Evaluation of carotid artery stenosis
- Karen L Furie, MD, MPH
Karen L Furie, MD, MPH
- Chair and Professor of Neurology
- Alpert Medical School of Brown University
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Computed tomographic (CT) scanning and magnetic resonance imaging (MRI) are useful for evaluating the question of cerebral infarction which may result from carotid artery stenosis. Infarctions related to internal carotid artery stenosis may be deep, subcortical, or cortical. However, carotid stenosis may exist in the absence of infarction on MRI and CT.
The definition of asymptomatic or symptomatic carotid artery stenosis is based upon the history and physical examination, depending upon whether or not there are symptoms or signs of carotid territory ischemia. In the large clinical trials addressing the management of carotid artery stenosis, the detection of "silent" infarcts on CT or MRI did not qualify the stenosis as symptomatic. In clinical practice, however, radiographic evidence of ischemia in the territory of a stenotic internal carotid artery may affect management.
Four diagnostic modalities are used to directly image the internal carotid artery:
●Carotid duplex ultrasoundTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Toole JF, Castaldo JE. Accurate measurement of carotid stenosis. Chaos in methodology. J Neuroimaging 1994; 4:222.
- Rothwell PM, Gibson RJ, Slattery J, et al. Equivalence of measurements of carotid stenosis. A comparison of three methods on 1001 angiograms. European Carotid Surgery Trialists' Collaborative Group. Stroke 1994; 25:2435.
- North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke 1991; 22:711.
- MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet 1991; 337:1235.
- Wardlaw JM, Lewis SC, Humphrey P, et al. How does the degree of carotid stenosis affect the accuracy and interobserver variability of magnetic resonance angiography? J Neurol Neurosurg Psychiatry 2001; 71:155.
- Rothwell PM, Eliasziw M, Gutnikov SA, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003; 361:107.
- Hankey GJ, Warlow CP, Sellar RJ. Cerebral angiographic risk in mild cerebrovascular disease. Stroke 1990; 21:209.
- Wolpert SM, Caplan LR. Current role of cerebral angiography in the diagnosis of cerebrovascular diseases. AJR Am J Roentgenol 1992; 159:191.
- Kappelle LJ, Eliasziw M, Fox AJ, et al. Importance of intracranial atherosclerotic disease in patients with symptomatic stenosis of the internal carotid artery. The North American Symptomatic Carotid Endarterectomy Trail. Stroke 1999; 30:282.
- Edwards JH, Kricheff II, Riles T, Imparato A. Angiographically undetected ulceration of the carotid bifurcation as a cause of embolic stroke. Radiology 1979; 132:369.
- O'Donnell TF Jr, Erdoes L, Mackey WC, et al. Correlation of B-mode ultrasound imaging and arteriography with pathologic findings at carotid endarterectomy. Arch Surg 1985; 120:443.
- Bendszus M, Koltzenburg M, Burger R, et al. Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: a prospective study. Lancet 1999; 354:1594.
- Bosanac Z, Miller RJ, Jain M. Rotational digital subtraction carotid angiography: technique and comparison with static digital subtraction angiography. Clin Radiol 1998; 53:682.
- Elgersma OE, Buijs PC, Wüst AF, et al. Maximum internal carotid arterial stenosis: assessment with rotational angiography versus conventional intraarterial digital subtraction angiography. Radiology 1999; 213:777.
- Carroll BA. Carotid sonography. Radiology 1991; 178:303.
- Tsuruda JS, Saloner D, Anderson C. Noninvasive evaluation of cerebral ischemia. Trends for the 1990s. Circulation 1991; 83:I176.
- Zwiebel WJ. Duplex sonography of the cerebral arteries: efficacy, limitations, and indications. AJR Am J Roentgenol 1992; 158:29.
- Hunink MG, Polak JF, Barlan MM, O'Leary DH. Detection and quantification of carotid artery stenosis: efficacy of various Doppler velocity parameters. AJR Am J Roentgenol 1993; 160:619.
- Huston J 3rd, James EM, Brown RD Jr, et al. Redefined duplex ultrasonographic criteria for diagnosis of carotid artery stenosis. Mayo Clin Proc 2000; 75:1133.
- Hallam MJ, Reid JM, Cooperberg PL. Color-flow Doppler and conventional duplex scanning of the carotid bifurcation: prospective, double-blind, correlative study. AJR Am J Roentgenol 1989; 152:1101.
- Steinke W, Kloetzsch C, Hennerici M. Carotid artery disease assessed by color Doppler flow imaging: correlation with standard Doppler sonography and angiography. AJR Am J Roentgenol 1990; 154:1061.
- Suwanwela N, Can U, Furie KL, et al. Carotid Doppler ultrasound criteria for internal carotid artery stenosis based on residual lumen diameter calculated from en bloc carotid endarterectomy specimens. Stroke 1996; 27:1965.
- Wardlaw JM, Chappell FM, Best JJ, et al. Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis. Lancet 2006; 367:1503.
- Nederkoorn PJ, van der Graaf Y, Hunink MG. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review. Stroke 2003; 34:1324.
- Criswell BK, Langsfeld M, Tullis MJ, Marek J. Evaluating institutional variability of duplex scanning in the detection of carotid artery stenosis. Am J Surg 1998; 176:591.
- Jahromi AS, Cinà CS, Liu Y, Clase CM. Sensitivity and specificity of color duplex ultrasound measurement in the estimation of internal carotid artery stenosis: a systematic review and meta-analysis. J Vasc Surg 2005; 41:962.
- Beach KW, Leotta DF, Zierler RE. Carotid Doppler velocity measurements and anatomic stenosis: correlation is futile. Vasc Endovascular Surg 2012; 46:466.
- Corriveau MM, Johnston KW. Interobserver variability of carotid Doppler peak velocity measurements among technologists in an ICAVL-accredited vascular laboratory. J Vasc Surg 2004; 39:735.
- Ammar AD, Mullins JR. Incidence of bilateral intraplaque hemorrhage in carotid artery disease. Cardiovasc Surg 1993; 1:717.
- Langsfeld M, Gray-Weale AC, Lusby RJ. The role of plaque morphology and diameter reduction in the development of new symptoms in asymptomatic carotid arteries. J Vasc Surg 1989; 9:548.
- Gupta A, Kesavabhotla K, Baradaran H, et al. Plaque echolucency and stroke risk in asymptomatic carotid stenosis: a systematic review and meta-analysis. Stroke 2015; 46:91.
- El-Barghouty NM, Levine T, Ladva S, et al. Histological verification of computerised carotid plaque characterisation. Eur J Vasc Endovasc Surg 1996; 11:414.
- Grønholdt ML, Nordestgaard BG, Wiebe BM, et al. Echo-lucency of computerized ultrasound images of carotid atherosclerotic plaques are associated with increased levels of triglyceride-rich lipoproteins as well as increased plaque lipid content. Circulation 1998; 97:34.
- Sabeti S, Schillinger M, Mlekusch W, et al. Quantification of internal carotid artery stenosis with duplex US: comparative analysis of different flow velocity criteria. Radiology 2004; 232:431.
- Moneta GL, Edwards JM, Chitwood RW, et al. Correlation of North American Symptomatic Carotid Endarterectomy Trial (NASCET) angiographic definition of 70% to 99% internal carotid artery stenosis with duplex scanning. J Vasc Surg 1993; 17:152.
- Wilterdink JL, Feldmann E, Easton JD, Ward R. Performance of carotid ultrasound in evaluating candidates for carotid endarterectomy is optimized by an approach based on clinical outcome rather than accuracy. Stroke 1996; 27:1094.
- Grant EG, Benson CB, Moneta GL, et al. Carotid artery stenosis: gray-scale and Doppler US diagnosis--Society of Radiologists in Ultrasound Consensus Conference. Radiology 2003; 229:340.
- Dawson DL, Zierler RE, Strandness DE Jr, et al. The role of duplex scanning and arteriography before carotid endarterectomy: a prospective study. J Vasc Surg 1993; 18:673.
- Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis: accuracy of noninvasive testing. Stroke 2002; 33:2003.
- Fujitani RM, Mills JL, Wang LM, Taylor SM. The effect of unilateral internal carotid arterial occlusion upon contralateral duplex study: criteria for accurate interpretation. J Vasc Surg 1992; 16:459.
- Johnston DC, Goldstein LB. Clinical carotid endarterectomy decision making: noninvasive vascular imaging versus angiography. Neurology 2001; 56:1009.
- Qureshi AI, Suri MF, Ali Z, et al. Role of conventional angiography in evaluation of patients with carotid artery stenosis demonstrated by Doppler ultrasound in general practice. Stroke 2001; 32:2287.
- Wilterdink JL, Furie KL, Benavides J, et al. Combined transcranial and carotid Duplex ultrasound optimizes screening for carotid artery stenosis. Can J Neurol Sci 1993; 20:S205.
- Wilterdink JL, Feldmann E, Furie KL, et al. Transcranial Doppler ultrasound battery reliably identifies severe internal carotid artery stenosis. Stroke 1997; 28:133.
- Molina CA, Montaner J, Abilleira S, et al. Timing of spontaneous recanalization and risk of hemorrhagic transformation in acute cardioembolic stroke. Stroke 2001; 32:1079.
- Sloan MA, Alexandrov AV, Tegeler CH, et al. Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2004; 62:1468.
- Can U, Furie KL, Suwanwela N, et al. Transcranial Doppler ultrasound criteria for hemodynamically significant internal carotid artery stenosis based on residual lumen diameter calculated from en bloc endarterectomy specimens. Stroke 1997; 28:1966.
- Siebler M, Kleinschmidt A, Sitzer M, et al. Cerebral microembolism in symptomatic and asymptomatic high-grade internal carotid artery stenosis. Neurology 1994; 44:615.
- Partovi S, Loebe M, Aschwanden M, et al. Contrast-enhanced ultrasound for assessing carotid atherosclerotic plaque lesions. AJR Am J Roentgenol 2012; 198:W13.
- Staub D, Schinkel AF, Coll B, et al. Contrast-enhanced ultrasound imaging of the vasa vasorum: from early atherosclerosis to the identification of unstable plaques. JACC Cardiovasc Imaging 2010; 3:761.
- Ten Kate GL, van den Oord SC, Sijbrands EJ, et al. Current status and future developments of contrast-enhanced ultrasound of carotid atherosclerosis. J Vasc Surg 2013; 57:539.
- Fenster A, Downey DB, Cardinal HN. Three-dimensional ultrasound imaging. Phys Med Biol 2001; 46:R67.
- Landry A, Spence JD, Fenster A. Measurement of carotid plaque volume by 3-dimensional ultrasound. Stroke 2004; 35:864.
- Wessels T, Harrer JU, Stetter S, et al. Three-dimensional assessment of extracranial Doppler sonography in carotid artery stenosis compared with digital subtraction angiography. Stroke 2004; 35:1847.
- Jespersen SK, Wilhjelm JE, Sillesen H. Multi-angle compound imaging. Ultrason Imaging 1998; 20:81.
- Kern R, Szabo K, Hennerici M, Meairs S. Characterization of carotid artery plaques using real-time compound B-mode ultrasound. Stroke 2004; 35:870.
- Bowen BC, Quencer RM, Margosian P, Pattany PM. MR angiography of occlusive disease of the arteries in the head and neck: current concepts. AJR Am J Roentgenol 1994; 162:9.
- Nederkoorn PJ, Elgersma OE, Mali WP, et al. Overestimation of carotid artery stenosis with magnetic resonance angiography compared with digital subtraction angiography. J Vasc Surg 2002; 36:806.
- Debrey SM, Yu H, Lynch JK, et al. Diagnostic accuracy of magnetic resonance angiography for internal carotid artery disease: a systematic review and meta-analysis. Stroke 2008; 39:2237.
- Sitzer M, Fürst G, Fischer H, et al. Between-method correlation in quantifying internal carotid stenosis. Stroke 1993; 24:1513.
- Takaya N, Yuan C, Chu B, et al. Association between carotid plaque characteristics and subsequent ischemic cerebrovascular events: a prospective assessment with MRI--initial results. Stroke 2006; 37:818.
- Watanabe Y, Nagayama M. MR plaque imaging of the carotid artery. Neuroradiology 2010; 52:253.
- Wasserman BA. Advanced contrast-enhanced MRI for looking beyond the lumen to predict stroke: building a risk profile for carotid plaque. Stroke 2010; 41:S12.
- Corti R, Ferrari C, Roberti M, et al. Spiral computed tomography: a novel diagnostic approach for investigation of the extracranial cerebral arteries and its complementary role in duplex ultrasonography. Circulation 1998; 98:984.
- Koelemay MJ, Nederkoorn PJ, Reitsma JB, Majoie CB. Systematic review of computed tomographic angiography for assessment of carotid artery disease. Stroke 2004; 35:2306.
- Mattle HP, Kent KC, Edelman RR, et al. Evaluation of the extracranial carotid arteries: correlation of magnetic resonance angiography, duplex ultrasonography, and conventional angiography. J Vasc Surg 1991; 13:838.
- Riles TS, Eidelman EM, Litt AW, et al. Comparison of magnetic resonance angiography, conventional angiography, and duplex scanning. Stroke 1992; 23:341.
- Atlas SW. MR angiography in neurologic disease. Radiology 1994; 193:1.
- Fisher M, Sotak CH, Minematsu K, Li L. New magnetic resonance techniques for evaluating cerebrovascular disease. Ann Neurol 1992; 32:115.
- Remonda L, Heid O, Schroth G. Carotid artery stenosis, occlusion, and pseudo-occlusion: first-pass, gadolinium-enhanced, three-dimensional MR angiography--preliminary study. Radiology 1998; 209:95.
- Chen CJ, Lee TH, Hsu HL, et al. Multi-Slice CT angiography in diagnosing total versus near occlusions of the internal carotid artery: comparison with catheter angiography. Stroke 2004; 35:83.
- El-Saden SM, Grant EG, Hathout GM, et al. Imaging of the internal carotid artery: the dilemma of total versus near total occlusion. Radiology 2001; 221:301.
- Rothwell PM. For severe carotid stenosis found on ultrasound, further arterial evaluation prior to carotid endarterectomy is unnecessary: the argument against. Stroke 2003; 34:1817.
- Hankey GJ, Warlow CP. Symptomatic carotid ischaemic events: safest and most cost effective way of selecting patients for angiography, before carotid endarterectomy. BMJ 1990; 300:1485.
- Zhu CZ, Norris JW. Role of carotid stenosis in ischemic stroke. Stroke 1990; 21:1131.
- 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 2008; 13:281.
- Turnipseed WD, Kennell TW, Turski PA, et al. Combined use of duplex imaging and magnetic resonance angiography for evaluation of patients with symptomatic ipsilateral high-grade carotid stenosis. J Vasc Surg 1993; 17:832.
- Polak JF, Kalina P, Donaldson MC, et al. Carotid endarterectomy: preoperative evaluation of candidates with combined Doppler sonography and MR angiography. Work in progress. Radiology 1993; 186:333.
- Kent KC, Kuntz KM, Patel MR, et al. Perioperative imaging strategies for carotid endarterectomy. An analysis of morbidity and cost-effectiveness in symptomatic patients. JAMA 1995; 274:888.
- U-King-Im JM, Hollingworth W, Trivedi RA, et al. Cost-effectiveness of diagnostic strategies prior to carotid endarterectomy. Ann Neurol 2005; 58:506.
- Young GR, Sandercock PA, Slattery J, et al. Observer variation in the interpretation of intra-arterial angiograms and the risk of inappropriate decisions about carotid endarterectomy. J Neurol Neurosurg Psychiatry 1996; 60:152.
- STENOSIS MEASUREMENT
- CONVENTIONAL CEREBRAL ANGIOGRAPHY
- CAROTID DUPLEX ULTRASOUND
- TRANSCRANIAL DOPPLER
- ADDITIONAL ULTRASOUND MODALITIES
- Contrast enhanced ultrasound
- 3D ultrasound
- Compound ultrasound
- MR ANGIOGRAPHY
- CT ANGIOGRAPHY
- DIAGNOSIS OF COMPLETE OCCLUSION
- CHOICE OF IMAGING TEST
- INFORMATION FOR PATIENTS