Carotid artery stenosis echocardiography or ultrasound

Carotid artery stenosis Microchapters
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Overview
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Differentiating Carotid artery stenosis from other Diseases
Epidemiology and Demographics
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Natural History, Complications and Prognosis
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ACC/AHA Guideline Recommendations
Diagnostic Testing Guidelines Recommendation
Primary Prevention and Screening Guidelines Recommendations
Secondary Prevention Guidelines Recommendations
Selection of Patients for Carotid Revascularization
Periprocedural Management of Patients Undergoing Carotid Endarterectomy
Management of Patients Undergoing Carotid Artery Stenting
Restenosis After Carotid Endarterectomy or Stenting
Vascular Imaging in Patients With Vertebral Artery Disease
Atherosclerotic Risk Factors in Patients With Vertebral Artery Disease
Occlusive Disease of the Subclavian and Brachiocephalic Arteries
Fibromuscular Dysplasia
Cervical Artery Dissection
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Case #1
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Carotid stenosis is usually diagnosed by ultrasound scan of the neck arteries. This is the first imaging option and usually used for follow up and observation as it involves no radiation and no contrast agents that may cause allergic reactions.

Echocardiography or Ultrasound

• Carotid duplex ultrasound is the test of choice to evaluate carotid disease.
• Grading:
  • Mild - < 40% stenosis
  • Moderate - 40 - 69% stenosis
  • Severe - 70 - 99% stenosis

Ultrasound Criteria for Carotid Artery Stenosis

• Normal:
  • ICA PSV is less than 125 cm/sec and no plaque or intimal thickening is visible sonographically.
  • 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:
  • ICA PSV is 125–230 cm/sec and plaque is visible sonographically.
  • 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
  • ICA PSV is greater than 230 cm/sec and visible plaque and luminal narrowing are seen at gray-scale and color Doppler US (The higher the Doppler parameter lies above the threshold of 230 cm/sec, the greater the likelihood of severe disease).
  • Additional criteria include ICA/CCA PSV ratio > 4 and ICA EDV > 100 cm/sec.
• Vear occlusion of the ICA:
  • Velocity parameters may not apply, since velocities may be high, low, or undetectable.
  • Diagnosis is established primarily by demonstrating a markedly narrowed lumen at color or power Doppler US (35).
• Total occlusion of the ICA
  • No detectable patent lumen at gray-scale US and no flow with spectral, power, and color Doppler US.

Examples

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2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS: Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (DO NOT EDIT)

Duplex Ultrasonography to Evaluate Asymptomatic Patients With Known or Suspected Carotid Stenosis (DO NOT EDIT)

Class I

"1. In asymptomatic patients with known or suspected carotid stenosis, duplex ultrasonography, performed by a qualified technologist in a certified laboratory, is recommended as the initial test to detect hemodynamically significant carotid stenosis. (Level of Evidence: C) "

Class III (No Benefit)

"1. Carotid duplex ultrasonography is not recommended for routine screening of asymptomatic patients who have no clinical manifestations of or risk factors for atherosclerosis. (Level of Evidence: C) "

"2. Carotid duplex ultrasonography is not recommended for routine evaluation of patients with neurological or psychiatric disorders unrelated to focal cerebral ischemia, such as brain tumors, familial or degenerative cerebral or motor neuron disorders, infectious and inflammatory conditions affecting the brain, psychiatric disorders, or epilepsy. (Level of Evidence: C) "

"3. Routine serial imaging of the extracranial carotid arteries is not recommended for patients who have no risk factors for development of atherosclerotic carotid disease and no disease evident on initial vascular testing. (Level of Evidence: C) "

Class IIa

"1. It is reasonable to perform duplex ultrasonography to detect hemodynamically significant carotid stenosis in asymptomatic patients with carotid bruit. (Level of Evidence: C)"

"2. It is reasonable to repeat duplex ultrasonography annually by a qualified technologist in a certified laboratory to assess the progression or regression of disease and response to therapeutic interventions in patients with atherosclerosis who have had stenosis greater than 50% detected previously. Once stability has been established over an extended period or the patient’s candidacy for further intervention has changed, longer intervals or termination of surveillance may be appropriate. (Level of Evidence: C)"

Class IIb

"1. Duplex ultrasonography to detect hemodynamically significant carotid stenosis may be considered in asymptomatic patients with symptomatic PAD, coronary artery disease (CAD), or atherosclerotic aortic aneurysm, but because such patients already have an indication for medical therapy to prevent ischemic symptoms, it is unclear whether establishing the additional diagnosis of ECVD in those without carotid bruit would justify actions that affect clinical outcomes. (Level of Evidence: C)"

"2. Duplex ultrasonography might be considered to detect carotid stenosis in asymptomatic patients without clinical evidence of atherosclerosis who have 2 or more of the following risk factors: hypertension, hyperlipidemia, tobacco smoking, a family history in a first degree relative of atherosclerosis manifested before age 60 years, or a family history of ischemic stroke. However, it is unclear whether establishing a diagnosis of ECVD would justify actions that affect clinical outcomes. (Level of Evidence: C)"