Diagnostic performance of duplex ultrasound in patients suspected of carotid artery disease: the ipsilateral versus contralateral artery.
OBJECTIVE
To evaluate duplex ultrasonographic thresholds for the determination of 70% to 99% stenosis of the ipsilateral and contralateral internal carotid artery in patients with symptoms of amaurosis fugax, transient ischemic attack (TIA), or minor stroke based on 2 criteria: maximizing accuracy and optimizing cost-effectiveness and to compare these with current recommendations.


METHODS
From January 1997 to January 2000, a prospective multicenter study was conducted including 350 consecutive patients with symptoms of amaurosis fugax, TIA, or minor stroke who underwent bilateral duplex ultrasonography and digital subtraction angiography. A linear regression analysis was performed to estimate the degree of angiographic stenosis as a function of the peak systolic velocity (PSV). PSV thresholds were calculated for the ipsilateral and contralateral carotid arteries based on maximizing accuracy and optimizing cost-effectiveness.


RESULTS
The PSV measurements significantly overestimated the angiographic stenosis in the contralateral artery (9.5%; 95% CI, 6.3% to 12.7%) compared with the ipsilateral carotid artery. The recommended PSV threshold for the diagnosis of 70% to 99% stenosis is 230 cm/s. Maximizing accuracy, the optimal PSV threshold for the ipsilateral artery was 280 cm/s, and for the contralateral artery, 370 cm/s for diagnosing a 70% to 99% stenosis. Optimizing cost-effectiveness, the optimal PSV threshold was 220 cm/s for ipsilateral and 290 cm/s for contralateral carotid arteries.


CONCLUSIONS
PSV measurements overestimate the degree of angiographic stenosis in the contralateral carotid artery in patients with symptoms of amaurosis fugax, TIA, or minor stroke. Separate PSV thresholds should be used for the ipsilateral and contralateral carotid artery. PSV thresholds that optimize cost-effectiveness differ from the recommended thresholds and from thresholds that maximize accuracy.
Heijenbrok-Kal
Majanka H
MH
Department of Epidemiology and Biostatistics, Erasmus MC-University Medical Center Rotterdam, The Netherlands. m.heijenbrok@erasmusmc.nl
Nederkoorn
Paul J
PJ
Buskens
Erik
E
van der Graaf
Yolanda
Y
Hunink
M G Myriam
MG
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D020757:Amaurosis Fugax / Q000175:diagnosis / Q000000981:diagnostic imaging*; D000792:Angiography; D015901:Angiography, Digital Subtraction; D002339:Carotid Arteries / Q000000981:diagnostic imaging / Q000473:pathology; D002340:Carotid Artery Diseases / Q000175:diagnosis* / Q000000981:diagnostic imaging*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis / Q000000981:diagnostic imaging*; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012372:ROC Curve; D012044:Regression Analysis; D012680:Sensitivity and Specificity; D020521:Stroke / Q000175:diagnosis / Q000000981:diagnostic imaging*; D018616:Ultrasonography, Doppler, Duplex / Q000379:methods*