Neurology 2001;56:1009-1015
© 2001 American Academy of Neurology
Articles
Clinical carotid endarterectomy decision making
Noninvasive vascular imaging versus angiography
Dean C.C. Johnston, MD; and
Larry B. Goldstein, MD
From the Department of Medicine (Neurology), Duke Center for Cerebrovascular Disease, Center for Clinical Health Policy Research, Duke University; and Durham VA Medical Center, Durham, NC.
Address correspondence and reprint requests to Dr. Larry B. Goldstein, Duke Center for Cerebrovascular Disease, Box 3561, Duke University Medical Center, Durham, NC 27710; e-mail: golds004{at}mc.duke.edu
OBJECTIVE: Carotid endarterectomy (CEA) is frequently performed based solely on noninvasive vascular imaging (NVI) results (duplex ultrasound, DU; magnetic resonance angiography, MRA; CT angiography, CTA). The authors determined how often intra-arterial contrast angiography (ANGIO) alters a CEA decision as compared to NVI in clinical practice.
METHODS: Reports of all NVI studies in 569 consecutive patients undergoing ANGIO at an academic medical center (AMC, n = 360) and a community hospital (CH, n = 209) over 3 years were reviewed. Patients were classified as to whether CEA was indicated based on each study. Misclassification rates, sensitivities, specificities, positive (PPV) and negative (NPV) predictive values were calculated.
RESULTS: CTA was performed infrequently (2.5%) and not considered further. Misclassification rates for CEA based on DU in the AMC and CH were similar. The misclassification rate for DU alone was 28% (95% CI: 24,32), and for MRA alone was 18% (95% CI: 11,25). Both NVI were done in 11% of patients, with a misclassification rate of 7.9% (95% CI: 0,16) when the two were concordant (76% of studies). DU had a sensitivity of 87% (95% CI: 83,91), specificity 46% (95% CI: 38,54), PPV 73% (95% CI: 68,78) and NPV 68% (95% CI: 60,77). MRA had a sensitivity of 75% (95% CI: 63,87), specificity 88% (95% CI: 80,96), PPV 84% (95% CI: 73,95) and NPV 80% (95% CI: 70, 90). The sensitivity of concordant NVIs was 96% (95% CI: 88,100), specificity 85% (95% CI: 65,100), PPV 93% (95% CI: 81,100) and NPV 92% (95% CI: 76,100).
CONCLUSION: These data suggest that surgical decisions should be made with caution if based on the results of noninvasive studies, particularly DU performed alone. Concordant DU and MRA results in a lower misclassification rate than either test used alone.
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|
|
|
|
|
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|
|
|
|
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|
|
|
|
|
|
|
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78(935):
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[Abstract]
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[PDF]
|
|
|
|
|
|
|
B Thanvi, S K Munshi, S L Dawson, and T G Robinson
Carotid and vertebral artery dissection syndromes
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81(956):
383 - 388.
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|
|
|
|
|
|
|
L. R. Sprouse II, G. H. Meier, F. N. Parent, R. J. DeMasi, C. J. LeSar, C. Nelms, K. Carter, M. J. Marcinczyk, R. G. Gayle, and B. Mendoza
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Vascular and Endovascular Surgery,
March 1, 2005;
39(2):
143 - 151.
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|
|
|
|
|
|
|
G. M. Hathout, J. R. Fink, S. M. El-Saden, and E. G. Grant
Sonographic NASCET Index: A New Doppler Parameter for Assessment of Internal Carotid Artery Stenosis
AJNR Am. J. Neuroradiol.,
January 1, 2005;
26(1):
68 - 75.
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[PDF]
|
|
|
|
|
|
|
D. E. Hyde, A. J. Fox, I. Gulka, P. Kalapos, D. H. Lee, D. M. Pelz, and D. W. Holdsworth
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December 1, 2004;
35(12):
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|
|
|
|
|
|
|
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25(10):
1856 - 1860.
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|
|
|
|
|
|
|
E. Buskens, P. J. Nederkoorn, T. Buijs-van der Woude, W. P. T. M. Mali, L. J. Kappelle, B. C. Eikelboom, Y. van der Graaf, and M. G. Myriam Hunink
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233(1):
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|
|
|
|
|
|
|
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June 1, 2004;
16(2):
89 - 99.
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[PDF]
|
|
|
|
|
|
|
J. M. U-King-Im, R. A. Trivedi, M. J. Graves, N. J. Higgins, J. J. Cross, B. D. Tom, W. Hollingworth, H. Eales, E. A. Warburton, P. J. Kirkpatrick, et al.
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|
|
|
|
|
|
|
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|
|
|
|
|
|
|
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62(6):
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|
|
|
|
|
|
|
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Concordance Rate Differences of 3 Noninvasive Imaging Techniques to Measure Carotid Stenosis in Clinical Routine Practice: Results of the CARMEDAS Multicenter Study
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|
|
|
|
|
|
|
G. M Hathout, M. J. Duh, and S. M. El-Saden
Accuracy of Contrast-Enhanced MR Angiography in Predicting Angiographic Stenosis of the Internal Carotid Artery: Linear Regression Analysis
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October 1, 2003;
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|
|
|
|
|
|
|
P. J. Nederkoorn, O. E. H. Elgersma, Y. van der Graaf, B. C. Eikelboom, L. J. Kappelle, and W. P. T. M. Mali
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September 1, 2003;
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|
|
|
|
|
|
|
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|
|
|
|
|
|
|
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June 1, 2003;
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[PDF]
|
|
|
|
|
|
|
J. W. Norris, F. Morriello, D. W. Rowed, and R. Maggisano
Vascular Imaging Before Carotid Endarterectomy
Stroke,
May 1, 2003;
34
(5):
e16 - e16.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. B. Goldstein, D. B. Matchar, J. Hoff-Lindquist, G. P. Samsa, R. D. Horner, and E. J. Kenton III
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Stroke,
April 1, 2003;
34(4):
999 - 1004.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Cosottini, A. Pingitore, M. Puglioli, M. C. Michelassi, G. Lupi, A. Abbruzzese, R. Calabrese, M. Lombardi, G. Parenti, and C. Bartolozzi
Contrast-Enhanced Three-Dimensional Magnetic Resonance Angiography of Atherosclerotic Internal Carotid Stenosis as the Noninvasive Imaging Modality in Revascularization Decision Making
Stroke,
March 1, 2003;
34(3):
660 - 664.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. M. Rothwell, S. A. Gutnikov, and C. P. Warlow
Reanalysis of the Final Results of the European Carotid Surgery Trial
Stroke,
February 1, 2003;
34(2):
514 - 523.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. C.C. Johnston, J. D. Eastwood, T. Nguyen, and L. B. Goldstein
Contrast-Enhanced Magnetic Resonance Angiography of Carotid Arteries: Utility in Routine Clinical Practice
Stroke,
December 1, 2002;
33(12):
2834 - 2838.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. J. Nederkoorn, Y. van der Graaf, B. C. Eikelboom, A. van der Lugt, L. W. Bartels, and W. P.T.M. Mali
Time-of-Flight MR Angiography of Carotid Artery Stenosis: Does a Flow Void Represent Severe Stenosis?
AJNR Am. J. Neuroradiol.,
November 1, 2002;
23(10):
1779 - 1784.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Schulte-Altedorneburg, D. W. Droste, S. Felszeghy, L. Csiba, V. Popa, K. Hegedus, J. Kollar, L. Modis, and E. B. Ringelstein
Detection of Carotid Artery Stenosis by In Vivo Duplex Ultrasound: Correlation With Planimetric Measurements of the Corresponding Postmortem Specimens
Stroke,
October 1, 2002;
33(10):
2402 - 2407.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. A. Fellner, W. Lang, A. I. Qureshi, S. H. Kim, M. F. K. Suri, and L. N. Hopkins
The Way Out * Response
Stroke,
August 1, 2002;
33(8):
1948 - 1949.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. J. Nederkoorn, W. P.Th.M. Mali, B. C. Eikelboom, O. E.H. Elgersma, E. Buskens, M.G. M. Hunink, L. J. Kappelle, P. C. Buijs, A. F.J. Wust, A. van der Lugt, et al.
Preoperative Diagnosis of Carotid Artery Stenosis: Accuracy of Noninvasive Testing
Stroke,
August 1, 2002;
33(8):
2003 - 2008.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. J.M. Barnett, H. E. Meldrum, and M. Eliasziw
The appropriate use of carotid endarterectomy
Can. Med. Assoc. J.,
April 1, 2002;
166(9):
1169 - 1179.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Ballotta, G. Da Giau, C. Baracchini, A. I. Qureshi, M.F. K. Suri, Z. Ali, S. H. Kim, and L.N. Hopkins
An Unjustified Return to the Past * Response
Stroke,
March 1, 2002;
33(3):
879 - 881.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. J Earnshaw
Carotid endarterectomy--the evidence
J R Soc Med,
January 4, 2002;
95(4):
168 - 170.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Young, P. Humphrey, D. C. C. Johnston, and L. B. Goldstein
Clinical carotid endarterectomy decision-making: Noninvasive vascular imaging versus angiography
Neurology,
December 26, 2001;
57(12):
2324 - 2324.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. C.C. Johnston, MD;, K. M. Chapman, MD;, and L. B. Goldstein, MD
Low rate of complications of cerebral angiography in routine clinical practice
Neurology,
December 11, 2001;
57(11):
2012 - 2014.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. L. Sacco
Extracranial Carotid Stenosis
N. Engl. J. Med.,
October 11, 2001;
345(15):
1113 - 1118.
[Full Text]
[PDF]
|
|
|
|
|
|
|
How Accurate Are Noninvasive Carotid Studies?
Journal Watch Cardiology,
June 15, 2001;
2001(615):
10 - 10.
[Full Text]
|
|
|
|
|
|
|
How Accurate Are Noninvasive Carotid Studies?
Journal Watch (General),
May 29, 2001;
2001(529):
1 - 1.
[Full Text]
|
|
|
|
|
|
|
J. W. Norris and P. M. Rothwell
Noninvasive carotid imaging to select patients for endarterectomy: Is it really safer than conventional angiography?
Neurology,
April 24, 2001;
56(8):
990 - 991.
[Full Text]
[PDF]
|
|
|
Correspondence:
Read all Correspondence
- Clinical carotid endarterectomy decision making: Noninvasive vascular imaging versus angiography
- G Young, et al.
- Neurology Online, 20 Aug 2001
[Full text]
- Reply to Drs Young and Humphrey
- D Johnson, et al.
- Neurology Online, 20 Aug 2001
[Full text]
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