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Noninvasive Assessment of Carotid Stenosis Caused by Atherosclerosis

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Noninvasive Assessment of Carotid Stenosis Caused by Atherosclerosis Neuroradiology/Original Noninvasive assessment of carotid stenosis caused by atherosclerosis: a correlation between color Doppler ultrasound and gadolinium-enhanced magnetic resonance angiography A.M. Surur a,*, T.V. Buccolinia, H.F. Londero b, M.A. Marangonia and N.J. Allende c a Imaging Diagnosis Department, Sanatorio Allende, Córdoba, Argentina b Hemodynamic and Catheterization Intervention Department, Sanatorio Allende, Córdoba, Argentina c Vascular Surgery Department, Sanatorio Allende, Córdoba, Argentina Received: December 2012; Accepted: August 2013. ©SAR Abstract Introduction: Carotid angiography is used to confirm carotid bifurcation (CB) stenosis. However, as this is an invasive method with some morbidity and mortality, there is growing interest in non-invasive methods such as gadolinium- enhanced magnetic resonance angiography (Gd-MRA) and color Doppler ultrasound (CDUS). The aim of this study is to determine the correlation between the color Doppler ultrasound and gadolinium-enhanced magnetic resonance angiography in the evaluation of the degree of stenosis. Materials and methods: We analyzed 100 cases of carotid bifurcation studied by color Doppler ultrasound and gadolinium-enhanced magnetic resonance angiography performed between January 2009 and August 2011 at Sana- torio Allende. The level of agreement was determined using the Kappa coefficient, analyzing the percentage of carotid stenosis according to diameter narrowing and peak systolic velocity (PSV) by color Doppler ultrasound and estimating luminal narrowing by gadolinium-enhanced magnetic resonance angiography. The NASCET criteria were used for both methods. The plaque surface was also assessed. Results: A very good correlation was obtained between color Doppler ultrasound and gadolinium-enhanced magnetic resonance angiography, with a Kappa coefficient of 0.90 and a confidence interval (CI) of 95% (0.786-0.99). However, US/MRA results were discordant when assessing the plaque surface. Gd-MRA demonstrated to be superior in detecting plaque irregularities or ulcerations. Conclusion: Technological advances and the growing number of studies demonstrating diagnostic reliability and cor- relation of non-invasive methods lead us to assume that in the short term these methods will replace angiography for the diagnosis and assessment of carotid disease. © 2012 Sociedad Argentina de Radiología. Published by Elsevier España, S.L. All rights reserved. Keywords: stenosis; internal carotid artery; color Doppler ultrasound; gadolinium-enhanced magnetic resonance an- giography. Introduction provides mainly hemodynamic data, while gadolinium-en- hanced magnetic resonance angiography (Gd-MRA), mul- A large number of studies have clearly demonstrated the tislice computed tomography angiography (MSCTA) and digi- benefits of carotid endarterectomy in patients with severe tal subtraction angiography (DSA) show the anatomy of the (70-99%) or moderate (50-69%) carotid bifurcation stenosis CB, the origin of carotid arteries and the intracranial segment (BS) 1-4. Carotid stenting has become an effective and less of the internal carotid arteries. invasive method, with clear advantages for certain patient Carotid angiography is used to confirm and assess internal subsets 5,6. carotid artery (ICA) stenosis, previously detected by noninva- Invasive and noninvasive methods are available for the evalu- sive techniques. However, as this method is associated with ation of the neck arteries. Color Doppler ultrasound (CDUS) some morbidity and mortality7-9, there is a growing interest Rev. Argent. Radiol. 2013;77(4):267-274 267 Noninvasive assessment of carotid stenosis caused by atherosclerosis: a correlation between color Doppler ultrasound and gadolinium-enhanced magnetic resonance angiography A.M. Surur et. al. in noninvasive methods for the detection and assessment of The presence of endothelial plaque was confirmed, with carotid stenosis. Thus, it is possible to identify candidates for characterization of the plaque surface into three categories confirmatory diagnostic angiography and potential candi- (regular, irregular or ulcerated), based on imaging features, dates for endovascular stent therapy or carotid surgery. according to the carotid artery stenosis consensus 7,9,10. Fol- At our institution, we use CDUS and Gd-MRA as standard lowing Zwiebel’s guidelines, ulceration was defined as any practice for the diagnosis and assessment of ICA stenosis, cavity within the plaque, having well-defined borders and limiting the use of DSA to the confirmation of severe stenosis intracavity flow11. or to cases of inconsistency or inaccuracy as regards the de- For measuring the PSV in the internal carotid artery, the trans- gree of carotid stenosis determined by noninvasive methods. ducer was placed longitudinally to the vessel, examining the The aim of this study is to correlate two noninvasive methods whole plaque and searching for the area with PSV. Based on that provide complementary information for the study of ca- hemodynamic findings, the degree of stenosis was classified as: rotid bifurcation and to determine their diagnostic correlation in carotid stenosis. 1) Normal: PSV < 125 cm/s. No endothelial plaques. 2) < 50% stenosis: PSV < 125 cm/s, considering the pres- ence of endothelial plaque that narrows the arterial lu- Materials and methods men diameter by < 50%. 3) 50-69% stenosis: PSV between 125 and 230 cm/s, con- We conducted a descriptive, retrospective and observational sidering the presence of endothelial plaque that narrows cross-sectional study of a number of cases where supra-aortic the arterial lumen diameter by > 50%. trunks (SATs) were evaluated by CDUS and Gd-MRA in all 4) 70-90% stenosis: PSV ≥ 230 cm/s, considering the pres- (non consecutive) patients referred to the Radiology Depart- ence of endothelial plaque that narrows the arterial lu- ment of Sanatorio Allende from January 2009 to August men diameter by ≥ 50%. 2011. The study was submitted to and accepted by the Insti- 5) > 90% stenosis (“near occlusion”): high, low or unde- tutional Review Board. tectable PSV, considering the presence of a visible plaque There was a maximum interval of three months between the with almost total luminal occlusion and a thin flow on scans, and the analysis was focused on the carotid bulb and color Doppler. bifurcation because this is the site with the highest incidence 6) 100% stenosis (“total occlusion”): undetectable flow, of atheromatous plaques. considering a visible occlusive plaque with undetectable Inclusion criteria: all patients of any age and gender who un- arterial lumen. derwent both diagnostic procedures at our institution during the time period established. According to its characteristics, the surface of the plaque vi- Exclusion criteria: patients who had not undergone both di- sualized by CDUS and Gd-MRA was classified as: agnostic procedures at our institution or with a time interval • Regular surface longer than 3 months between the two studies. Patients with • Irregular surface intracarotid stents or carotid endarterectomy or those with • Ulcerated surface stenosis caused by non-atherosclerotic causes (including, but not limited to, vasculitis) were also excluded. Plaque composition and texture (lipid, fibrous lipid, calcific or fibrous calcific plaques) are parameters that were evaluated only by CDUS and were not correlated with Gd-MRA, as no Doppler technique specific sequences for characterization of plaque structure were performed. CDUS of the neck vessels was performed using a Philips HD 11 ultrasound system with 3-12 MHz linear transducer. The patient was placed in supine position with neck hyperexten- Gadolinium-enhanced magnetic resonance sion and rotation of the head in the direction opposite the angiography technique probe. Images were obtained from both carotid axes with gray-scale, color Doppler and spectral Doppler ultrasound, Magnetic resonance images were acquired on a 1.5 T Philips examining the subclavian and vertebral arteries, the com- Intera™ scanner, using fast gradient-echo (GRE) sequences at mon, internal and external carotid arteries and the carotid the level of the SATs, with gadolinium bolus injection (Opa- bifurcation, recording the peak systolic velocity (PSV) at a cite™15 ml), in the coronal plane with acquisition times of Doppler angle of 60° (fig. 1a). 35 seconds. Technical parameters were: 5.1/2 (repetition time 268 Rev. Argent. Radiol. 2013;77(4):267-274 Rev. Argent. Radiol. 2013;77(4):267-274 Noninvasive assessment of carotid stenosis caused by atherosclerosis: a correlation between color Doppler ultrasound and gadolinium-enhanced magnetic resonance angiography A.M. Surur et. al. a b Figure 1 (a) Color Doppler ultrasound shows the methodology to obtain the peak systolic velocity of the internal carotid artery. (b) Gadolinium-enhanced magnetic resonance angiography of supra-aortic trunks, in coronal plane. Scanning volume where the carotid arch, the proximal segment of the subclavian arteries and carotid and vertebral basilar territories are evaluated. Table 1: Assessment of Kappa coefficient Value of k Strength of agreement < 0.20 Poor 0.21 -0.40 Fair 0.41-0.60 Moderate 0.61-0.80 Good 0.41-1 Very good –TR-/ echo time –TE-); number of excitations (NEX): 1; recon- struction matrix: 512 x 512; field of view (FOV): 300 x 150; number of slices: 70; slice thickness: 1 mm; no GAP (fig. 1b). In maximum intensity projection (MIP) reconstructions, the degree of stenosis of the internal carotid artery was measured by Gd-MRA according
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