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Duplex ultrasound for the diagnosis of symptomatic carotid stenosis: real value in clinical practice

Ines Esteves Cruz, Ricardo Sousa, Francisco Silva, Isabel Madruga.

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Background: Atherosclerotic plaque leading to internal carotid stenosis greater than 50%, accounts for about 10 to 15% of all acute ischemic stroke (AIS) causes. Stenosis identification and severity is frequently estimated by Duplex ultrasound (DUS) assessment. Symptomatic carotid disease is defined as focal neurologic symptoms with sudden onset and related to the appropriate carotid artery cerebral distribution. It includes established acute ischemic stroke, one or more transient ischemic attacks characterized by focal neurologic dysfunction or transient monocular blindness, in the preceding 6 months of the carotid stenosis identification. Revascularization should be considered in symptomatic patients with a carotid artery stenosis of 50–69% and recommended in symptomatic patients with a stenosis of 70–99%. In our clinical practice it is seen frequently the indiscriminate use of DUS in the etiological study for AIS. Therefore, we consider the possibility of such an exam being excessively performed, since most patients may have no indication for DUS assessment.
Objectives: (1) estimation of symptomatic carotid artery disease prevalence in hospitalized patients with the diagnosis of AIS and ≥ 50% carotid stenosis; (2) determination of carotid artery revascularization in this subgroup of patients; (3) evaluation of the centre clinical practice and to determine a real estimative of the therapeutic impact associated with DUS in patients with AIS.
Methods: Retrospective observational cohort study of patients admitted with established AIS within the year of 2017 and followed for an additional 12 month period. Inclusion criteria: a definite diagnosis of AIS (based in symptoms within 24 hours’ period and/or image in CT scan suggestive of AIS), date of hospitalization within the mentioned timeframe and patients who underwent carotid DUS within the first 6 months after the event. No hemorrhagic stroke or transient ischemic attacks were considered in this study.
Results: Of the 198 stroke patients, 144 (72%) underwent Doppler ultrasound. The average age was 78 years, 50% were male and 23.6% had previous stroke. From the total 144 included patients, only 18 (12.5%) had stenosis ≥50%, and 9 (6.25%) had ipsilateral lesions to the carotid stenosis. The remaining had lesions contralateral to the stenosis or lacunar strokes. Considering this, 6.25% of patients were assumed to have symptomatic carotid disease. None underwent surgical intervention for various reasons (e.g. high risk procedure, contraindications, high degree disability and/or multiple comorbidities).
Conclusions: The present study reinforces the idea that etiological study of AIS is essential, and DUS appears as a first line exam. However, we emphasize that DUS should only be performed in patients with non-disabling AIS (mRS score 0–2) who are candidates for vascular intervention.

Key words: Carotid artery disease, Symptomatic carotid stenosis, Acute ischemic stroke, Duplex ultrasound, Carotid endarterectomy, Carotid artery stenting

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