Volumen 68, Broj 5 VOJNOSANITETSKI PREGLED Strana 423 UDC: 616.133-073 ORIGINAL ARTICLE DOI:10.2298/VSP1105423V Color Doppler ultrasonography and multislice computer tomography angiography in carotid plaque detection and characterization Primena kolor dopler ultrasonografije i višeslojne kompjuterizovane tomografske angiografije u otkrivanju i karakterizaciji karotidnog plaka Viktorija Vučaj-Ćirilović*, Miloš Lučić†, Kosta Petrović*, Olivera Nikolić*, Mira Govorčin*, Sanja Stojanović* *Clinical Center of Vojvodina, Radiology Department, Novi Sad, Serbia; †Vojvodina Institute of Oncology, Center for Imaging Diagnostics, Sremska Kamenica, Serbia Abstract 97%; for plaques with irregular surface CDU 75% : MSCTA 87%; for ulcerations CDU 54% : MSCTA 87%). Regarding Beckground/Aim. Cerebrovascular diseases are the third determination of plaque structure (mixed plaque CDU 66% leading cause of mortality in the world, following malignant : MSCTA 70%; correlation with HP findings CDU 94% : and cardiovascular diseases. Therefore, their timely and pre- MSCTA 96%) and localization (CDU 63% : MSCTA 65%), cise diagnostics is of great importance. The aim of this study and in terms of sensitivity and specificity, both methods was to compare duplex scan Color Doppler ultrasonogra- showed almost the same results. Also, there is no statistical phy (CDU) with multislice computed tomography angiog- difference between these two methods for the degree of raphy (MSCTA) in detection of morphological and func- stenosis (CDU 96% : MSCTA 98%). Conclusion. Athero- tional disorders at extracranial level of carotid arteries. sclerotic disease of extracranial part of carotid arteries pri- Methods. The study included 75 patients with 150 carotid marily affects population of middle-aged and elderly, arteries examined in the period from January 2008 to April showing more associated risk factors. Sensitivity and speci- 2009. The patients were firstly examined by CDU, then ficity of CDU and MSCTA regarding plaque composition, MSCTA, followed by the surgery of extracranial segment of the degree of stenosis and plaque localization are almost the carotid arteries. In 10 patients, the obtained material was re- same. These results and the fact that there are no adverse ef- ferred for histopathological (HP) examination. We used fects (high radiation dose) compared to MSCTA indicate that both CDU and MSCT in the analysis of: plaque surface, CDU should be the initial method in diagnostic algorythm for plaque structure, degree of stenosis, and the presence of in- carotid arteries. traplaque hemorrhage. Results. The results obtained by CDU and MSCTA were first compared between themselves, and Key words: then to intraoperative findings. Retrospective analysis showed ultrasonography, doppler, color; cerebral angiography; that MSCTA is more sensitive than CDU in assessment of carotid artery diseases; carotid stenosis; tomography, plaque surface (for smooth plaques CDU 89% : MSCTA x ray computed. Apstrakt MSCTA, a zatim operacija karotidnih arterija. Kod 10 bole- snika uzet je materijal za patohistološku (PH) analizu. Anali- Uvod/Cilj. Cerebrovaskularne bolesti posle malignih i zirani su sledeći parametri : površina plaka, sastav plaka, kardiovaskularnih oboljenja najčešći su uzrok mortaliteta u stepen stenoze ekstrakranijalnog dela karotidne arterije i po- svetu. Zbog toga, pravovremena i tačna dijagnostika obo- stojanje intraplakalne hemoragije. Rezultati. Rezultati CDU ljenja na ekstrakranijalnom segmentu karotidnih arterija, kao i MSCTA upoređeni su međusobno, a zatim i sa intraopera- jednog od osnovnih činilaca u nastanku cerebrovaskularnih tivnim nalazom. Utvrđeno je da je MSCTA senzitivnija ne- bolesti, od velikog je značaja. Cilj ove studije bio je da se go CDU u vizulizaciji površine plaka (kod glatkih plakova uporede rezultati kolor dopler ultrasonografije (CDU) i vi- CDU 89% : MSCTA 97%; kod plakova neravne površine šeslojne kompjuterizovane tomografske angiografije CDU 75% : MSCTA 87%; kod ulkusa CDU 54% : MSCTA (MSCTA) u određivanju postojanja morfoloških i funkcio- 87%). U odnosu na sastav plaka MSCTA je senzitivnija u nalnih poremećaja na ekstrakranijalnom segmentu karotid- odnosu na CDU (mešoviti plak CDU 66% : MSCTA 70%; nih arterija. Metode. Studija je obuhvatala 75 bolesnika korelacija sa PH nalazom CDU 94% : MSCTA 96%), dok kod kojih je pregledano 150 karotidnih arterija, od januara su u odnosu na lokalizaciju plaka (CDU 63% : MSCTA 2008. do aprila 2009. Bolesnicima je prvo urađen CDU i 65%) senzitivnost i specifičnost obe metode približno isti. Correspondence to: Viktorija Vučaj-Ćirilović, Clinical Center of Vojvodina, Radiology Department, Hajduk Veljkova Str. 1–7, 21 000 Novi Sad, Serbia. Phone: +381 21 520 577, +381 63 516 000. E-mail: [email protected] Strana 424 VOJNOSANITETSKI PREGLED Volumen 68, Broj 5 Ne postoji statistički značajna razlika između metoda u od- i činjenice da nema štetnog efekta (visoke doze zračenja) u nosu na postojanje stepena stenoze ekstrakranijalnog dela odnosu na MSCTA, CDU treba da predstavlja inicijalnu karotidne arterije (CDU 96% : MSCTA 98%). Zaključak. metodu u dijagnostičkom algoritmu karotidnih arterija. Aterosklerotska bolest karotidnih arterija javlja se kod bole- snika srednjeg i starijeg životnog doba, često udružena sa Ključne reči: faktorima rizika. Senzitivnost i specifičnost CDU i MSCTA ultrasonografija, dopler, kolor; angiografija mozga; a. u proceni sastava plaka, stepena stenoze i lokalizacije plaka carotis, bolesti; a carotis, stenoza; tomografija, karotidnih arterija približno je ista. Zbog dobijenih rezultata kompjuterizovana, rendgenska. Introduction 2008 – May 2009). There were 24 female and 51 male pa- tients, average age of 63.7 years (ranging from 37 to 86). All Carotid atherosclerotic disease is the cause of cerebro- the patients were referred to examination by the vascular vascular insult in 20% of cases and is often associated with surgeon, with prior MRA findings. atherosclerotic changes in coronary and peripheral vessels. The following symptoms were analyzed: headache, diz- Carotid disease is determined by the level of arterial stenosis, ziness, vertigo, tingling in extremities, sight problems. The morphology of plaque and present ulceration. Ulceration of following risk factors were analyzed: smoking, diabetes, hy- plaque is defined as “intimal defect greater than 1000 µm in pertension, chronic renal insufficiency, hyperlipoproteine- depth covered with necrotic atherosclerotic plaque 1. mia, and associated pathology: cerebrovascular insult, coro- The presence of ulceration in plaque is an important nary infarction and peripheral arterial occlusive disease. risk factor for the occurrance of neurological symptoms, Prior vascular interventions, such as classical surgical inter- while high-grade stenosis associated with ulceration carries venton (TEA), coronary stenting, peripheral stenting (aorto- high risk of developing cerebrovascular insult (CVI). The in- iliac or femoropopliteal segment) or contralateral carotid cidence of ulceration in the carotid artery varies from 14% to stenting were also taken into account. Neurological status in- 68%, and is more often in symptomatic patients. cluded history of prior CVI. Conventional or digital subtractional angiography (DSA) The patients were firstly subjected to CDU, and then to is still considered to be the gold standard for assessing the MSCTA of carotid arteries in the same day, and afterwards level of stenosis, but is somewhat insufficient in determination (with the maximum of two-days delay) operation of the ex- of plaque morphology (sensitivity 46%, specificity 74%) 2. tracranial segment of carotid arteries was performed. After In spite of constant improvement of angiographic tech- thrombendarterectomy, plaque sample was referred to patho- nique, it is sometimes followed by some complications. histological analysis. There are local, general 3 and neurological complications 4. CDU was performed by the experienced radiologist on These complications are the main reason for common use of the GE LOGIC 7 sonographic unit, with a transducer of non-invasive techniques, such as color Doppler ultrasonog- 12MHz. MSCTA was performed by the same radiologist at raphy (CDU), 5, magnetic resonance angiography (MRA) and multislice spiral CT scanner Somatom Sensation 64 Siemens, multislice computed tomographic angiography (MSCTA) in using the bolus-triggering technique. After a short explana- the diagnostics and assessment of carotid disease, as well as tion of examination technique, all the patients signed the in determination of plaque morphology. standard informed consent. No patients presented with con- Stenosis of carotid arteries is one of the main factors in traindications to application of iv contrast agent (all the pa- defining further treatment of a patient 6. Treatment modalities tients had normal values of urea and creatinine, and no his- in a preventive programme of cerebrovascular insult are: ca- tory of allergic reactions to iodine). rotid endarterectomy (CEA), stenting of the carotid artery Intravenous non-iodine contrast agent (iopromid – Ul- (CAS) and medicamentous therapy. The NASCET (North travist 370, Bayer Shering) was applied via cubital vein in American Symptomatic Carotid Endarterectomy Trial) 7, 8 the dose of 100–120 mL, flow 4 mL, programme Carotid and ACAS study (Asymptomatic Carotid Atherosclerotic vascular. The contrast agent was applied using an automatic Group) 7, 9 showed that carotid thrombendarterectomy (CEA) injector,