Carotid artery stenosis diagnostic testing guidelines

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2]

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Diagnostic Testing in Patients With Symptoms or Signs of Extracranial Carotid Artery Disease (DO NOT EDIT)

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Class I Noninvasive imaging for detection of ECVD is recommended in the initial evaluation of patients with transient retinal or hemispheric neurological symptoms of possible ischemic origin. (Level of Evidence: C) Duplex ultrasonography is recommended to detect carotid stenosis in patients who develop focal neurological symptoms corresponding to the internal carotid artery territory. (Level of Evidence: C) In patients with acute, focal ischemic neurological symptoms corresponding to the territory supplied by the left or right internal carotid artery, magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is indicated to detect carotid stenosis when definitive sonography cannot be obtained. (Level of Evidence: C) When intracranial or ECVD is not severe enough to account for neurological symptoms of suspected ischemic origin, echocardiography should be performed seeking a source of cardiogenic embolism.(Level of Evidence: C) Class IIa In revascularization candidates MRA or CTA can be useful when carotid duplex ultrasonography is nondiagnostic. (Level of Evidence: C) CTA, MRA or elective cerebral angiography can be useful to search for intracranial vascular disease when an extracranial source of ischemia is not identified or to evaluate severity of stenosis and identify intrathoracic or intracranial vascular lesions not adequately assessed by ultrasonography. (Level of Evidence: C) Catheter-based angiography can be useful when noninvasive imaging is not sufficient. (Level of Evidence: C) MRA without contrast is reasonable to assess extent of disease in patients with renal insufficiency or extensive vascular calcification. (Level of Evidence: C) CTA is reasonable in patients who are not candidates for MRA because of claustrophobia, implanted pacemakers, or other incompatible devices. (Level of Evidence: C) Class IIb Duplex carotid ultrasonography might be considered for patients with nonspecific neurological symptoms when cerebral ischemia is a plausible cause. (Level of Evidence: C) When complete carotid arterial occlusion is suggested by duplex ultrasonography, MRA, or CTA, catheter-based angiography may be considered to determine whether the arterial lumen is sufficient to permit carotid revascularization. (Level of Evidence: C) Catheter-based angiography may be reasonable in patients with renal dysfunction to limit the amount of radiographic contrast material required for definitive imaging for evaluation of a single vascular territory. (Level of Evidence: C)

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