Edward G.

Grant, MD Carotid Artery Stenosis:

Radiology

Carol B. Benson, MD
Gregory L. Moneta, MD
Andrei V. Alexandrov, MD, RVT
Gray-Scale and Doppler US
J. Dennis Baker, MD
Edward I. Bluth, MD Diagnosis—Society of
Barbara A. Carroll, MD
Michael Eliasziw, PhD
John Gocke, MD, MPH, RVT
Radiologists in Ultrasound
Barbara S. Hertzberg, MD
Sandra Katanick, RN, RVT Consensus Conference1
Laurence Needleman, MD
John Pellerito, MD
Joseph F. Polak, MD The Society of Radiologists in Ultrasound convened a multidisciplinary panel of
Kenneth S. Rholl, MD experts in the field of vascular ultrasonography (US) to come to a consensus
Douglas L. Wooster, MD, RVT regarding Doppler US for assistance in the diagnosis of carotid artery stenosis. The
Eugene Zierler, MD panel’s consensus statement is believed to represent a reasonable position on the
basis of analysis of available literature and panelists’ experience. Key elements of the
Index terms: statement include the following: (a) All internal carotid artery (ICA) examinations
Carotid arteries, flow dynamics
should be performed with gray-scale, color Doppler, and spectral Doppler US.
Carotid arteries, stenosis or
obstruction, 172.4311, 172.4312, (b) The degree of stenosis determined at gray-scale and Doppler US should be
172.721 stratified into the categories of normal (no stenosis), ⬍50% stenosis, 50%– 69%
Carotid arteries, US, 172.12981, stenosis, ⱖ70% stenosis to near occlusion, near occlusion, and total occlusion.
172.12983, 172.12984 (c) ICA peak systolic velocity (PSV) and presence of plaque on gray-scale and/or
Special Reports
color Doppler images are primarily used in diagnosis and grading of ICA stenosis;
Published online before print two additional parameters, ICA-to– common carotid artery PSV ratio and ICA end-
10.1148/radiol.2292030516 diastolic velocity may also be used when clinical or technical factors raise concern
Radiology 2003; 229:340 –346
that ICA PSV may not be representative of the extent of disease. (d) ICA should be
diagnosed as (i) normal when ICA PSV is less than 125 cm/sec and no plaque or
1
intimal thickening is visible; (ii) ⬍50% stenosis when ICA PSV is less than 125 cm/sec
From the Dept of Radiology, Univ of South-
and plaque or intimal thickening is visible; (iii) 50%– 69% stenosis when ICA PSV is
ern California, Keck School of Medicine, USC
University Hospital, 1500 San Pablo St, Los 125–230 cm/sec and plaque is visible; (iv) ⱖ70% stenosis to near occlusion when
Angeles, CA 90033 (E.G.G.); Dept of Radiol- ICA PSV is greater than 230 cm/sec and visible plaque and lumen narrowing are
ogy, Brigham and Women’s Hosp, Harvard seen; (v) near occlusion when there is a markedly narrowed lumen at color Doppler
Med School, Boston, Mass (C.B.B., J.F.F.);
Dept of Surgery, Oregon Health and Science US; and (vi) total occlusion when there is no detectable patent lumen at gray-scale
Univ, Portland, Ore (G.L.M.); Cerebrovascu- US and no flow at spectral, power, and color Doppler US. (e) The final report should
lar Ultrasound and Stroke Treatment Team, discuss velocity measurements and gray-scale and color Doppler findings. Study
Univ of Texas Houston Med School (A.V.A.);
Dept of Surgery, West Los Angeles VA Med
limitations should be noted when they exist. The conclusion should state an esti-
Ctr, Calif (J.D.B.); Dept of Radiology, mated degree of ICA stenosis as reflected in the above categories. The panel also
Ochsner Clinic, New Orleans, La (E.I.B.); considered various technical aspects of carotid US and methods for quality assess-
Dept of Radiology, Duke Univ Med School, ment and identified several important unanswered questions meriting future re-
Durham, NC (B.A.C., B.S.H.); Dept of Biosta-
tistics, Univ of Calgary, Alberta, Canada search.
(M.E.); Midwest Heart Specialists Vascular © RSNA, 2003
Lab and La Grange Memorial Vascular Labo-
ratory, Downers Grove, Ill (J.G.); Intersocietal
Accreditation Commission, Columbia, Md
(S.K.); Dept of Radiology, Thomas Jefferson
Univ, Philadelphia, Pa (L.N.); Dept of Radiol- A panel of experts from a variety of medical specialties was convened under the auspices
ogy, North Shore Univ Hosp, New York Univ
School of Med, NY (J.P.); Dept of Radiology, of the Society of Radiologists in Ultrasound to arrive at a consensus about the performance
Inova Alexandria Hosp, Va (K.S.R.); Dept of of Doppler ultrasonography (US) to aid in diagnosis of internal carotid artery (ICA)
Surgery, Univ of Toronto, Ontario, Canada stenosis. The panel met in San Francisco, Calif, October 22–23, 2002, and drew up a
(D.L.W.); and Dept of Surgery, Univ of Wash- consensus statement. Although there are several facets of carotid disease that could be
ington Med School, Seattle (R.E.Z.). Received
Apr 1, 2003; revision requested May 7; revi-
considered by such a panel, carotid stenosis (and by extension, carotid occlusion) is by far
sion received May 21; accepted May 22. Ad- the most common pathologic process involving carotid arteries. Furthermore, the clinical
dress correspondence to E.G.G. (e-mail: suspicion of ICA stenosis is responsible for most of the referrals for carotid imaging.
edgrant@usc.edu). Authors of recent major studies have shown a decrease in stroke risk when carotid
© RSNA, 2003 endarterectomy is performed for carotid stenosis (1– 4).
The performance of carotid US and the interpretation of US results vary considerably

340
 TABLE 1
Literature Review of Doppler US Thresholds and Performance in Diagnosis of ICA Stenosis
Threshold Performance
Stenosis PSV EDV Sensitivity Specificity PPV NPV Accuracy
Radiology

Study and Year (%) (cm/sec) (cm/sec) Ratio (%) (%) (%) (%) (%)
Huston et al (6), 2000 50 130 ... 1.6 92 90 90 91 91
70 230 70 3.2 86 90 83 92 89
Grant et al (7), 1999 60 200 ... 3 AP* AP* AP* AP* AP*
70 175 ... 2.5 SP* SP* SP* SP* SP*
Abu Rahma et al (8), 1998 50 140 ... ... 92 95 97 89 93
60 150 65 ... 82 97 96 86 90
70 150 90 ... 85 95 91 92 92
Carpenter et al (9), 1996 70 210 ... ... 94 77 68 96 83
70 ... 70 ... 92 60 73 86 77
70 ... ... 3.3 100 65 65 100 79
Hood et al (10), 1996 70 130 100 ... 78 97 88 94 93
Carpenter et al (11), 1995 60 170 ... ... 98 87 88 98 92
60 ... 40 ... 97 52 86 86 86
60 ... ... 2.0 97 73 78 96 76
60 230 40 2.0 100 100 100 100 100
Browerman et al (12), 1995 70 175 ... ... 91 60 ... ... ...
Moneta et al (13), 1995 60 260 70 3.2–3.5 84 94 92 88 90
Neale et al (14), 1994 70 270 110 ... 96 91 ... ... 93
Moneta et al (15), 1993 70 325 130 ... 83 90 80 92 88
Note.—EDV ⫽ end diastolic velocity in ICA, NPV ⫽ negative predictive value, PPV ⫽ positive predictive value, PSV ⫽ peak systolic velocity in ICA. Ratio
is ICA PSV to distal common carotid artery (CCA) PSV.
* AP ⫽ asymptomatic patients, SP ⫽ symptomatic patients. Thresholds based on outcome ⬎ sensitivity/specificity ⬎ accuracy.

from laboratory to laboratory (5). Accred- typically has had a neurologic event examinations performed annually is con-
itation of vascular laboratories has re- (stroke, transient ischemic attack, or am- siderable (22). This imaging modality is
sulted in an increased degree of standard- aurosis fugax) secondary to cerebral isch- increasingly becoming the only exami-
ization of the carotid US examination, emia, likely as a result of an embolic nation performed before surgical inter-
but a wide range of practice patterns still event arising from atherosclerotic disease vention. It was estimated by the panelists
exist. The goal of the conference was to at the carotid bifurcation. Patients in this that as many as 80% of patients in the
develop recommendations for the perfor- group have formed the basis for such United States undergo carotid endarter-
mance of Doppler US and interpretation well-known studies as the North Ameri- ectomy after a US examination as the
of the results in the diagnosis of ICA ste- can Symptomatic Carotid Endarterec- only preoperative imaging study. There-
nosis. The panel limited its discussion to tomy Trial (1) and the European Symp- fore, it is of utmost importance that in-
atherosclerotic stenosis of the ICA at or tomatic Carotid Trial (3). formation provided by the US examina-
just beyond the carotid bifurcation and The asymptomatic group includes pa- tion be reproducible and reliable.
to vessels without prior intervention. tients who have not had a neurologic Considerable gains have been made in
event. The seminal investigation in this the quality of US examinations of the
METHODS AND CONFERENCE population, the Asymptomatic Carotid carotid arteries over the past 2 decades.
PREPARATIONS Artery Study (2), included patients who, The technology has experienced great ad-
Conference Participants though they had not had a neurologic vances in equipment, ranging from con-
event, typically had clinical markers for tinued improvements in gray-scale reso-
Prior to the meeting, 30 representative diffuse atherosclerosis. Overall, the prev- lution to landmark advances in Doppler
articles were selected by the moderator alence of significant (⬎50%) stenotic dis- methods, including color Doppler imag-
(E.G.G.) and sent to conference partici- ease in symptomatic patients is stated as ing. The imaging community has gained
pants, along with a summary spreadsheet being in the range of 18%–20% (27,28), expertise in performance of carotid US
with such information as the purpose of while the prevalence in asymptomatic and interpretation of the results through
the research, the statistical methods patients referred for carotid imaging is widespread use of technology, research,
used, and the pertinent results and con- 14% (29). The prevalence of ICA disease and continuing medical education. In
clusions (Tables 1, 2) (6 –26). The panel in the asymptomatic group, therefore, addition, various accrediting bodies have
consisted of a moderator and 16 panelists approaches that found in symptomatic been established by groups such as the
from various medical specialties. patients. Intersocietal Commission for Accredita-
Doppler US is by far the most common tion of Vascular Laboratories, the Ameri-
Background and Summary of the imaging examination performed world- can Institute of Ultrasound in Medicine,
Literature
wide to aid in the diagnosis of carotid and the American College of Radiology
Historically, clinical studies of carotid disease. Given the prevalence of patients in an attempt to improve and standard-
artery disease have classified patients in with carotid disease and the frequency ize the quality of vascular US examina-
two groups: symptomatic and asymp- with which patients are referred for ca- tions.
tomatic. The former group of patients rotid imaging, the number of carotid US Despite improvements and advances,

Volume 229 䡠 Number 2 Society of Radiologists in Ultrasound Consensus Conference 䡠 341

 TABLE 2
Other Pertinent Literature on ICA Stenosis
Threshold Chosen*
Study and Year Stenosis (%) PSV (cm/sec) Ratio† Assessment and Results
Radiology

Umemura and Yamada NA NA NA Evaluated results of B-flow imaging without Doppler

(16), 2001
Perkins et al (17), 2000 NA NA NA Survey results show that laboratories use inconsistent
thresholds
Grant et al (18), 2000 NA NA NA Doppler US cannot be used to estimate a single degree of
stenosis but is better for differentiating less than or
more than a single degree of stenosis
Beebe et al (19), 1999 NA NA NA Color and gray scale perform well alone; Doppler helps
for midrange lesions
Soulez et al (20), 1999 70, 60 NA 3.4, 2.9 Ratio of ICA PSV at and distal to stenosis performs better
than ICA/CCA ratio
Ranke et al (21), 1999 70 NA NA Ratio of ICA PSV at stenosis to that distal to stenosis:
sensitivity, 97%, specificity, 98%
Derdeyn and Powers 60 230 NA Evaluation of cost-effectiveness of asymptomatic screening
(22), 1996
Griewig et al (23), 1996 NA NA NA Power Doppler better than color Doppler (not quantified)
Srinivasan et al (24), NA NA NA Doppler poor for differentiating degree of ⬍50% stenosis
1995
Hunink et al (25), 1993 70 230 NA PSV best parameter for predicting ⬎70% stenosis
Bluth et al (26), 1988 NA NA NA EDV best Doppler parameter; did not use NASCET
angiography criteria‡
* NA ⫽ not applicable.
† Ratio is ICA PSV to distal CCA PSV.
‡ NASCET ⫽ North American Symptomatic Carotid Endarterectomy Trial.

the consensus panel agreed that, overall, given laboratory, there is often a failure greater consistency. Other panelists did
carotid US is often performed inconsis- to follow a consistent protocol. not agree that a fixed angle of insonation
tently within a given laboratory, and Recommendation.—Examinations of the for all carotid US examinations is re-
there is nonuniformity in practice from ICA should be performed with gray-scale, quired and instead expressed that it is
one laboratory to the next. In many set- color Doppler, and spectral Doppler US in necessary only to maintain an angle of
tings, interpretive criteria for carotid ste- a standardized fashion, according to a rig- less than or equal to 60°. It was thought
nosis are either indiscriminately applied idly applied laboratory protocol, in accor- that further investigation on this matter
or the interpreters are uncertain about dance with the standards of one of the is warranted.
exactly how to make the diagnosis of ca- accrediting bodies. The panel encourages
rotid stenosis. all sonographers performing carotid US to Sample Volume Position
become credentialed as vascular technolo-
gists. Issue.—Other common technical short-
CONSENSUS CONFERENCE comings in ICA examinations include in-
correct positioning of the sample volume,
The results of the consensus conference Positioning and Angulation incomplete sampling through an area of
regarding performance of carotid US and stenosis, and failure to depict the distal end
interpretation of the results and the diag- Issue.—Errors in positioning the Dopp- of a carotid plaque.
nosis of ICA stenosis can be summarized ler gate and in accounting for the Dopp- Recommendation.—Care should be taken
into six key areas: (a) technical consider- ler angle are common in current clinical to position the sample volume within the
ations, (b) diagnostic strata, (c) imaging practices. Since interpretative criteria for area of greatest stenosis. The ICA must be
and Doppler parameters, (d) Doppler di- carotid stenosis are heavily based on sampled through the region of stenosis
agnostic thresholds; (e) the final report of Doppler velocities, errors in Doppler po- completely until the distal end of the
the gray-scale and Doppler US examina- sition and angle correction will lead to plaque is visualized, to ensure that the site
tions, and (f) quality assessment. The serious errors in diagnosis. of highest velocity has been located.
panel identified a number of issues re- Recommendation.—The Doppler wave-
lated to performance of carotid US and form should be obtained with an angle of
Patient Considerations
interpretation of the results and made insonation less than or equal to 60°, as
recommendations to address these issues. measurements obtained with an angle of Issue.—Several errors may result from
insonation greater than 60° are likely to problems inherent to the patient, such as
Technical Considerations be inaccurate, even with appropriate an- extensive plaque calcification, severe ICA
gle adjustment, because of the physical tortuosity, and tandem lesions.
Standardization
properties of Doppler. Recommendation.—It is important to
Issue.—The performance of carotid US Conflicting opinions.—Some believed recognize these patient conditions and
examinations is not standardized from that maintaining a constant angle of in- understand that, in such cases, the exam-
laboratory to laboratory. Even within a sonation of exactly 60° would provide ination may be limited.

342 䡠 Radiology 䡠 November 2003 Grant et al

 Equipment
Issue.—There is substantial variability
in equipment from machine to machine,
from manufacturer to manufacturer, and
between older and newer equipment
Radiology

(30 –33). This variability in equipment

may explain, in part, the lack of agree-
ment and inconsistency in the literature
concerning Doppler thresholds for the
diagnosis of carotid stenosis.
Recommendation.—The panel encourages
US equipment manufacturers to mini-
mize equipment variability by establish-
ing industry-wide standards for Doppler
measurement and calibration and the de-
velopment of a reliable Doppler phan- Graph demonstrates the relationship between mean PSV and percent-
age of stenosis as measured arteriographically. PSV increases with
tom that can be made readily available to increasing severity of stenosis. Note marked overlap in adjacent cat-
industry and to vascular laboratories. egories of stenosis. Error bars ⫽ 1 SD about the mean. (Reprinted, with
permission, from reference 18.)
Diagnostic Strata
Methods of Reporting
Issue.—Methods by which the degree grees of ICA stenosis is based on Doppler Recommendation.—The ICA US exami-
of ICA stenosis is reported vary from lab- findings. nation should consist of gray-scale imag-
oratory to laboratory, as well as within Recommendation.—Because Doppler is ing, color Doppler imaging, and spectral
some laboratories. Some report an esti- inaccurate for subcategorizing stenoses Doppler velocity determination. Because
mate of the specific percentage of steno- less than 50%, these stenoses should be stenosis is typically an area of narrowing
sis, others stratify their estimates into five reported under a single category as caused by plaque, with a focal area of
or six diagnostic categories or gradations “⬍50% stenosis.” Subcategories for mi- increased velocity and a poststenotic dis-
of stenosis. nor degrees of stenosis should not be turbed flow, the location and character-
Recommendation.—Doppler US cannot used. istics of plaque in the ICA should be de-
be used to predict a single percentage of termined. The color Doppler appearance
stenosis. Therefore, the consensus panel- Stratification of Stenoses of the lumen should also be assessed.
ists strongly recommend the use of de-
fined diagnostic strata. Laboratories Issue.—How should reporting of ICA
should establish protocols for stratifying stenosis be stratified?
Recommendation.—The consensus panel Primary US Parameters
the degree of ICA stenosis, and, once es-
tablished, these criteria should be consis- recommends stratification of the degree Issue.—Numerous imaging and Dopp-
tently applied. of stenosis on the basis of gray-scale and ler parameters are currently used at vari-
Doppler US results into the following ous laboratories for the evaluation of ICA
strata: normal (no stenosis), ⬍50% steno- stenosis, including ICA PSV, ICA EDV
Doppler Measurement Variability
sis, 50%– 69% stenosis, ⱖ70% stenosis and ICA/CCA PSV ratio, CCA EDV, and
Although investigators have confirmed but less than near occlusion, near occlu- ICA/CCA EDV ratio. The application of
that the average Doppler velocity rises in sion, and total occlusion. these parameters for diagnosis of ICA ste-
direct proportion to the degree of steno- Discussion.—The threshold of 70% ste- nosis varies from laboratory to laboratory
sis as determined with angiography nosis was chosen because it was believed and sometimes within a given labora-
(18,26), there are very wide ranges of to be the threshold currently used by tory.
Doppler values around those means, most major vascular centers for surgical
Recommendation.—The panel suggested
which makes it impossible to classify le- intervention. The panel agreed, however,
that the ICA PSV and the presence of
sions into gradations as narrow as 10% that in some laboratories, there may be a
plaque on gray-scale and/or color Dopp-
(Figure) (18,34). Even in evaluations of compelling reason to choose a different
ler US images are the parameters that
the ability of Doppler US to help estimate stratification scheme. The diagnoses of
should be used when diagnosing and
the degree of stenosis by using more ex- near occlusion and total occlusion are
grading ICA stenosis.
panded strata (eg, ⬍50%, 50%– 69%, and usually not based primarily on the Dopp-
Discussion.—The ICA PSV is easy to ob-
ⱖ70% stenosis), the findings have been ler measurement of velocity but rather on
disappointing. US is most accurate when tain and has good reproducibility and
gray-scale and color and/or power Dopp-
lesions are classified as being above or ler imaging. should be used in conjunction with avail-
below a single level, such as 60% stenosis able gray-scale and color Doppler informa-
or 70% stenosis (18). tion to ensure concordance of diagnostic
Imaging and Doppler Parameters
information. The degree of stenosis esti-
Key Components of ICA
mated by using ICA PSV and the degree
Stenosis of Less than 50% Examination
of narrowing of the ICA lumen on gray-
Issue.—In many laboratories, stratifica- Issue.—What are the key components scale and color Doppler images should be
tion or diagnosis of minor (⬍50%) de- of the US examination of the ICA? similar.

Volume 229 䡠 Number 2 Society of Radiologists in Ultrasound Consensus Conference 䡠 343

 5. In cases of near occlusion of the
TABLE 3 ICA, the velocity parameters may not ap-
Consensus Panel Gray-Scale and Doppler US Criteria for Diagnosis
of ICA Stenosis ply, since velocities may be high, low, or
undetectable. This diagnosis is estab-
Primary Parameters Additional Parameters lished primarily by demonstrating a
Radiology

Degree of ICA PSV Plaque Estimate ICA/CCA PSV ICA EDV markedly narrowed lumen at color or
Stenosis (%) (cm/sec) (%)* Ratio (cm/sec) power Doppler US (35).
6. Total occlusion of the ICA should
Normal ⬍125 None ⬍2.0 ⬍40
⬍50 ⬍125 ⬍50 ⬍2.0 ⬍40 be suspected when there is no detectable
50–69 125–230 ⱖ50 2.0–4.0 40–100 patent lumen at gray-scale US and no
ⱖ70 but less than ⬎230 ⱖ50 ⬎4.0 ⬎100 flow with spectral, power, and color
near occlusion Doppler US. Magnetic resonance (MR)
Near occlusion High, low, or Visible Variable Variable
undetectable angiography, computed tomographic (CT)
Total occlusion Undetectable Visible, no Not applicable Not applicable angiography, or conventional angiogra-
detectable phy may be used for confirmation in this
lumen setting (35).
* Plaque estimate (diameter reduction) with gray-scale and color Doppler US.
Final Report of the Gray-Scale and
Doppler US Examination
Issue.—The structure and content of fi-
Additional US Parameters and stratification of ICA stenosis (Table 3). nal reports of carotid US examinations
These recommendations were derived vary greatly from laboratory to labora-
Issue.—Should other Doppler parame- tory, as well as within given laboratories.
from analysis of numerous studies and
ters be used and, if so, when? Recommendation.—The final report of
do not represent the results of any one
Recommendation.—Two additional pa- the gray-scale and Doppler US interpreta-
laboratory or study. For a particular lab-
rameters, ICA/CCA PSV ratio and ICA tion of the ICA examination should in-
oratory setting, internal validation is en-
EDV, are useful for internal checks or clude the following:
couraged when possible. This may yield
may be used when ICA PSV may not be Body of the report.—(a) Pertinent US
alternative diagnostic criteria that can be
representative of the extent of disease findings, including velocity measure-
used successfully at that facility. How-
owing to technical or clinical factors such ments and gray-scale findings (presence,
ever, each laboratory should have a sin-
as in the presence of tandem lesions, con- location, and characteristics of ICA
gle set of diagnostic criteria that is ap-
tralateral high-grade stenosis, discrep- plaque), as well as color Doppler findings
plied uniformly. The following points are
ancy between visual assessment of when appropriate; (b) comments about
included in Table 3 and should be con-
plaque and ICA PSV, elevated CCA veloc- limitations of the study or deviations
sidered in the diagnosis of ICA stenosis:
ity, hyperdynamic cardiac state, or low from usual interpretive criteria due to
1. The ICA is considered normal when
cardiac output. For example, in a patient technical factors or hemodynamic con-
ICA PSV is less than 125 cm/sec and no
with low cardiac output, the ICA PSV siderations; and (c) comparison with re-
plaque or intimal thickening is visible
may be disproportionately low when sults of prior studies.
sonographically. Additional criteria in-
compared with the ICA/CCA PSV ratio. Conclusion or impression.—Estimated
clude ICA/CCA PSV ratio ⬍ 2.0 and ICA
This discrepancy should prompt the in- degree of ICA stenosis, categorized by the
EDV ⬍ 40 cm/sec.
terpreter to consider all gray-scale and laboratory’s established diagnostic crite-
2. A <50% ICA stenosis is diagnosed
Doppler information when stratifying ria (modified, as appropriate, by techni-
the degree of ICA stenosis. In particular when ICA PSV is less than 125 cm/sec
and plaque or intimal thickening is visi- cal factors or hemodynamic consider-
in such cases, the interpretation should ations).
be based more heavily on the ICA/CCA ble sonographically. Additional criteria
PSV ratio than on absolute values such as include ICA/CCA PSV ratio ⬍ 2.0 and
ICA EDV ⬍ 40 cm/sec. Quality Assessment
the ICA PSV or ICA EDV. The panel be-
3. A 50%– 69% ICA stenosis is diag- Need for Quality Assessment
lieved that outlining the reasons for mak-
ing diagnostic choices that are not in nosed when ICA PSV is 125–230 cm/sec
Issue.—Should every laboratory have a
keeping with usual practice should be in- and plaque is visible sonographically. Ad-
system for quality assessment?
cluded in the final report. ditional criteria include ICA/CCA PSV ra-
Recommendation.—All laboratories should
tio of 2.0 – 4.0 and ICA EDV of 40 –100
institute a program of quality assessment.
cm/sec.
Doppler Diagnostic Thresholds
4. A >70% ICA stenosis but less than
Internal Validation of Doppler
Issue.—Published literature is replete near occlusion of the ICA is diagnosed
Thresholds
with velocity thresholds for categorizing when the ICA PSV is greater than 230
ICA stenosis (Table 1). Tremendous vari- cm/sec and visible plaque and luminal Issue.—Development of internally val-
ation exists among these studies in the narrowing are seen at gray-scale and idated Doppler thresholds may be diffi-
methods used to assess individual Dopp- color Doppler US. Additional criteria in- cult given the infrequency of correlative
ler parameters and in the thresholds rec- clude ICA/CCA PSV ratio ⬎ 4 and ICA angiograms at most institutions.
ommended for diagnosing ICA stenosis EDV ⬎ 100 cm/sec. The higher the Dopp- Recommendation.—The panel agreed
(7). ler parameter lies above the threshold of that it may not always be feasible to ob-
Recommendation.—The consensus panel 230 cm/sec, the greater the likelihood of tain angiographic or clinical correlation
developed recommendations for diagnosis severe disease. for quality assessment of US studies at

344 䡠 Radiology 䡠 November 2003 Grant et al

 each laboratory. For this reason, the con- lowed up at 6 –12-month intervals, and ficial effect of carotid endarterectomy in
sensus panel developed the table of rec- high-risk patients with visible plaque and symptomatic patients with high-grade ca-
rotid stenosis. N Engl J Med 1991; 325:
ommended Doppler thresholds for diag- ⬍50% stenosis should be evaluated every 445– 453.
nosis of ICA stenosis (Table 3), which can 1–2 years. Patients who have normal ca- 2. Executive Committee for the Asymptom-
be applied at laboratories that cannot val- rotid US studies but marked risk factors atic Carotid Atherosclerosis Study. Endar-
idate their own Doppler thresholds on might be evaluated every 3–5 years. In all terectomy for asymptomatic carotid ar-
Radiology

the basis of correlative imaging or clinical cases of follow-up or surveillance, a com- tery stenosis. JAMA 1995; 273:1421–
1428.
information. plete examination should be performed. 3. European Carotid Surgery Trialists’ Collab-
Discussion: Although angiography has Follow-up studies should be compared orative Group. MRC European Carotid Sur-
historically been considered the “gold with results from prior examinations. gery Trial: interim results for symptomatic
standard” for assessing Doppler thresh- patients with severe (70–99%) or with mild
Research Topics (0 –29%) carotid stenosis. Lancet 1991; 337:
olds for various degrees of ICA stenosis, 1235–1243.
few angiographic examinations are still 4. Barnett HJM, Taylor DW, Eliasziw M, et
The panel identified several important
performed. Those that are performed at a al. Benefit of carotid endarterectomy in
unanswered questions that merit future
given institution are probably not repre- patients with symptomatic moderate or
research. severe stenosis. N Engl J Med 1998; 339:
sentative cases, but rather those cases in
1. What is the role of ICA plaque char- 1415–1425.
which the US results were equivocal or 5. Byrd S, Robless P, Baxter A, Emson M,
acterization in carotid disease?
otherwise problematic. The use of CT an- Halliday A. Carotid duplex ultrasonogra-
2. What is the role of the ICA intimal-
giography and MR angiography for cor- phy: importance of standardisation. Int
medial thickness? There are several ongo- Angiol 1998; 17:248 –254.
relation has not, as yet, been fully vali-
ing large clinical trials in which the inti- 6. Huston J III, James EM, Brown RD Jr, et al.
dated (36).
mal-medial thickness is being evaluated Redefined duplex ultrasonographic crite-
as a marker of atherosclerotic disease, but ria for diagnosis of carotid artery stenosis.
Reference Standard there are not yet enough data to establish Mayo Clin Proc 2000; 75:1133–1140.
7. Grant EG, Duerinckx AJ, El Saden S, et al.
Issue.—When angiography is used as the role of this measurement in the as- Doppler sonographic parameters for de-
the reference standard for assessment of sessment of carotid disease in individual tection of carotid stenosis: is there an op-
Doppler criteria for ICA stenosis, differ- patients. timum method for their selection? AJR
3. At follow-up examination, how Am J Roentgenol 1999; 172:1123–1129.
ent techniques for measuring ICA steno- 8. AbuRahma AF, Robinson PA, Strickler DL,
sis have been used. much of a change in estimated ICA ste- Alberts S, Young L. Proposed new duplex
Recommendation.—The panel recom- nosis or ICA PSV should be considered classification for threshold stenoses used
mended that the NASCET method of ca- relevant? in various symptomatic and asymptom-
4. What criteria should be used to as- atic carotid endarterectomy trials. Ann
rotid stenosis measurement should be
Vasc Surg 1998; 12:349 –358.
employed when angiography is used to sess patients after ICA surgery or stent
9. Carpenter JP, Lexa FJ, Davis JT. Determi-
correlate the US findings. placement? nation of duplex Doppler ultrasound cri-
Discussion.—In this method, the nar- 5. Should US be used to screen for ca- teria appropriate to the North American
rowest portion of the vascular lumen was rotid disease? Symptomatic Carotid Endarterectomy
Other issues that need to be addressed Trial. Stroke 1996; 27:695– 699.
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atic Carotid Trial study and studies per- 1. There is considerable variation in teria to identify 70% internal carotid ar-
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degree of stenosis was determined by
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comparing the narrowest diameter of the ture. This should be rectified, because
nation of sixty percent or greater carotid
residual lumen to an estimate of the orig- such variation leads to inconsistencies artery stenosis by duplex Doppler ultra-
inal lumen in the same area. Because the and inaccuracies in diagnosing ICA ste- sonography. J Vasc Surg 1995; 22:697–
original lumen cannot be depicted on the nosis. 703.
2. Phantoms for Doppler US need to 12. Browman MW, Cooperberg PL, Harrison
angiogram, exact measurement is impos- PB, Marsh JI, Mallek N. Duplex ultrasonog-
sible. While the NASCET method of mea- be developed to facilitate calibration of raphy criteria for internal carotid stenosis
surement may not reflect the burden of Doppler US equipment. of more than 70% diameter: angiographic
atherosclerosis in the proximal ICA, it 3. Improved methods for calculating correlation and receiver operating charac-
velocity with angle correction should be teristic curve analysis. Can Assoc Radiol J
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developed to eliminate or minimize the 1995; 46:291–295.
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The panel discussed the issue of appro-
tories can assess their performance of the nificant carotid stenosis with special refer-
priate follow-up of asymptomatic pa-
carotid US examination. This should lead ence to reports from the North American
tients with known ICA stenosis, as well as Symptomatic Carotid Endarterectomy Trial
to greater consistency in the performance
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Volume 229 䡠 Number 2 Society of Radiologists in Ultrasound Consensus Conference 䡠 345

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346 䡠 Radiology 䡠 November 2003 Grant et al