Clinical Guidelines | 18 December 2007

Screening for Carotid Artery Stenosis: U.S. Preventive Services Task Force Recommendation Statement FREE
U.S. Preventive Services Task Force [+] Article and Author Information

Companion Article(s): Screening for Carotid Artery Stenosis: An Update of the Evidence for the U.S. Preventive Services Task Force
Ann Intern Med. 2007;147(12):854-859. doi:10.7326/0003-4819-147-12-200712180-00005

Abstract
Abstract | Summary of Recommendations and Evidence | Clinical Considerations | Discussion |References | Appendices Description: Update of the 1996 U.S. Preventive Services Task Force statement about screening for asymptomatic carotid artery stenosis (CAS) in the general population. Methods: The U.S. Preventive Services Task Force examined the evidence on the natural history of CAS; systematic reviews of the accuracy of screening tests; observational studies of the harms of screening and treatment of asymptomatic CAS; and randomized, controlled trials of the benefits of treatment for CAS with carotid endarterectomy. Recommendation: Do not screen for asymptomatic CAS in the general adult population. (Grade D recommendation) The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition. It bases its recommendations on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service. The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation.

Summary of Recommendations and Evidence

Abstract | Summary of Recommendations and Evidence | Clinical Considerations | Discussion |References | Appendices The USPSTF recommends against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population (Figure). This is a grade D recommendation. Figure. Screening for carotid artery stenosis: clinical summary of U.S. Preventive Services Task Force Recommendation. For a summary of the evidence systematically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go tohttp://www.preventiveservices.ahrq.gov. USPSTF = U.S. Preventive Services Task Force. *This recommendation applies to adults without neurologic symptoms and without a history of transient ischemic attacks or stroke. If otherwise eligible, an individual who has a carotid-area transient ischemic attack should be evaluated promptly for consideration of carotid endarterectomy.

View Large | Save Figure | Download Slide (.ppt) Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty about net benefit. Both are also available online at www.annals.org. Table 1. What the U.S. Preventive Services Task Force Grades Mean and Suggestions for Practice*

View Large | Save Table | Download Slide (.ppt) Table 2. U.S. Preventive Services Task Force Levels of Certainty about Net Benefit

View Large | Save Table | Download Slide (.ppt)

Rationale

Importance

Good evidence indicates that although stroke is a leading cause of death and disability in the United States, a relatively small proportion of all disabling, unheralded strokes is due to CAS.
Detection

The most feasible screening test for severe CAS (for example, 60% to 99% stenosis) is duplex ultrasonography. Good evidence indicates that this test has moderate sensitivity and specificity and yields many false-positive results. A positive result on duplex ultrasonography is often confirmed by digital subtraction angiography, which is more accurate but can cause serious adverse events. Noninvasive confirmatory tests, such as magnetic resonance angiography, involve some inaccuracy. Given these facts, some people with false-positive test results may receive unnecessary invasive carotid endarterectomy surgery.
Benefits of Detection and Early Intervention

Good evidence indicates that in selected, high-risk trial participants with asymptomatic severe CAS, carotid endarterectomy by selected surgeons reduces the 5-year absolute incidence of all strokes or perioperative death by approximately 5%. These benefits would be less among asymptomatic people in the general population. For the general primary care population, the benefits are judged to be no greater than small.
Harms of Detection and Early Intervention

Good evidence indicates that both the testing strategy and the treatment with carotid endarterectomy can cause harms. A testing strategy that includes angiography will itself cause some strokes. A testing strategy that does not include angiography will cause some strokes by leading to carotid endarterectomy in people who do not have severe CAS. In excellent centers, carotid endarterectomy is associated with a 30-day stroke or mortality rate of about 3%; some areas have higher rates. These harms are judged to be no less than small.
USPSTF Assessment

The USPSTF concludes that, for individuals with asymptomatic CAS, there is moderate certainty that the benefits of screening do not outweigh the harms.

Clinical Considerations
Abstract | Summary of Recommendations and Evidence | Clinical Considerations | Discussion |References | Appendices
Patient Population

This recommendation applies to adults without neurologic signs or symptoms, including a history of transient ischemic attacks or stroke. If otherwise eligible, an individual who has a carotid-area transient ischemic attack should be evaluated promptly for consideration of carotid endarterectomy.
Risk Assessment

In a setting of excellent surgical care and low complication rates, screening may benefit patients who have a very high risk for stroke. It is not clear, however, how to identify people whose risk for stroke is high enough to justify screening yet who do not also have a high risk for surgical complications. The major risk factors for CAS include older age, male sex, hypertension, smoking, hypercholesterolemia, and heart disease.
Screening Tests

Available screening and confirmatory tests (duplex ultrasonography, digital subtraction angiography, and magnetic resonance angiography) all have imperfect sensitivity and appreciable harms. Therefore, screening could lead to nonindicated surgeries that result in serious harms, including death, stroke, and myocardial infarction, in some patients.
Useful Resources

In other recommendations, the USPSTF notes that adults should be screened for hypertension, hyperlipidemia, and smoking. In addition, clinicians should discuss aspirin chemoprevention for patients who have an increased risk for cardiovascular disease. The evidence and recommendations

on these conditions from the USPSTF are available on the Agency for Healthcare Research and Quality Web site athttp://www.preventiveservices.ahrq.gov.

Discussion
Abstract | Summary of Recommendations and Evidence | Clinical Considerations | Discussion |References | Appendices
Burden of Disease

The contribution of CAS 60% to 99% to the morbidity and mortality associated with stroke, or to the natural progression of asymptomatic CAS in the general population, is not precisely known (12). Based on population-based studies and the accuracy of carotid duplex ultrasonography, the estimated prevalence of CAS 60% to 99% in the general population older than age 65 years is about 1%. Studies have found that CAS is more prevalent in older adults, smokers, those with hypertension, and those with heart disease. Research has not found any single risk factor or clinically useful risk stratification tool that can reliably and accurately distinguish people who have clinically important CAS from those who do not.
Scope of Review

In 1996, the USPSTF concluded that evidence was insufficient to recommend for or against screening of asymptomatic patients for CAS by using a physical examination or carotid ultrasonography. To update its recommendation, the USPSTF examined high-quality evidence on the natural history of CAS; systematic reviews of the accuracy of screening tests; and randomized, controlled trials (RCTs) of the benefits of treatment of CAS with carotid endarterectomy. Because the magnitude of potential surgical harms is such an important consideration in the treatment of CAS, the USPSTF conducted a systematic review of this issue.
Accuracy of Screening Tests

Two meta-analyses provide information on the accuracy of carotid duplex ultrasonography in detecting clinically important stenosis. Recent systematic reviews of studies about the accuracy of carotid duplex ultrasonography, using digital subtraction angiography as the reference standard, estimated the sensitivity to be 86% to 90% and the specificity to be 87% to 94% for detecting CAS greater than 70% (34). The estimated sensitivity and specificity of carotid duplex ultrasonography to detect CAS of 60% or more are approximately 94% and 92%, respectively (3). The reliability of carotid duplex ultrasonography is not established (3). One meta-analysis noted that the measurement properties used among various ultrasonography laboratories varied greatly and to a clinically important degree (3). In 1996, the USPSTF reviewed the evidence for screening for bruits on physical examination and found that the test had poor reliability and poor sensitivity (5).
Effectiveness of Early Detection and Treatment

Two good-quality RCTs, the ACAS (Asymptomatic Carotid Atherosclerosis Study) and the ACST (Asymptomatic Carotid Surgery Trial), compared carotid endarterectomy plus medical management to medical management alone in participants without symptoms attributable to the studied artery (67). The ACAS projected a 5-year rate of ipsilateral stroke and any perioperative stroke or death that was lower in the carotid endarterectomy group than in the medical group: 5.1% versus 11.0% (relative risk reduction, 0.53 [95% CI, 0.22% to 0.72%]). If strokes associated with angiography were included, the difference between the groups was 5.6% versus 11.0%, or an absolute difference of 5.4 percentage points over 5 years. The estimated relative risk reduction was greater for men than for women (0.66 and 0.17, respectively). The ACST projected a lower 5-year rate of any stroke or perioperative death in the carotid endarterectomy group than in the medical group: 6.4% versus 11.8% (absolute difference, 5.4 percentage points [CI 2.96 to 7.75 percentage points]). About half of the strokes prevented by carotid endarterectomy were disabling. The treatment groups did not statistically significantly differ in all-cause mortality in either study. The RCTs on carotid endarterectomy for asymptomatic CAS have important limitations in their generalizability to the primary care population. The RCTs included highly selected participants and surgeons. The 30-day perioperative results of the RCTs were reported as a combined outcome that did not include acute nonfatal myocardial infarction, which is an important complication. The medical treatment group in the RCTs was poorly defined, was not kept constant over the course of the study, and would not have included treatments that are now considered to be optimal medical management, including aggressive management of blood pressure and lipids.

Potential Harms of Screening and Treatment

Tests done to confirm carotid duplex ultrasonography have associated harms. If all positive tests are followed by digital subtraction angiography, about 1% of people would experience a nonfatal stroke as a result of the angiography. If positive tests are not followed by confirmatory angiography but rather by magnetic resonance angiography or computed tomography angiographytests with less than 100% accuracysome patients will have unnecessary carotid endarterectomy, with consequent harms in the absence of proven benefit. Fourteen good- or fair-quality observational studies that evaluated carotid endarterectomy complications in patients with asymptomatic CAS were identified for USPSTF review. Overall, 30-day perioperative stroke or death rates in asymptomatic patients ranged from 1.6% to 3.7% (2). Participants in ACAS had a perioperative rate of stroke or death of 2.7% overall (1.7% for men and 3.6% for women). In ACST, the perioperative rate of stroke or death was 3.1% overall but was higher for women (3.7%) than for men (2.4%). The observational studies reporting perioperative nonfatal myocardial infarctions showed a rate of approximately 0.7% to 1.1% (810). Patients with more comorbid conditions had a rate of nonfatal myocardial infarction up to 3.3% (9). The rate of nonfatal perioperative myocardial infarction reported for the surgical group in the RCTs varied from 0.6% to 1.9%. Two Medicare-based studies found variation in perioperative stroke and death among 10 states (1112). In the first study, the statewide rates ranged from 2.3% to 6.7%; a follow-up study for the same 10 states found similar results as those in 2001, with rates ranging from 1.4% to 6.0%.
Estimate of the Magnitude of Net Benefit

In patients and surgeons similar to those in the RCTs, treatment with carotid endarterectomy for asymptomatic CAS can result in a net absolute reduction in stroke rates approximately 5% over 5 to 6 years (about 2.5% absolute risk reduction for disabling strokes). The number needed to treat for 5 years to prevent 1 stroke is about 20 (number needed to treat to prevent 1 disabling stroke is about 40). This benefit has been shown in selected patients with selected surgeons, and it must be weighed against a small increase in nonfatal myocardial infarctions. The net benefit for carotid endarterectomy largely depends on people surviving the perioperative period without complications and living for 5 years. The 2 RCTs that found a benefit to surgery compared with medical management had 30-day perioperative rates of stroke and death of 2.7% to 3.1%, and some large observational studies have shown higher rates. If ultrasonography screening were followed by magnetic resonance angiography confirmation, about 23 strokes would be prevented over 5 years by screening 100 000 people with a prevalence of CAS of 1%. Thus, about 4348 people would need to undergo screening to prevent 1 stroke (number needed to screen) after 5 years. Twice this number (8696 people) would need to be screened to prevent 1 disabling stroke.
How Does the Evidence Fit with Biological Understanding?

The medical treatment group in the RCTs was poorly defined and probably did not include intensive blood pressure and lipid control, which is standard practice today. It is difficult to determine what effect current standard medical therapy would have on overall benefit from carotid endarterectomy. The KaplanMeier curves in ACST cross from net harm to net benefit at about 1.5 years after carotid endarterectomy for men and at nearly 3 years after carotid endarterectomy for women (1317). The average follow-up time in ACAS and ACST was 2.7 and 3.4 years, respectively; the estimated survival beyond the actual follow-up time may not be applicable in this situation. It is possible that the benefit from carotid endarterectomy is limited to a specific interval and does not continue unabated into the future. Thus, the actual (not projected) risk reduction for carotid endarterectomy over 5 to 10 years is still uncertain. Although this report did not review the evidence on medical treatment, accepted medical strategies to prevent stroke are available. Until research addresses the gaps in the evidence that screening and treatment with carotid endarterectomy provides overall benefits to the general population, clinicians' efforts might be more practically focused on optimizing medical management of risk factors of stroke.
Recommendations of Other Groups

In 2006, the American Heart Association/American Stroke Association did not recommend screening the general population for asymptomatic carotid stenosis (18). The American Society of Neuroimaging released recommendations in 2007 that also recommended against screening in unselected populations but advised that screening of adults age 65 years or older with 3 or more cardiovascular

risk factors should be considered (19). In 2007, the Society for Vascular Surgery recommended ultrasonography screening for individuals age 55 years or older with cardiovascular risk factors, such as a history of hypertension, diabetes mellitus, smoking, hypercholesterolemia, or known cardiovascular disease (20).

References
Abstract | Summary of Recommendations and Evidence | Clinical Considerations | Discussion |References | Appendices

1
Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening for asymptomatic carotid artery stenosis. Evidence Synthesis no. 50. AHRQ Publication no. 08-05102-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; December 2007. Accessed athttp://www.preventiveservices.ahrq.govon 12 October 2007.

2
Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening for carotid artery stenosis: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2007; 147:860.70

3
Jahromi AS, 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 metaanalysis. J Vasc Surg. 2005; 41:962.-72 PubMed CrossRef

4
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.-32 PubMed

5
. Guide to Clinical Preventive Services. 2nd ed. Rockville, MD: U.S. Preventive Services Task Force; 1996.

6
. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995; 273:1421.-8 PubMed

7
Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004; 363:1491.-502 PubMed

8
Horner RD, Oddone EZ, Stechuchak KM, Grambow SC, Gray J, Khuri SF. et al. Racial variations in postoperative outcomes of carotid endarterectomy: evidence from the Veterans Affairs National Surgical Quality Improvement Program. Med Care. 2002; 40:I35.-43 PubMed

9
Halm EA, Chassin MR, Tuhrim S, Hollier LH, Popp AJ, Ascher E. et al. Revisiting the appropriateness of carotid endarterectomy. Stroke. 2003; 34:1464.-71 PubMed

10

Karp HR, Flanders WD, Shipp CC, Taylor B, Martin D. Carotid endarterectomy among Medicare beneficiaries: a statewide evaluation of appropriateness and outcome. Stroke. 1998; 29:46.52 PubMed

11
Kresowik TF, Bratzler D, Karp HR, Hemann RA, Hendel ME, Grund SL, et al. Multistate utilization, processes, and outcomes of carotid endarterectomy. J Vasc Surg. 2001;33:227-34; discussion 234-5. [PMID: 11174772]

12
Kresowik TF, Bratzler DW, Kresowik RA, Hendel ME, Grund SL, Brown KR. et al. Multistate improvement in process and outcomes of carotid endarterectomy. J Vasc Surg. 2004; 39:372.80 PubMed

13
C. ACST: which subgroups will benefit most from carotid endarterectomy? [Letter]. Lancet. 2004;364:1124; author reply 1125-6. [PMID: 15451214]

14
Kietselaer BL, Hofstra L, Narula J. ACST: which subgroups will benefit most from carotid endarterectomy? [Letter]. Lancet. 2004;364:1124-5; author reply 1125-6. [PMID: 15451215]

15
Kumar S, Sinha B. ACST: which subgroups will benefit most from carotid endarterectomy? [Letter]. Lancet. 2004;364:1125; author reply 1125-6. [PMID: 15451217]

16
Masuhr F, Busch M. ACST: Which subgroups will benefit most from carotid endarterectomy? [Letter]. Lancet. 2004;364:1123-4; author reply 1125-6. [PMID: 15451213]

17
Rothwell PM. ACST: Which subgroups will benefit most from carotid endarterectomy? [Letter]. Lancet. 2004;364:1122-3; author reply 1125-6. [PMID: 15451212]

18
Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. American Heart Association/American Stroke Association Stroke Council. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006; 37:1583.-633 PubMed

19
Qureshi AI, Alexandrov AV, Tegeler CH, Hobson RW II, Dennis Baker J, Hopkins LN, American Society of Neuroimaging. Guidelines for screening of extracranial carotid artery disease: a statement for healthcare professionals from the multidisciplinary practice guidelines committee of the American Society of Neuroimaging; cosponsored by the Society of Vascular and Interventional Neurology. J Neuroimaging. 2007; 17:19.-47 PubMed

20
Society for Vascular Surgery. SVS Position Statement on Vascular Screenings, 2007. Accessed athttp://www.vascularweb.org/_CONTRIBUTION_PAGES/Patient_Information/screenings/SVS_Position_Stat ement_on_Vascular_Screenings.htmlon 11 May 2007.

Appendices
Abstract | Summary of Recommendations and Evidence | Clinical Considerations | Discussion |References | Appendices
Appendix: U.S. Preventive Services Task Force

Members of the U.S. Preventive Services Task Force are Ned Calonge, MD, MPH, Chair (Colorado Department of Public Health and Environment, Denver, Colorado); Diana B. Petitti, MD, MPH, Vice Chair(Keck School of Medicine, University of Southern California, Sierra Madre, California); Thomas G. DeWitt, MD (Children's Hospital Medical Center, Cincinnati, Ohio); Leon Gordis, MD, MPH, DrPH (Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland); Kimberly D. Gregory, MD, MPH (Cedars-Sinai Medical Center, Los Angeles, California); Russell Harris, MD, MPH (University of North Carolina School of Medicine, Chapel Hill, North Carolina); Kenneth W. Kizer, MD, MPH (National Quality Forum, Washington, DC); Michael L. LeFevre, MD, MSPH (University of Missouri School of Medicine, Columbia, Missouri); Carol Loveland-Cherry, PhD, RN (University of Michigan School of Nursing, Ann Arbor, Michigan); Lucy N. Marion, PhD, RN (Medical College of Georgia, Augusta, Georgia); Virginia A. Moyer, MD, MPH (University of Texas Health Science Center, Houston, Texas); Judith K. Ockene, PhD (University of Massachusetts Medical School, Worcester, Massachusetts); George F. Sawaya, MD (University of California, San Francisco, California); Albert L. Siu, MD, MSPH (Mount Sinai Medical Center, New York, New York); Steven M. Teutsch, MD, MPH (Merck & Company, West Point, Pennsylvania); and Barbara P. Yawn, MD, MSc (Olmsted Research Center, Rochester, Minnesota). This list includes members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.

http://my.americanheart.org/idc/groups/ahamahpublic/@wcm/@sop/@spub/documents/downloadable/ucm_430166.pdf

Carotid artery stenosis - ultrasound criteria

Dr Bruno Di Muzio and Radswiki et al. Ultrasound for internal carotid artery stenosis has become the first line examination in most cases, and images both the macroscopic appearance of the artery as well as flow characteristics.

normal additional criteria include ICA / CCA PSV ratio < 2.0 and ICA EDV < 40 cm/sec. < 50 % ICA stenosis ICA PSV is less than 125 cm/sec and plaque or intimal thickening is visible sonographically. additional criteria include ICA / CCA PSV ratio < 2.0 and ICA EDV < 40 cm/sec. 50 - 69 % ICA stenosis

o o o o o

ICA PSV is less than 125 cm/sec and no plaque or intimal thickening is visible sonographically.

ICA PSV is 125 - 230 cm/sec and plaque is visible sonographically.

o additional criteria include ICA / CCA PSV ratio of 2.0 - 4.0 and ICA EDV of 40 - 100 cm/sec. > / = 70 % ICA stenosis but less than near occlusion o
ICA PSV is greater than 230 cm / sec and visible plaque and luminal narrowing are seen at grayscale and color Doppler US (the higher the Doppler parameters lie above the threshold of 230 cm/sec, the greater the likelihood of severe disease).

o additional criteria include ICA / CCA PSV ratio > 4 and ICA EDV > 100 cm/sec. near occlusion of the ICA o o
velocity parameters may not apply, since velocities may be high, low, or undetectable. diagnosis is established primarily by demonstrating a markedly narrowed lumen at colour or power

Doppler US. total occlusion of the ICA

no detectable patent lumen at gray-scale US and no flow with spectral, power, and colour Doppler US.

Ultrasound assessment of carotid arterial atherosclerotic disease

Dr Ian Bickle and Dr Yuranga Weerakkody et al. Carotid arterial disease can be conveniently graded into percentage stenoses by assesing several sonographic parameters. The NASCET criteria is as follows.

no stenosis : normal wave form < 15 % stenosis : o deceleration spectral broadening with a peak systolic velocity (PSV) of < 125cm/s 16 - 49 % stenosis : o pan-systolic spectral broadening with a peak systolic velocity (PSV) of < 125 cm/s 50 - 69 % stenosis : o pan-systolic spectral broadening with a peak systolic velocity (PSV) of > 125 cm/s and

o o

end diastolic velocity (EDV) < 110 cm/s or ICA/CCA PSV ratio > 2 but < 4

70 - 79 % stenosis : o pan-systolic spectral broadening with PSV > 270 cm/s or

o o

EDV > 110 cm/s or ICA/CCA PSV ratio > 4

80 - 99% stenosis : EDV > 140 cm/s complete occlusion : no flow : terminal thump

Carotid Artery Stenosis: Gray-Scale and Doppler US DiagnosisSociety of

Radiologists in Ultrasound Consensus Conference

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 1. Edward G. Grant, MD, Carol B. Benson, MD, Gregory L. Moneta, MD, Andrei V. Alexandrov, MD, RVT, J. Dennis Baker, MD, Edward I. Bluth, MD, Barbara A. Carroll, MD, Michael Eliasziw, PhD, John Gocke, MD, MPH, RVT, Barbara S. Hertzberg, MD, Sandra Katanick, RN, RVT, Laurence Needleman, MD, John Pellerito, MD, Joseph F. Polak, MD, Kenneth S. Rholl, MD, Douglas L. Wooster, MD, RVT and R. Eugene Zierler, MD 1 From the Dept of Radiology, Univ of Southern California, Keck School of Medicine, USC University Hospital, 1500 San Pablo St, Los Angeles, CA 90033 (E.G.G.); Dept of Radiology, Brigham and Womens Hosp, Harvard Med School, Boston, Mass (C.B.B., J.F.F.); Dept of Surgery, Oregon Health and Science Univ, Portland, Ore (G.L.M.); Cerebrovascular Ultrasound and Stroke Treatment Team, Univ of Texas Houston Med School (A.V.A.); Dept of Surgery, West Los Angeles VA Med Ctr, Calif (J.D.B.); Dept of Radiology, Ochsner Clinic, New Orleans, La (E.I.B.); Dept of Radiology, Duke Univ Med School, Durham, NC (B.A.C., B.S.H.); Dept of Biostatistics, Univ of Calgary, Alberta, Canada (M.E.); Midwest Heart Specialists Vascular Lab and La Grange Memorial Vascular Laboratory, Downers Grove, Ill (J.G.); Intersocietal Accreditation Commission, Columbia, Md (S.K.); Dept of Radiology, Thomas Jefferson Univ, Philadelphia, Pa (L.N.); Dept of Radiology, North Shore Univ Hosp, New York Univ School of Med, NY (J.P.); Dept of Radiology, Inova Alexandria Hosp, Va (K.S.R.); Dept of Surgery, Univ of Toronto, Ontario, Canada (D.L.W.); and Dept of Surgery, Univ of Washington Med School, Seattle (R.E.Z.). Received Apr 1, 2003; revision requested May 7; revision received May 21; accepted May 22. Address correspondence to E.G.G. (e-mail:edgrant@usc.edu).

Abstract
The Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts in the field of vascular ultrasonography (US) to come to a consensus regarding Doppler US for assistance in the diagnosis of carotid artery stenosis. The panels consensus statement is believed to represent a reasonable position on the bas is of analysis of available literature and panelists experience. Key elements of the statement include the following:(a) All internal carotid artery (ICA) examinations should be performed with gray-scale, color Doppler, and spectral Doppler US. (b) The degree of stenosis determined at gray-scale and Doppler US should be stratified into the categories of normal (no stenosis), <50% stenosis, 50% 69% stenosis, 70% stenosis to near occlusion, near occlusion, and total occlusion. (c) ICA peak systolic velocity (PSV) and presence of plaque on gray-scale and/or color Doppler images are primarily used in diagnosis and grading of ICA stenosis; two additional parameters, ICA-tocommon carotid artery PSV ratio and ICA end-diastolic velocity may also be used when clinical or technical factors raise concern that ICA PSV may not be representative of the extent of disease. (d) ICA should be diagnosed as (i) normal when ICA PSV is less than 125 cm/sec and no plaque or intimal thickening is visible; (ii) <50% stenosis when ICA PSV is less than 125 cm/sec and plaque or intimal thickening is visible; (iii) 50%69% stenosis when ICA PSV is 125230 cm/sec and plaque is visible; (iv) 70% stenosis to near occlusion when ICA PSV is greater than 230 cm/sec and visible plaque and lumen narrowing are seen; (v) near occlusion when there is a markedly narrowed lumen at color Doppler US; and (vi) total occlusion when there is no detectable patent lumen at gray-scale US and no flow at spectral, power, and color Doppler US. (e) The final report should discuss velocity measurements and gray-scale and color Doppler findings. Study limitations should be noted when they exist. The conclusion should state an estimated degree of ICA stenosis as reflected in the above categories. The panel also considered various technical aspects of carotid US and methods for quality assessment and identified several important unanswered questions meriting future research.

 RSNA, 2003

Sonographic NASCET Index: A New Doppler Parameter for Assessment of Internal Carotid Artery Stenosis
1. 2. 3. 4. Gasser M. Hathouta,b, James R. Finka, Suzie M. El-Sadena,b and Edward G. Grantc + Author Affiliations 1. aDepartment of Radiology, University of California at Los Angeles 2. bDepartment of Radiology, West Los Angeles Veterans Administration Medical Center 3. cDepartment of Radiology, University of Southern California Medical Center, Los Angeles, CA Address reprint requests to Gasser M. Hathout, M.D., Department of Radiology, West Los Angeles Veterans Administration Medical Center, 11301 Wilshire Blvd, Los Angeles, CA 90073 Next Section

1.

Abstract
BACKGROUND AND PURPOSE: Established Doppler parameters for carotid stenosis assessment do not reflect North American Symptomatic Carotid Endarterectomy Trial (NASCET)-style methodology. We derived a Doppler parameter, termed sonographic NASCET index (SNI), and hypothesized that the SNI would provide greater angiographic correlation and better accuracy in predicting stenosis of 70% or greater than that of currently used peak systolic velocity (PSV) measurements. METHODS: Inclusion criteria of angiographically proved carotid stenoses of 4095% and measured proximal and distal internal carotid artery Doppler PSV values were established. Occlusions and near occlusions were specifically excluded. Doppler and angiographic data meeting the inclusion criteria from 32 carotid bifurcations were identified; actual angiographic stenoses ranged 40 89%. SNI values were calculated for each vessel. PSV and SNI were correlated with angiography by using linear regression analysis. Accuracies of SNI and PSV in predicting stenosis of 70% or greater were compared at two thresholds. RESULTS: Correlation between SNI and angiography was superior to that between PSV and angiography ( r2 = 0.64 vs 0.38). PSV and SNI values that corresponded to 70% angiographic stenosis were 345 cm/s and 45.5, respectively. Accuracy of PSV of 345 cm/s or greater in predicting stenosis of 70% or greater was 78%, compared with 88% for SNI of 45.5 or greater. The SNI value that corresponded to a PSV threshold of 250 cm/s was 33. Accuracy of PSV of 250 cm/s or greater in predicting stenosis of 70% or greater was 81%, compared with 88% for SNI of 33 or greater. CONCLUSION: Correlation between SNI and angiography was greater than that between PSV and angiography. Accuracy of SNI in predicting stenosis of 70% or greater was also superior to that of PSV at two thresholds. These results suggest that SNI may be a better predictor of high-grade carotid stenosis than is PSV. Vascular sonography is a safe, convenient, and relatively inexpensive means of evaluating atheromatous disease of the extracranial carotid arteries. Numerous studies have demonstrated the ability of sonography to help grade carotid stenosis, with accuracy rates approaching or exceeding 90% (115). Despite the emergence of new technologies such as CT angiography, duplex sonography remains a relatively accurate and noninvasive means of selecting surgically significant carotid stenoses. Sonography, alone or in combination with MR angiography, probably remains the most widely used initial method for preoperative evaluation at most medical centers worldwide ( 1617). According to the Society of Radiologists in Ultrasound (SRU) consensus statement published in 2003, Doppler sonography is increasingly becoming the sole imaging technique used before surgery for the evaluation of carotid stenosis (18). In fact, the SRU panelists estimated that as many as 80% of patients in the United States undergo carotid endarterectomy after a sonographic examination as the

only preoperative imaging study. Thus, it is extremely important that sonographic evaluation provide the most accurate possible results. Elevation of the internal carotid artery (ICA) peak systolic velocity (PSV) has been shown to be the single most useful Doppler sonographic parameter for detecting hemodynamically significant carotid stenosis and for selecting patients for carotid endarterectomy ( 1921). However, Doppler sonography has previously been shown to be unreliable in the quantification of stenosis severity as compared with the reference standard of arteriography, regardless of whether PSV alone or a ratio of ICA PSV to common carotid artery (CCA) PSV is considered ( 21, 22). However, the difference in benefit of carotid endarterectomy between the moderate stenosis category (50 69%), where only modest benefit is achieved, and the high-grade stenosis category (70%), where significant benefit is achieved, underscores the importance of accurate risk stratification by using sonography ( 23). The diagnostic accuracy of PSV in relation to North American Symptomatic Carotid Endarterectomy Trial (NASCET) angiographic stenosis measurement is limited in part by a significant difference in methodology. Historically, practitioners of vascular sonography have attempted to assess the degree of carotid stenosis through the use of Doppler parameters that incorporate flow velocity measured at a single point along the proximal ICA, such as PSV or end-diastolic velocity (EDV). Alternatively, a simple ratio comparison has been used that incorporates data from the distal CCA: the ICA PSV to CCA PSV ratio (VICA/VCCA ratio). In either case, these parameters ignore flow velocity information from the distal normal ICA and, therefore, do not reflect the NASCET methodology of carotid stenosis quantification, which relies on a ratio of the diseased lumen to the more normal ICA lumen (24). It has been suggested that inclusion of velocity data from a second point along the downstream normal ICA would be useful to improve the accuracy of Doppler sonography in the quantification of stenosis, akin to the NASCET method for measurement of angiographic stenosis ( 25). A simple ratio between the ICA systolic velocity at the carotid bulb and the distal ICA systolic velocity has been previously studied, and a slight improvement over PSV in predicting certain types of stenoses was found (26). We have proposed a new Doppler parameter based on the NASCET-style methodology of stenosis quantification that is herein called the sonographic NASCET index (SNI). Our derivation of the SNI incorporates flow velocity measurements obtained from within the normal distal ICA through application of the mass balance principle of bulk flow in a mathematically rigorous fashion. We have compared the diagnostic accuracy of the SNI with PSV by means of a retrospective analysis of 32 carotid bifurcations, with use of conventional angiography as the reference standard. Our hypothesis was that the SNI would be both more sensitive and more accurate than PSV for the diagnosis of highgrade carotid stenoses, as the SNI has been specifically derived to reflect the NASCET methodology of stenosis measurement. Previous SectionNext Section

Methods
Material A review of all carotid angiographic studies reported at our institution between October 1992 and July 1999 was performed. Vessels that were evaluated with both sonography and conventional arteriography were identified, with initial inclusion criteria of angiographically proven stenosis in the range of 4095%, as well as measured proximal and distal ICA Doppler PSV values. The lower bound was chosen to exclude insignificant degrees of luminal narrowing. The upper bound was chosen to exclude occlusions and near occlusions with partial luminal collapse, because such vessels do not submit to accurate NASCET-style measurements and may have paradoxically low PSV values (18, 24). Also, sonographic evaluation of near occlusions is based primarily on gray-scale and color Doppler imaging, rather than velocity data, making such vessels unsuitable for inclusion in this study (18). From this subgroup, 32 ICAs with stenoses ranging between 40% and 89% as determined with arteriography by using the NASCET methodology were identified (32 ICAs in 27 patients). Vessels were excluded if an intervening carotid endarterectomy was performed. The average time interval between sonography and arteriography was 2 months. Original sonographic studies were reviewed on a picture archiving and communication system workstation to obtain flow velocity data that had been recorded at the time of the study. Only archived data that remained accessible to the investigators were available for inclusion in this study. Vessels wherein the reported PSV corresponded to the distal-most velocity observed within the ipsilateral ICA were excluded. Angiography Digital subtraction angiography was performed through a femoral artery approach, with selective injections in the CCAs. At least two orthogonal views of each carotid bifurcation were obtained. Delayed imaging and prolonged injections were performed for all patients. Technical considerations included an exposure rate of one

image per second for 20 seconds or less and a manual injection volume of 20 mL or less of contrast material (Isovue 300 [iopamidol]; Bracco Diagnostics, Milan, Italy). In each case, the digital subtraction angiograms were reviewed in a blinded fashion by two experienced neuroradiologists (G.M.H., S.M.E.), and the final results were determined by consensus by averaging the two independent measurements for each vessel. Angiographic percentage stenosis determination was made in accordance with published NASCET guidelines (27). Sonography Carotid sonography was performed by experienced technologists in a single accredited laboratory at our institution, and the sonograms were interpreted by an experienced sonologist. Commercially available equipment that was state-of-the-art during the time period encompassed by this study was used for all examinations (Advanced Technology Laboratories, Bothell, WA; Acuson, Mountain View, CA). Five- or 7.5-MHz lineararray transducers were used, as dictated by patient body habitus. All images were obtained in accordance with an established laboratory protocol. All patients underwent gray-scale as well as color and spectral Doppler imaging. Angle adjustment was based on flow direction as depicted by color Doppler. Angle-adjusted spectral Doppler samples were obtained from predetermined sites within each CCA and ipsilateral ICA, including proximal, middle, and distal sites along the course of each vessel. The highest angle-adjusted velocities observed within each of the proximal, middle, and distal segments of the ICA were routinely recorded by the technologist, and the highest of these recorded velocities was routinely reported as the PSV by the interpreting radiologist. Doppler parameters routinely evaluated and reported for each carotid bifurcation included PSV, EDV, and VICA/VCCA ratio. Definition and Derivation of the SNI According to the principle of mass balance, the net flux at two different points along a single, nonbranching vessel must remain equal. With regard to the ICA, the flux proximally at point p (the point of maximal stenosis in the ICA) must equal the flux distally at point d (a more distal point along the normal ICA lumen). This is illustrated in Figure 1.

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FIG 1. Left ICA angiogram (lateral projection) shows high-grade (70%) proximal ICA stenosis. The flux proximally (Fluxp) at the point of maximal narrowing must equal the flux distally ( Fluxd) along the normal vessel lumen. To state this mathematically, Since flux is equal to the flow of blood passing through a defined cross-sectional area per unit time, the ICA flux is equal to the product of flow velocity and the luminal cross-sectional area. We may therefore substitute, Assuming that the cross-sectional area of the ICA approximates the area of a circle, we may also substitute, Rearranging algebraically, we derive, According to NASCET guidelines for the angiographic measurement of ICA stenosis, the luminal diameter, D, is measured proximally at the point of maximal stenosis and distally at a point where the ICA lumen becomes normal; the resultant percentage stenosis is expressed as, Recognizing that cross-sectional diameter is equal to twice the radius, Therefore, by substitution,

Thus, we have derived a new Doppler sonographic parameter, herein referred to as the SNI, according to the principle of mass balance, in a way that mirrors NASCET methodology for the angiographic determination of ICA stenosis. For each carotid bifurcation included in our study, values for the SNI were obtained by using the following equation: In this equation, the measured velocity originally reported as the PSV was used for PSV p, whereas the value recorded as the highest angle-adjusted velocity observed within the ipsilateral distal ICA was used for PSV d, to calculate each SNI value. Regression Model We used the standard model of linear regression, assuming that there is a dependent variable, Y, which in this case is the measured digital subtraction angiographic stenosis, and an independent variable, X, which in this case is the measured Doppler parameter from which Y is to be predicted. Output data and figures for this linear regression analysis were generated by using the Excel software package (Microsoft Corporation, Redmond, WA). Regression lines for both the PSV values and the SNI values were plotted against the measured angiographic stenosis values (Figs 2 and 3). The values for PSV and SNI that corresponded to 70% angiographic stenosis were determined from the linear regression plots. The accuracy of SNI in predicting 70% or greater angiographic stenosis was compared with that of PSV by using these threshold values.

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FIG 2. Linear regression plot of PSV versus measured NASCET linear percentage angiographic (ANGIO) stenosis (r2 = 0.38).

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FIG 3. Linear regression plot of SNI versus measured NASCET linear percentage angiographic ( ANGIO) stenosis (r2 = 0.64). A second set of threshold values was also obtained by using a PSV value of 250 cm/s, which was the value in clinical use at our institution for most of the study duration to identify significant carotid stenosis (see Discussion). Using the linear regression plots, the angiographic stenosis value corresponding to a PSV of 250 cm/s on Figure 2 was then used to read off the corresponding SNI value from Figure 3. Sensitivity, specificity, and accuracy tables for PSV and SNI at these two different Doppler thresholds were then calculated.

It is noted that both sets of threshold values were chosen prospectively after the linear regression analysis, but before any calculations of sensitivity, specificity, or accuracy, and hence were not chosen retrospectively to enhance the performance of the SNI. No other threshold values were evaluated. Previous SectionNext Section

Results
A total of 32 carotid bifurcations were included in the study, with NASCET-style digital subtraction angiographic measurements of linear percentage stenosis ranging from 40% to 89%. Sonographic PSV measurements ranged from 80 to 631 cm/s. Distal ICA velocities ranged from 32 to 201 cm/s. SNI values that were calculated by using the described methodology ranged from 3.9 to 72.4 (unitless parameter). Statistical Analysis Linear regression analysis showed a better correlation between SNI and measured NASCET linear percentage angiographic stenosis (r2 = 0.64) as compared with that between PSV and measured NASCET linear percentage angiographic stenosis (r2 = 0.38) (Figs 2 and 3). By using the data in Figure 2 and the associated linear regression equation of angiographic stenosis versus PSV, the value of PSV that corresponded to a NASCET linear percentage angiographic stenosis of 70% was determined to be 345 cm/s. Similarly, by using the data in Figure 3 and the associated linear regression equation of angiographic stenosis versus SNI, the SNI value that corresponded to a NASCET linear percentage angiographic stenosis of 70% was determined to be 45.5. This set of parameters formed one set of threshold values for comparison of PSV and SNI. The relevant data are in Table 1.
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TABLE 1: Accuracy of PSV and SNI in identifying significant (NASCET 70%) stenoses at a Doppler PSV threshold of 345 cm/s Of the 32 carotid arteries in this study, 15 had a measured NASCET linear percentage angiographic stenosis of 70% or greater, whereas 17 had a stenosis of less than 70%. In the 70% or greater group, nine of 15 stenoses were correctly identified by the PSV threshold of 345 cm/s, whereas 12 of 15 were correctly identified by the corresponding SNI threshold of 45.5. Both PSV and SNI criteria showed a true-negative rate of 16 of 17 in the less than 70% group (Table 1). A second comparison between the PSV and SNI criteria was undertaken at a lower PSV threshold of 250 cm/s (see Discussion). The SNI value that corresponded to this PSV threshold was 33. This was obtained by first using the PSV versus angiographic stenosis linear regression equation to identify the degree of angiographic stenosis corresponding to a PSV of 250 cm/s in our data set. This value of angiographic stenosis was then used in the SNI versus angiographic stenosis linear regression equation to identify the corresponding SNI value. The relevant data for this set of threshold values are presented in Table 2.
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TABLE 2: Accuracy of PSV and SNI in identifying significant (NASCET 70%) stenoses at a Doppler PSV threshold of 250 cm/s In the 70% or greater group, 13 of 15 stenoses were correctly identified by the PSV threshold of 250 cm/s, whereas 14 of 15 were correctly identified by the corresponding SNI threshold of 33. PSV criteria showed a truenegative rate of 13 of 17, whereas SNI criteria showed a true-negative rate of 14 of 17 in the less than 70% group (Table 2). Comparing a PSV threshold of 345 cm/s to the corresponding SNI value of 45.5 for identification of angiographic stenosis of 70% or greater, the sensitivity, specificity, and overall accuracy of Doppler sonography were 60% vs. 80%, 94% vs. 94%, and 78% vs. 88%, respectively. Thus, the SNI showed both a greater sensitivity and higher overall accuracy than those of PSV for this set of threshold values.

Comparing a PSV threshold of 250 cm/s and the corresponding SNI value of 33 for prediction of angiographic stenosis of 70% or greater, the sensitivity, specificity, and overall accuracy of Doppler sonography were 87% vs. 93%, 76% vs. 82%, and 81% vs. 88%, respectively. By using this set of threshold values, the SNI showed higher sensitivity, specificity, and accuracy when compared with those of PSV. As an example of the improved sensitivity of SNI, we present the data of a symptomatic patient who had a left ICA angiographic stenosis of 77% (Fig 4A). On the day before conventional angiography, this patient underwent bilateral carotid sonography (Fig 4BD) wherein the left ICA PSV was measured to be 165 cm/s, classifying this patients as having only a moderate stenosis based on the Doppler PSV threshold of 250 cm/s. The calculated SNI value of 35.3 exceeds the corresponding SNI threshold of 33, correctly identifying this stenosis as being 70% or greater.

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FIG 4. A, Left ICA angiogram (lateral projection) shows 77% stenosis of the proximal ICA by NASCET criteria, with a small plaque ulceration. BD, Color (B) and spectral Doppler images of the same proximal ( C) and distal (D) ICA obtained 1 day before conventional angiography. By using the higher PSV threshold of 345 cm/s, which is similar to the higher threshold value of 325 cm/s (favoring accuracy over sensitivity) published by Moneta et al (5), our database showed that six of 15 patients with high-grade stenosis would be misclassified as having a less than 70% stenosis by using the conventional PSV measurements. Four of these six patients misclassified by PSV alone had SNI values above the corresponding SNI threshold of 45.5, indicating a greater sensitivity of SNI even at high threshold values. Previous SectionNext Section

Discussion
During the past 2 decades, numerous different sonographic parameters for the identification of hemodynamically significant carotid stenosis (such as PSV, EDV, and the VICA/VCCA ratio), as well as different thresholds for each of these parameters, have been published (115, 18). In an attempt to establish a more universal set of standards, the SRU consensus guidelines for the diagnosis of carotid artery stenosis by using vascular sonography have recently been disseminated (18). In addition to recommending a general protocol for the performance of ICA examinations, the panel recommends stratification of the degree of stenosis as determined by sonography into categories that match those used by the NASCET investigators: no stenosis, less than 50% stenosis, 5069% stenosis, 70% or greater stenosis, near occlusion, and total occlusion. This decision was clearly made to facilitate the use of carotid sonographic evaluations in clinical decision making according to published NASCET data (23, 2729). The consensus panel also recommends reliance on PSV as the primary Doppler parameter used in the diagnosis and grading of ICA stenosis. Nonetheless, the utility of these various Doppler parameters in the detection and grading of carotid stenosis is largely determined by the numeric thresholds selected for their interpretation. These thresholds may be selected according to the presence or absence of symptoms, the desired levels of stenosis prediction (e.g., 70% stenosis for symptomatic patients), and the desired levels of accuracy, sensitivity and specificity. Furthermore, the ability of Doppler sonography to substratify angiographic stenoses within the recommended subgroups (e.g., within the 5069% group) through measurement of PSV has been shown to be limited (21).

It has been suggested that one reason for the limited correlation of Doppler sonography in substratifying patients when compared with cerebral angiography is that the two methodologies of stenosis measurement rely on different anatomic landmarks of internal reference: NASCET guidelines for angiographic diagnosis rely on the normal distal ipsilateral ICA lumen as an internal standard against which the degree of narrowing may be judged, whereas sonography relies on either a single velocity measurement in the proximal ICA (such as PSV and EDV) or on a velocity ratio (such as the VICA/VCCA ratio) by using the distal CCA for comparison rather than the normal distal ICA as in the NASCET methodology. This difference reflects the fact that these Doppler parameters were originally developed independent of the NASCET methodology. After the wide acceptance of NASCET results, Doppler sonography proceeded to fit threshold values to various sets of data to optimize agreement with NASCET-style angiographic measurements, rather than developing brand new sonographic parameters more consistent with the NASCET methodology. Our pilot study was intended to derive and initially evaluate such a new parameter, the SNI. Since the velocity within a given vessel may vary significantly along its course, it has generally become routine that velocity measurements be obtained at three different points along the ICA, designated as proximal, middle, and distal based on their location relative to the bulb. (Since the location of the carotid bifurcation with respect to the angle of the mandible is variable among patients, the ability to interrogate velocities along the more distal segments of the ICA is also variable.) The highest angle-adjusted velocity observed among the proximal, middle, and distal measurements is then generally taken to represent the PSV within the ICA. Since most ICA stenoses arise at or near the bifurcation, it has been our experience that the proximal or middle ICA velocity measurements are more frequently elevated with respect to the distal velocity and are therefore more often taken to represent the PSV within the vessel. Although the distal ICA velocity is routinely observed, this measurement is only sporadically used in clinical practice. Previous attempts to improve on the diagnostic accuracy of Doppler sonography by incorporating flow velocity information from the distal ICA have been made. The simple ratio of ICA PSV to distal ipsilateral ICA systolic velocity (called the ICSV/DICSV ratio) has been evaluated prospectively in the assessment of carotid stenosis, by using angiography as the reference standard. In comparison with PSV, the ICSV/DICSV ratio showed better correlation with angiographic stenosis for identifying stenoses of 60% or greater and 70% or greater in vessels with PSV of 100 cm/s or greater (26). Theoretic advantages of this technique include reduction in the possibility of stenosis overestimation due to compensatory increased flow across the stenosis, or from flow diversion to the external carotid artery. In practice, measurement of flow velocity within the distal ICA may occasionally be technically challenging, although technical failure occurs in a small minority of patients. Although data regarding the technical failure rate could not be obtained retrospectively for the purposes of our study, it should be noted that Soulez et al (26) reported a 7.9% technical failure rate by using the strict criteria that DICSV must be measured at least 4 cm distal to the site of PSV measurement and in an area of laminar flow (based on comparison of velocity bandwidth to that of the ipsilateral CCA or the contralateral, nonstenotic ICA). Our investigation suggests that perhaps the noninvasive detection of critical stenosis and the quantification of stenosis may be further improved in comparison with angiographic measurements through a mathematic incorporation of NASCET principles of measurement. The SNI is derived to specifically mirror the NASCET stenosis measurement by using the assumption of mass balance. Therefore, it is theoretically superior to the traditional Doppler parameters of PSV or simple ICA/CCA velocity ratios, which do not particularly correlate with the NASCET measurement of comparing the diseased site to the normal distal ICA. Moreover, since the SNI is derived to specifically reflect the NASCET stenosis ratio, it is, at least theoretically, also more accurate than the method of Soulez et al (26), which used only the distal ICA flow velocity in a simple ratio. Although our preliminary investigation suggests that the SNI may be a more optimal sonographic parameter than those currently in use vis--vis NASCET angiographic stenosis evaluation, ultimately, like any sonographic parameter, its utility will depend on well-chosen threshold values. In our study, we prospectively chose two sets of threshold values to compare the SNI to the PSV. The first of these was derived from the regression analysis of PSV versus measured angiographic stenosis, by using the PSV value (345 cm/s) corresponding to a stenosis of 70% on the regression line. The value for PSV thus obtained was similar to that of 325 cm/s reported by Moneta et al (7) in a study of various Doppler parameters that were selected to maximize the overall accuracy of predicting stenosis of 70% or greater. However, this value is higher than that used in most laboratories, including our own, and may lead to diminished sensitivity. The second PSV threshold chosen was 250 cm/s, which was the threshold value for high-grade stenosis used in our vascular laboratory during most the study time. It is nearly identical with the values of 270 cm/s proposed by Neale et al (6) derived with special reference to the NASCET data, and 230 cm/s proposed by Huston et al (10). It is also the value used in a new criteria recently proposed by Berland and Weber (30) for diagnosing 7099% stenosis. In the attempt to develop a new sonographic parameter more closely correlated to the NASCET methodology of measurement, several important ancillary issues deserve further comment. The first of these is regarding the use

of sonographic planimetry for direct stenosis measurement, by measuring either the linear vessel diameter or vessel cross-sectional area in the proximal ICA and the distal ICA to directly calculate the degree of stenosis. Certainly, such an approach would correlate more closely with NASCET methodology than anything else. However, various authors have indicated that such measurements, especially in high-grade stenosis, are often difficult to perform and do not reliably correlate to angiography (3031). Reasons for this include heavy calcification in the area of greatest stenosis, inability to accurately measure vessel borders, and lack of accuracy of longitudinal plane measurements of carotid lumen. Therefore, it has been widely accepted that physiologic assessment of flow velocity as a reflection of carotid stenosis is the more accurate sonographic method, until critical stenoses with near-occlusion are reached. Although, to our knowledge, the SNI is the sonographic parameter most closely correlated to the NASCET methodology thus far, it is important to note that it still relies on velocity measurements at a single time point (the point of PSV). Therefore, there is still a lack of a simple correlation between the SNI and measured angiographic stenosis, with no straightforward way available to provide a conversion table from one to the other. This is because there are several other considerations not accounted for in the derivation presented, which is intentionally kept simple so that the SNI may be readily used in the vascular laboratory. Attempting to fully characterize the complex biologic compensations that occur in the face of significant stenosis with a single PSV measurement is quite difficult. Certainly, as a vessel becomes narrower, velocity must increase to maintain flux, which is the crux of our mass-balance argument. However, the true mass-balance equations stipulate that bulk flow into the carotid equals bulk flow out. Thus, in reality, we must take into account the entire velocity profile over a cardiac cycle, or a defined unit of time, not just a single PSV measurement. Thus, In this equation, A represents the cross-sectional area of the vessel, whereas vrepresents the flow velocity within it. Calculating true bulk flow would require integrating over the entire velocity-time curve for a given period of time, such as one cardiac cycle. If there are changes in the Doppler waveform between the stenotic proximal ICA and the distal normal ICA (e.g., a greater distal diastolic flow component in the setting of tighter stenoses), then we are dealing with a more complex phenomenon than can be captured by measuring a single PSV value proximally and distally. To further complicate matters, the cross-sectional area A is actually also a function of time, A(t), varying with cardiac pulsations. A final and potentially serious limitation of the SNI has to do with the evaluation of near occlusion in the setting of a highly stenotic ICA. The SNI, of course, still relies on velocity measurements to assess the degree of luminal narrowing. However, it is known that velocity-based sonographic measurements become unreliable in this setting, and gray-scale evaluation along with color or power Doppler of the ICA are the preferred modes of sonographic evaluation (18, 30). In our preliminary study, no attempt was made to evaluate the accuracy of the SNI in the setting of near occlusion. Since velocity alterations, including velocity normalization or decrease in the setting of critical stenosis, would affect both the proximal and the distal ICA, the SNI may function better than PSV, EDV, or the VICA/VCCA ratio. However, this issue will require further separate study. Overall, although the SNI demonstrated increased sensitivity, specificity, and accuracy in this pilot study, we underscore that it would be premature to base surgical decision making solely on the SNI. We also note that at our institution, surgical decisions continue to be made primarily by using a combination of MR angiography and sonography and assessing for a concordance between these two modalities, as this has been shown to be superior to either technique alone (32). However, the SNI makes a serious attempt at tackling the issue of an essentially independent development of the NASCET-style measurement protocols and the sonographic criteria for significant stenosis, with an almost retrospective attempt to fit together two disjointed measurement methods. The former is obviously based on an anatomic measurement, whereas the latter is physiologic, and it is unlikely that a perfect match can ever be achieved. Previous SectionNext Section

Conclusion
We have shown that the incorporation of distal ICA flow velocity information in a rigorous mathematical fashion based on the principle of bulk flow mass balance improves the diagnostic accuracy of the most widely used and most accurate Doppler sonographic parameter, the PSV. We believe this is because the SNI is derived to specifically mirror the NASCET methodology of stenosis measurement. Confirmation of this hypothesis through a larger, prospective study is needed. Previous Section

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Received February 4, 2004. Accepted after revision April 5, 2004. Copyright American Society of Neuroradiology

CAROTID DUPLEX PROTOCOL

Published February 8, 2012 | By Dr. Ido Weinberg

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Vascular Laboratory

Every vascular laboratory performs carotid duplex in a different manner. ICAVL has published a guide to writing a protocol for extracranial carotid artery duplex. But it did not suggest a particular protocol over others. This article is meant to offer a guide for persons that are performing a carotid duplex. It will outline the practical steps of a standard carotid duplex.

Step 1 Patient placement for carotid duplex

Patient placement can mean a world of difference in carotid duplex. It is the difference between great images and missing important information. It is also the difference between chronic shoulder pain and healthy joints. You may want to read more about carotid duplex patient placement. Remember that every carotid duplex should be bilateral. This is because pathology in one carotid artery affects the other carotid artery.

Screening images of the carotid artery

Every carotid duplex should start with B-mode images. These offer information about artery contour and about plaque build up. Here are some suggestions for screening images:

Transverse and long images of the mid-common carotid artery in B-mode. Some labs suggest a color flow image of the mid-common carotid artery in long view to show color filling.

Common carotid b-mode duplex

Transverse image of the carotid bifurcation. Some labs also suggest a transverse image of the carotid bulb. I like to have both color and b-mode images.

Carotid bifurcation duplex

Long images of the external carotid artery and the internal carotid artery in B-mode and in color flow mode.

Color may make for easier identification. Also, the branch never lies...

Duplex of the internal carotid artery in b-mode and color

Carotid artery flow velocities

Flow velocities should be measured in standard locations: Proximal, mid and distal common carotid artery. The proximal common carotid artery should be sampled as close to the clavicle as possible. The distal common carotid artery should be sampled just before the carotid bulb.

Mid common carotid artery pulse wave Doppler

Next, the velocity in the external carotid artery is measured. Proof of location can be suggested by temporal tap. Some labs require this as part of the waveform images. Then, the internal carotid artery is sampled. The proximal internal carotid artery should receive special attention and thorough interogation. The distal internal carotid artery should be sampled as high as possible. Sometimes a posterior approach is better for this purpose than an anterior one. The mid internal carotid artery is sampled between these two. Finally, the vertebral artery flow velocity is checked.

If there is any suspicion forvertebral artery stenosis, effort should be made to sample as close to the vertebral artery origin as possible.

Vertebral artery pulse wave Doppler. Note the direction of the flow in relation to the internal jugular vein

Things to look out for outside the carotid arteries during a carotid duplex
The ultrasound field of vision is seldom limited to the carotid arteries alone. Other structures can be visualized. Obviously, the focus of the exam are the carotid arteries. But major findings in structures surrounding them should not be missed. Examples of such findings include:

Internal jugular vein thrombosis Carotid body tumor A carotid body tumor will often show as a wide splay of the carotid arteries.

Thyroid nodules are commonly noted on carotid duplex. An open mind should also be kept regarding potential unexpected findings in the carotid arteries themselves. Examples include carotid artery dissection, distal internal carotid artery stenosis suggestive of fibromuscular dysplasiaor long segments of stenosis suspect of Takayasus arteritis or post-radiation effects.

Common carotid artery dissection duplex (Courtesy of Lauren Dulkis)

Scanning the subclavian arteries as part of a carotid duplex

Scanning the subclavian arteries is not part of a standard carotid duplex in most places. They should be scanned as part of the carotid duplex in two instances:

At the end of the carotid duplex, blood pressure should be scanned in both arms. If there is a difference in blood pressure, subclavian artery stenosis should be suspected. Subclavian artery duplex is a good initial test to assess for subclavian artery stenosis.

Some common carotid artery or vertebral artery waveforms suggest proximal stenosis. For examplereverse flow in the vertebral artery suggestive of pre-steal or blunted waveforms, especially if these are unilateral.