Is Doppler ultrasound sufficient as the sole investigation before carotid endarterectomy?

BACKGROUND AND AIMS: Doppler ultrasound (DU) of the extracranial carotid arteries has been advocated as the sole imaging modality in carotid endarterectomy (CE) candidates. However this approach fails to identify patients with potentially significant intracranial disease, at high risk of stroke and death. Therefore, many stroke clinicians recommend angiography after screening DU. We aimed to identify the proportion of cases referred for CE in whom the identification of intracranial disease could have altered management. METHODS: Two neuroradiologists, blinded to the clinical history, reviewed the films of 111 CE candidates, predominantly of Caucasian background, who had undergone carotid angiography after screening DU. Intracranial stenoses >50% luminal diameter, incidental aneurysms and non-atherosclerotic lesions were documented. Demographic and epidemiological data were collected. RESULTS: Of the 111 patients, 87 had >50% extracranial stenoses although two thirds were asymptomatic. Intracranial stenotic lesions were recorded in 29% of patients. Over half of these were tandem lesions, distal to an extracranial stenosis. Aneurysms were found in 4.5% of patients. CONCLUSIONS: DU alone would have failed to detect significant intracranial disease in nearly a third of cases. These patients are at high risk of stroke. The identification of this group allows more aggressive stroke prevention therapy.