We perform like this… how about you? Quick guide for the sonological assessment of carotid stenosis.
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Published:
Jun 10, 2024
Keywords:
carotid stenosis, ultrasound, NASCET, ECST, carotid stenosis classifications, clinical neuro-sonology.
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Abstract
For over forty years, ultrasound has been used to detect carotid plaque and to follow its evolution over time. Treatment protocols have greatly reduced its impact on people's health, but the choice between medical and surgical therapy is based on a clinical and instrument-based evaluation that is only simple in appearance.
In an ultrasound examination report, we most often report percentage of stenosis, sometimes in terms of range or we express ourselves with adjectives that describe the severity of the stenosis. However, we are often confused by the numbers and the different ways of calculating the range of stenosis and there is no doubt that, at times, the conclusions are ambiguous and extremely dependent on the interpretation of the operator. The problem is that digital angiography, the diagnostic gold standard for carotid stenosis, adopts metrics that are not entirely reproducible with ultrasound technology.
With this document we want to share the search for a common language, starting with the report of our examinations. We do it this way, how about you?
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Malferrari, G., Zini, A. ., Arnone, G. ., Migliaccio, L. ., Paolucci, M. ., Gentile, G. ., … Inchingolo, V. . (2024). We perform like this… how about you? Quick guide for the sonological assessment of carotid stenosis. Journal of Biomedical Practitioners, 8(1). https://doi.org/10.13135/2532-7925/10241
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Guidelines and good clinical practice
The authors agree to transfer the right of their publication to the Journal, simultaneously licensed under a Creative Commons License - Attribution that allows others to share the work indicating intellectual authorship and the first publication in this magazine.
References
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[17] Jahromi AS, Cinà 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 meta-analysis. J Vasc Surg. 2005 Jun;41(6):962-72. doi: 10.1016/j.jvs.2005.02.044. PMID: 15944595.
[18] Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, Carroll BA, Eliasziw M, Gocke J, Hertzberg BS, Katanick S, Needleman L, Pellerito J, Polak JF, Rholl KS, Wooster DL, Zierler RE. Carotid artery stenosis: gray-scale and Doppler US diagnosis--Society of Radiologists in Ultrasound Consensus Conference. Radiology. 2003 Nov;229(2):340-6. doi: 10.1148/radiol.2292030516. Epub 2003 Sep 18. PMID: 14500855.
[19] Oates CP, Naylor AR, Hartshorne T, Charles SM, Fail T, Humphries K, Aslam M, Khodabakhsh P. Joint recommenda-tions for reporting carotid ultrasound investigations in the United Kingdom. Eur J Vasc Endovasc Surg. 2009 Mar;37(3):251-61. doi: 10.1016/j.ejvs.2008.10.015. Epub 2008 Nov 29. PMID: 19046904.
[20] Arning C, Widder B, von Reutern GM, Steigler H, Gortler M (2010) Ultraschallkriterien zur Graduierung von Ste-nosen der A. carotis interna—Revision der DEGUM-Kriterien und Transfer in NASCET-Stenosierungsgrade. Ultra-schall Med 31:251–257
[21] Glagov S, Weisenberg E, Zarins CK, Stankunavicius R, Kolettis GJ. Compensatory enlargement of human athero-sclerotic coronary arteries. N Engl J Med. 1987 May 28;316(22):1371-5. doi: 10.1056/NEJM198705283162204. PMID: 3574413.
[22] Gray-Weale AC, Graham JC, Burnett JR, Byrne K, Lusby RJ. Carotid artery atheroma: comparison of preoperative B-mode ultrasound appearance with carotid endarterectomy specimen pathology. J Cardiovasc Surg (Torino). 1988 Nov-Dec;29(6):676-81. PMID: 3062007
[23] Sztajzel R. Ultrasonographic assessment of the morphological characteristics of the carotid plaque. Swiss Med Wkly. 2005 Oct 29;135(43-44):635-43. doi: 10.4414/smw.2005.11038. PMID: 16380850.
[24] JM Valdueza, SJ Schreiber, JE Roehl, F Connolly, R Klingebiel. Neurosonology and Neuroimaging of Stroke: a comprehensive reference, edition. 2017; 630 p; Thieme; Stoccarda (Germania); ISBN 978-3-13-141872-21
[25] Polak JF, Kremkau FW. The 60° Doppler Angle Correction Paradigm: Reality or Myth? (an Uncomfortable Truth?). J Ultrasound Med. 2021 Oct;40(10):2227-2233. doi: 10.1002/jum.15603. Epub 2020 Dec 23. PMID: 33355961.
[26] Nicolaides AN. Asymptomatic carotid stenosis and risk of stroke. Identification of a high risk group (ACSRS). A natural history study. Int Angiol. 1995 Mar;14(1):21-3. PMID: 7658100.
[27] Valaikiene J, Schlachetzki F, Azevedo E, Kaps M, Lochner P, Katsanos AH, Walter U, Baracchini C, Bartels E, Ško-loudík D. Point-of-Care Ultrasound in Neurology - Report of the EAN SPN/ESNCH/ERcNsono Neuro-POCUS Working Group. Ultraschall Med. 2022 Aug;43(4):354-366. English. doi: 10.1055/a-1816-8548. Epub 2022 May 5. PMID: 35512836.
[28] Felix Schlachetzki, Max Nedelman, Holger Poppert, Dorothee Saur, Andreas Haroff, Jan Liman, Matthias Reinhardt, Erwin Stoltz, Manfred Kaps. Neurosonological Diagnosis in the Acute Phase of Stroke is a Sign of Qualified Care. Neurology International Open 2017; 01(03): E182-E188 DOI: 10.1055/s-0043-109331
[29] Gornik HL, Rundek T, Gardener H, Benenati JF, Dahiya N, Hamburg NM, Kupinski AM, Leers SA, Lilly MP, Lohr JM, Pellerito JS, Rholl KS, Vickery MA, Hutchisson MS, Needleman L. Optimization of duplex velocity criteria for dia-gnosis of internal carotid artery (ICA) stenosis: A report of the Intersocietal Accreditation Commission (IAC) Va-scular Testing Division Carotid Diagnostic Criteria Committee. Vasc Med. 2021 Oct;26(5):515-525. doi: 10.1177/1358863X211011253. Epub 2021 May 19. PMID: 34009060; PMCID: PMC8493430.
[30] Polak JF, Alexandrov AV. Accuracy of the Society of Radiologists in Ultrasound (SRU) Carotid Doppler Velocity Criteria for Grading North American Symptomatic Carotid Endarterectomy Trial (NASCET) Stenosis: A Meta-Analysis. J Ultrasound Med. 2023 Jul;42(7):1423-1435. doi: 10.1002/jum.16150. Epub 2022 Dec 17. PMID: 36527708.
[31] Beach KW, Leotta DF, Zierler RE. Carotid Doppler velocity measurements and anatomic stenosis: correlation is fu-tile. Vasc Endovascular Surg. 2012 Aug;46(6):466-74. doi: 10.1177/1538574412452159. Epub 2012 Jul 10. PMID: 22786979.
[32] Serena J, Irimia P, Calleja S, Blanco M, Vivancos J, Ayo-Martín O; Representación de la Sociedad Española de Neurosonología (SONES). Cuantificación ultrasonográfica de la estenosis carotídea: recomendaciones de la Socie-dad Española de Neurosonología [Ultrasound measurement of carotid stenosis: recommendations from the Spanish Society of Neurosonology]. Neurologia. 2013 Sep;28(7):435-42. Spanish. doi: 10.1016/j.nrl.2012.07.011. Epub 2012 Oct 4. PMID: 23040716.
[33] Chatzikonstantinou A, Wolf ME, Schaefer A, Hennerici MG. Asymptomatic and symptomatic carotid stenosis: an ob-solete classification? Stroke Res Treat. 2012;2012:340798. doi: 10.1155/2012/340798. Epub 2012 Jan 23. PMID: 22315705; PMCID: PMC3270474.
[34] Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Mar-kus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Esvs Guidelines Committee, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Esvs Guideline Reviewers, Archie J, Bell-munt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Athero-sclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Va-scular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018 Jan;55(1):3-81. doi: 10.1016/j.ejvs.2017.06.021. Epub 2017 Aug 26. PMID: 28851594.
[35] Paraskevas KI, Veith FJ, Spence JD. How to identify which patients with asymptomatic carotid stenosis could be-nefit from endarterectomy or stenting. Stroke Vasc Neurol. 2018 Feb 24;3(2):92-100. doi: 10.1136/svn-2017-000129. PMID: 30022795; PMCID: PMC6047337.
[36] Abbott AL, Paraskevas KI, Kakkos SK, Golledge J, Eckstein HH, Diaz-Sandoval LJ, Cao L, Fu Q, Wijeratne T, Leung TW, Montero-Baker M, Lee BC, Pircher S, Bosch M, Dennekamp M, Ringleb P. Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis. Stroke. 2015 Nov;46(11):3288-301. doi: 10.1161/STROKEAHA.115.003390. Epub 2015 Oct 8. PMID: 26451020.
[37] linee guida SPREAD 2017
[38] linee guida SICVE 2021
[39] Paraskevas KI, Nicolaides AN, Kakkos SK. Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study: what have we learned from it? Ann Transl Med. 2020 Oct;8(19):1271. doi: 10.21037/atm.2020.02.156. PMID: 33178803; PMCID: PMC7607063.
[40] Siniscalchi A, Murphy S, Gray C, De Sarro G, Gallelli L. Biomarkers in Unstable Carotid Plaque: Physiopathology and Prediction. Cardiovasc Hematol Agents Med Chem. 2022;20(1):13-19. doi: 10.2174/1871525719666210901131509. PMID: 34468303.
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[2] Saba L, Nardi V, Cau R, Gupta A, Kamel H, Suri JS, Balestrieri A, Congiu T, Butler APH, Gieseg S, Fanni D, Cerro-ne G, Sanfilippo R, Puig J, Yang Q, Mannelli L, Faa G, Lanzino G. Carotid Artery Plaque Calcifications: Lessons From Histopathology to Diagnostic Imaging. Stroke. 2022 Jan;53(1):290-297. doi: 10.1161/STROKEAHA.121.035692. Epub 2021 Nov 10. PMID: 34753301.
[3] Gray-Weale AC, Graham JC, Burnett JR, Byrne K, Lusby RJ. Carotid artery atheroma: comparison of preoperative B-mode ultrasound appearance with carotid endarterectomy specimen pathology. J Cardiovasc Surg (Torino). 1988 Nov-Dec; 29(6):676-81. PMID: 3062007.
[4] MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet. 1991 May 25;337(8752):1235-43. PMID: 1674060.
[5] North American Symptomatic Carotid Endarterectomy Trial Collaborators; Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, Ferguson GG, Fox AJ, Rankin RN, Hachinski VC, Wiebers DO, Eliasziw M. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991 Aug 15;325(7):445-53. doi: 10.1056/NEJM199108153250701. PMID: 1852179.
[6] Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995 May 10;273(18):1421-8. PMID: 7723155.
[7] Schäberle, W. Sonographic grading of recurrent stenosis after carotid stenting and stented peripheral arte-ries. Gefässchirurgie 24 (Suppl 1), 40–51 (2019). https://doi.org/10.1007/s00772-018-0496-3
[8] Tambasco M, Steinman DA. Path-dependent hemodynamics of the stenosed carotid bifurcation. Ann Biomed Eng. 2003 Oct;31(9):1054-65. doi: 10.1114/1.1603257. PMID: 14582608.
[9] Williams MA, Nicolaides AN. Predicting the normal dimensions of the internal and external carotid arteries from the diameter of the common carotid. Eur J Vasc Surg. 1987 Apr;1(2):91-6. doi: 10.1016/s0950-821x(87)80004-x. PMID: 3503020.
[10] Rothwell PM, Gibson RJ, Slattery J, Sellar RJ, Warlow CP. Equivalence of measurements of carotid stenosis. A comparison of three methods on 1001 angiograms. European Carotid Surgery Trialists' Collaborative Group. Stro-ke. 1994 Dec;25(12):2435-9. doi: 10.1161/01.str.25.12.2435. PMID: 7974586.
[11] Rothwell PM, Warlow CP. The European Carotid Surgery Trial (ECST). In: Greenhalgh RM, Hollier LH, eds. Surge-ry for Stroke. London, England: WB Saunders; 1993.
[12] Spencer MP, Reid JM. Quantitation of carotid stenosis with continuous-wave (C-W) Doppler ultrasound. Stroke. 1979 May-Jun;10(3):326-30. doi: 10.1161/01.str.10.3.326. PMID: 462521.
[13] Spencer MP. Hemodynamics of arterial stenosis.In: Spencer MP, ed. Ultrasonic Diagnosis Of Cerebrovascular Di-sease. Dordrecht: Martinus Nijhof Publishers; 1987, 117–146.
[14] Ohara T, Toyoda K, Otsubo R, Nagatsuka K, Kubota Y, Yasaka M, Naritomi H, Minematsu K. Eccentric stenosis of the carotid artery associated with ipsilateral cerebrovascular events. AJNR Am J Neuroradiol. 2008 Jun;29(6):1200-3. doi: 10.3174/ajnr.A0997. Epub 2008 Mar 13. PMID: 18339721; PMCID: PMC8118845.
[15] Steinman DA, Poepping TL, Tambasco M, Rankin RN, Holdsworth DW. Flow patterns at the stenosed carotid bifur-cation: effect of concentric versus eccentric stenosis. Ann Biomed Eng. 2000 Apr;28(4):415-23. doi: 10.1114/1.279. PMID: 10870898.
[16] AbuRahma AF, Srivastava M, Stone PA, Mousa AY, Jain A, Dean LS, Keiffer T, Emmett M. Critical appraisal of the Carotid Duplex Consensus criteria in the diagnosis of carotid artery stenosis. J Vasc Surg. 2011 Jan;53(1):53-9; discussion 59-60. doi: 10.1016/j.jvs.2010.07.045. Epub 2010 Oct 15. PMID: 20951536.
[17] Jahromi AS, Cinà 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 meta-analysis. J Vasc Surg. 2005 Jun;41(6):962-72. doi: 10.1016/j.jvs.2005.02.044. PMID: 15944595.
[18] Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, Carroll BA, Eliasziw M, Gocke J, Hertzberg BS, Katanick S, Needleman L, Pellerito J, Polak JF, Rholl KS, Wooster DL, Zierler RE. Carotid artery stenosis: gray-scale and Doppler US diagnosis--Society of Radiologists in Ultrasound Consensus Conference. Radiology. 2003 Nov;229(2):340-6. doi: 10.1148/radiol.2292030516. Epub 2003 Sep 18. PMID: 14500855.
[19] Oates CP, Naylor AR, Hartshorne T, Charles SM, Fail T, Humphries K, Aslam M, Khodabakhsh P. Joint recommenda-tions for reporting carotid ultrasound investigations in the United Kingdom. Eur J Vasc Endovasc Surg. 2009 Mar;37(3):251-61. doi: 10.1016/j.ejvs.2008.10.015. Epub 2008 Nov 29. PMID: 19046904.
[20] Arning C, Widder B, von Reutern GM, Steigler H, Gortler M (2010) Ultraschallkriterien zur Graduierung von Ste-nosen der A. carotis interna—Revision der DEGUM-Kriterien und Transfer in NASCET-Stenosierungsgrade. Ultra-schall Med 31:251–257
[21] Glagov S, Weisenberg E, Zarins CK, Stankunavicius R, Kolettis GJ. Compensatory enlargement of human athero-sclerotic coronary arteries. N Engl J Med. 1987 May 28;316(22):1371-5. doi: 10.1056/NEJM198705283162204. PMID: 3574413.
[22] Gray-Weale AC, Graham JC, Burnett JR, Byrne K, Lusby RJ. Carotid artery atheroma: comparison of preoperative B-mode ultrasound appearance with carotid endarterectomy specimen pathology. J Cardiovasc Surg (Torino). 1988 Nov-Dec;29(6):676-81. PMID: 3062007
[23] Sztajzel R. Ultrasonographic assessment of the morphological characteristics of the carotid plaque. Swiss Med Wkly. 2005 Oct 29;135(43-44):635-43. doi: 10.4414/smw.2005.11038. PMID: 16380850.
[24] JM Valdueza, SJ Schreiber, JE Roehl, F Connolly, R Klingebiel. Neurosonology and Neuroimaging of Stroke: a comprehensive reference, edition. 2017; 630 p; Thieme; Stoccarda (Germania); ISBN 978-3-13-141872-21
[25] Polak JF, Kremkau FW. The 60° Doppler Angle Correction Paradigm: Reality or Myth? (an Uncomfortable Truth?). J Ultrasound Med. 2021 Oct;40(10):2227-2233. doi: 10.1002/jum.15603. Epub 2020 Dec 23. PMID: 33355961.
[26] Nicolaides AN. Asymptomatic carotid stenosis and risk of stroke. Identification of a high risk group (ACSRS). A natural history study. Int Angiol. 1995 Mar;14(1):21-3. PMID: 7658100.
[27] Valaikiene J, Schlachetzki F, Azevedo E, Kaps M, Lochner P, Katsanos AH, Walter U, Baracchini C, Bartels E, Ško-loudík D. Point-of-Care Ultrasound in Neurology - Report of the EAN SPN/ESNCH/ERcNsono Neuro-POCUS Working Group. Ultraschall Med. 2022 Aug;43(4):354-366. English. doi: 10.1055/a-1816-8548. Epub 2022 May 5. PMID: 35512836.
[28] Felix Schlachetzki, Max Nedelman, Holger Poppert, Dorothee Saur, Andreas Haroff, Jan Liman, Matthias Reinhardt, Erwin Stoltz, Manfred Kaps. Neurosonological Diagnosis in the Acute Phase of Stroke is a Sign of Qualified Care. Neurology International Open 2017; 01(03): E182-E188 DOI: 10.1055/s-0043-109331
[29] Gornik HL, Rundek T, Gardener H, Benenati JF, Dahiya N, Hamburg NM, Kupinski AM, Leers SA, Lilly MP, Lohr JM, Pellerito JS, Rholl KS, Vickery MA, Hutchisson MS, Needleman L. Optimization of duplex velocity criteria for dia-gnosis of internal carotid artery (ICA) stenosis: A report of the Intersocietal Accreditation Commission (IAC) Va-scular Testing Division Carotid Diagnostic Criteria Committee. Vasc Med. 2021 Oct;26(5):515-525. doi: 10.1177/1358863X211011253. Epub 2021 May 19. PMID: 34009060; PMCID: PMC8493430.
[30] Polak JF, Alexandrov AV. Accuracy of the Society of Radiologists in Ultrasound (SRU) Carotid Doppler Velocity Criteria for Grading North American Symptomatic Carotid Endarterectomy Trial (NASCET) Stenosis: A Meta-Analysis. J Ultrasound Med. 2023 Jul;42(7):1423-1435. doi: 10.1002/jum.16150. Epub 2022 Dec 17. PMID: 36527708.
[31] Beach KW, Leotta DF, Zierler RE. Carotid Doppler velocity measurements and anatomic stenosis: correlation is fu-tile. Vasc Endovascular Surg. 2012 Aug;46(6):466-74. doi: 10.1177/1538574412452159. Epub 2012 Jul 10. PMID: 22786979.
[32] Serena J, Irimia P, Calleja S, Blanco M, Vivancos J, Ayo-Martín O; Representación de la Sociedad Española de Neurosonología (SONES). Cuantificación ultrasonográfica de la estenosis carotídea: recomendaciones de la Socie-dad Española de Neurosonología [Ultrasound measurement of carotid stenosis: recommendations from the Spanish Society of Neurosonology]. Neurologia. 2013 Sep;28(7):435-42. Spanish. doi: 10.1016/j.nrl.2012.07.011. Epub 2012 Oct 4. PMID: 23040716.
[33] Chatzikonstantinou A, Wolf ME, Schaefer A, Hennerici MG. Asymptomatic and symptomatic carotid stenosis: an ob-solete classification? Stroke Res Treat. 2012;2012:340798. doi: 10.1155/2012/340798. Epub 2012 Jan 23. PMID: 22315705; PMCID: PMC3270474.
[34] Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Mar-kus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Esvs Guidelines Committee, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Esvs Guideline Reviewers, Archie J, Bell-munt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Athero-sclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Va-scular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018 Jan;55(1):3-81. doi: 10.1016/j.ejvs.2017.06.021. Epub 2017 Aug 26. PMID: 28851594.
[35] Paraskevas KI, Veith FJ, Spence JD. How to identify which patients with asymptomatic carotid stenosis could be-nefit from endarterectomy or stenting. Stroke Vasc Neurol. 2018 Feb 24;3(2):92-100. doi: 10.1136/svn-2017-000129. PMID: 30022795; PMCID: PMC6047337.
[36] Abbott AL, Paraskevas KI, Kakkos SK, Golledge J, Eckstein HH, Diaz-Sandoval LJ, Cao L, Fu Q, Wijeratne T, Leung TW, Montero-Baker M, Lee BC, Pircher S, Bosch M, Dennekamp M, Ringleb P. Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis. Stroke. 2015 Nov;46(11):3288-301. doi: 10.1161/STROKEAHA.115.003390. Epub 2015 Oct 8. PMID: 26451020.
[37] linee guida SPREAD 2017
[38] linee guida SICVE 2021
[39] Paraskevas KI, Nicolaides AN, Kakkos SK. Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study: what have we learned from it? Ann Transl Med. 2020 Oct;8(19):1271. doi: 10.21037/atm.2020.02.156. PMID: 33178803; PMCID: PMC7607063.
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