title: High-risk asymptomatic carotid stenosis: ulceration on 3D ultrasound vs TCD microemboli.
abstract: OBJECTIVE
  We compared microemboli on transcranial Doppler (TCD) with carotid ulcerations on 3D ultrasound (US) as an additional method for identifying the small proportion of patients with asymptomatic carotid stenosis (ACS) who can benefit from revascularization such as endarterectomy or stenting.
  
  
  METHODS
  Patients with ACS (n = 253) with carotid stenosis >60% by Doppler ultrasound were studied prospectively with TCD embolus detection and 3D US to detect ulcers (the total number of ulcers in both internal carotids) and followed for 3 years.
  
  
  RESULTS
  Mean age was 69.66 (SD 8.51) years; 11 (4%) had ≥3 ulcers (Ulcer 3), 11 (6%) had microemboli, and 25 (10%) had microemboli or ≥3 ulcers. Ulcer 3 patients were more likely to have a stroke or death in 3 years (18% vs 2%; p = 0.03), regardless of the side on which the ulcers were found. The 3-year risk of stroke or death was 20% with microemboli vs 2% without (p = 0.003). The annual rate of ipsilateral stroke was 0.8%.
  
  
  CONCLUSIONS
  Adding 3D US detection of ulcers doubles (to 10%) the proportion of patients with ACS who may benefit from endarterectomy or stenting. However, until 3-year event rates of stroke or death with endarterectomy or stenting reach <2%, 90% of patients with ACS would be better treated medically until they develop symptoms, ulcers, or emboli.
authors.affiliation: Schulich School of Medicine and Dentistry, University of Western Ontario, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Madani
authors.forename: V
authors.initials: V
authors.lastname: Beletsky
authors.forename: A
authors.initials: A
authors.lastname: Tamayo
authors.forename: C
authors.initials: C
authors.lastname: Munoz
authors.forename: J D
authors.initials: JD
authors.lastname: Spence
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery; D004617:Embolism / Q000000981:diagnostic imaging* / Q000209:etiology; D016894:Endarterectomy, Carotid / Q000379:methods; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015203:Reproducibility of Results; D015607:Stents; D020521:Stroke; D014456:Ulcer / Q000000981:diagnostic imaging* / Q000209:etiology / Q000601:surgery; D017585:Ultrasonography, Doppler, Transcranial / Q000379:methods*