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(Stroke. 2003;34:1817.)
© 2003 American Heart Association, Inc.

Controversies in Stroke

For Severe Carotid Stenosis Found on Ultrasound, Further Arterial Evaluation Prior to Carotid Endarterectomy Is Unnecessary: The Argument Against

From the Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK.

Correspondence to Dr P.M. Rothwell, Radcliffe Infirmary, Stroke Prevention Research Unit, Department of Clinical Neurology, Oxford OX2 6HE, UK. E-mail peter.rothwell@clneuro.ox.ac.uk

Key Words: carotid endarterectomy • carotid stenosis • magnetic resonance angiography • ultrasonography, Doppler, transcranial

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Carotid endarterectomy reduces the risk of stroke in certain patients with recently symptomatic carotid stenosis¹ and to a lesser extent inpatients with severe asymptomatic stenosis.² Screening of patients for inclusion in the randomized controlled trials (RCTs) was usually performed with Doppler ultrasound (DU), but conventional arterial angiography (CAA) was required prior to randomization in the RCTs in symptomatic stenosis¹ and prior to surgery in ACAS.² However, CAA is costly, time-consuming, and can cause stroke. A systematic review of prospective studies of the risks of CAA inpatients with cerebrovascular disease reported a 0.1% risk of death and a 1.0% risk of permanent neurological sequelae.³ More recent studies have reported lower risks in both academic centers and community hospitals,⁴ but many centers have already adopted a policy of operating on the basis of DU alone.⁵

What Are the Advantages of Doppler Ultrasound?

The main advantage of DU over CAA is the absence of a procedural risk. However, it should be noted that most studies of the risk of CAA classified all strokes that occurred within 24 hours of CAA as procedural complications. Given that the risk of stroke shortly after presentation with symptomatic carotid stenosis and prior to endarterectomy is about 0.5% per day, ⁶ the excess stroke risk due to CAA in recently symptomatic patients is probably only about 0.5%.

Has Practice With Ultrasound Alone Been Shown to Be Adequate?

In contrast to pharmaceutical products, new diagnostic or imaging strategies are not subject to regulatory control, and no standards are set for validation. Given that the available techniques of carotid imaging use completely different source data to estimate stenosis, . . . [Full Text of this Article]

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