the hospital with a 3-day history of vertigo and headache. Color-coded duplex ultrasonography performed to evaluate the carotid and vertebral arteries revealed a normal configuration on the left side. However, the right CCA could not be found; instead, there were two vessels of approximately equal size in close proximity to each other. The cerebral angiographic findings were consistent with the ultrasonographic findings. The ECA and ICA originated directly from the brachiocephalic trunk, and the ECA arose proximal to the ICA.

Conclusions

The ultrasonographic findings revealed absence of the CCA, the ECA and ICA originating separately from the aortic arch. Color-coded duplex ultrasonography appears to be an effective and sensitive method for detecting absence of the CCA. These findings should help to further our understanding of the embryologic development of the carotid arteries.     

Diagnosis of Moyamoya Disease with Transcranial Doppler Sonography: Correlation Study with Magnetic Resonance Angiography

BACKGROUND AND PURPOSE: Although the diagnosis of moyamoya disease may be confirmed by digital subtraction angiography, recent studies have shown the accuracy of magnetic resonance angiography. Characteristics of transcranial Doppler, a noninvasive and cost-effective method, and specific transcranial Doppler parameters reflecting distinct vascular status in moyamoya disease are explored. METHOD AND PATIENTS: Consecutive patients (> 15 years of age) diagnosed with moyamoya disease by a typical clinical history and digital sub traction angiography or magnetic resonance angiography were included. The statuses of the anterior, middle, and posterior cerebral arteries were graded as stage 1, stage 2, and stage 3 by magnetic resonance angiography. Mean flow velocity and pulsatility index were compared between these groups, and the receiver operating characteristic analysis was used to define transcranial Doppler criteria for distinct vascular status. RESULTS: Forty-five patients were included (37 women; mean age, 34.9 +/- 11.4 years). Mean flow velocity was higher and pulsatility index was lower in stage 2 (P < .01), while mean flow velocity was lower and pulsatility index was higher in stage 3 than in stage 1 (P < .01). Cutoff values reflecting stenosis or occlusion with substantial sensitivity and specificity were as follows: mean flow velocity > 85 cm/s or pulsatility index < 0.60 for stage 2, and mean flow velocity < 50 cm/s for stage 3 of middle cerebral artery; mean flow velocity > 80 cm/s or pulsatility index < 0.60 for stage 2 of anterior cerebral artery; and mean flow velocity > 60 cm/s or pulsatility index < 0.60 for stage 2 of posterior cerebral artery. CONCLUSION: Transcranial Doppler may help to refine magnetic resonance angiography findings and thus help clinicians differentiate severity or stages of moyamoya disease.     

Transcranial Doppler and Carotid Duplex Ultrasonography Findings in Bow Hunter''s Syndrome

Bow hunter's syndrome (BHS) is caused by transient vertebro-basilar ischemia on head rotation. We report a patient with BHS who was identified from dynamic changes to blood flow velocities in the posterior cerebral, basilar and vertebral arteries using carotid duplex ultrasonography and transcranial Doppler, simultaneously. Neurosonology appears to be useful for diagnosing and evaluating BHS.     

Patency and flow velocity profiles in the internal carotid artery assessed by digital subtraction angiography and Doppler studies two years after endarterectomy

A follow-up of 55 patients 2 years after a total of 60 carotid endarterectomies. Fifty-two patients who had a total of 57 endarterectomies survived the first 2 post-operative years and were re-examined using pulsed Doppler spectral analysis and intravenous digital subtraction angiography (IVDSA). One patient had died following a stroke and 2 after a cardiac infarction. The Doppler and IVDSA examinations revealed a non-symptomatic restenosis of the relevant internal carotid artery in 2 patients. There were no relevant occlusions and no symptomatic re-stenoses were detected. Spectral spreading of the Doppler signal at the site of the endarterectomy was found in 18% of the internal carotid arteries, whereas wall irregularities (diameter reduction less than 10%) were demonstrated in 25% by IVDSA. A stenosis or occlusion was found in 14 (25%) of the 57 ipsilateral external carotid arteries.     

二维相位对比磁共振血管成像测量脑血流量：颈动脉及其同侧分支血流量的验证

课题组前期研究证实,相位对比磁共振血管成像测量脑血流量的最佳速度编码为60～80cm/s。为验证二维相位对比磁共振血管成像测量脑血流量的准确性,实验以三维时间飞越法磁共振血管成像定位颈部血管感兴趣区,设定速度编码为80cm/s,对10名健康志愿者的20组颈总动脉、颈内动脉和颈外动脉的血流量测量结果显示,颈总动脉与其分支颈内动脉和颈外动脉血流量之和误差为（7.0±6.0）%,二者比较差异无显著性意义,且具有明显的相关性,同时颈总动脉血流量也与同侧颈内动脉血流量相关。造成误差的主要原因来自于颈外动脉及其分支。合理运用扫描参数及方案,二维相位对比磁共振血管成像可准确测量脑血流量。     

Clinical implications of the Doppler cerebrovascular examination: a correlation with angiography.

A directional Doppler ultrasound cerebrovascular examination was compared with angiographical findings of 152 internal carotid arteries. The Doppler examination was abnormal in 36 of 38 (95%) arteries with occlusion or stenosis greater than 75%. Of 63 arteries with lesser degrees of stenosis, the Doppler examination identified only four. There were no false-positive Doppler examinations. If the decision to perform angiography had been predicated exclusively on the presence of abnormal Doppler findings, 61 of 101 (60%) carotid lesions of potential clinical significance would have been overlooked. While the Doppler ultrasound cerebrovascular examinations is the most useful noninvasive technique available for the evaluation of certain specific categories of patients with cerebrovascular disease, the technique is based on hemodynamic alterations of pressure and flow, and cannot be expected to identify the relatively large number of non-hemodynamically significant carotid lesions that are still clinically significant as sources of emboli. This paper illustrates that in the routine evaluation of patients with symptomatic cerebrovascular disease, the Doppler examination should not play a part in the decision to proceed with angiography.