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Detection of carotid artery stenosis using histological specimens: a comparison of CT angiography, magnetic resonance angiography, digital subtraction angiography and Doppler ultrasonography

  • Clinical Article - Vascular
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Abstract

Background

Carotid endarterectomy (CEA) is accepted as a primary modality to treat carotid stenosis. The accuracy of measuring carotid stenosis is important for indication of the CEA procedure. Different diagnostic tools have been developed and used in the past 2 decades for the diagnosis of carotid stenosis. Only a few studies, however, have focused on the comparison of different diagnostic tools to histological findings of carotid plaque.

Method

Patients with internal carotid artery (ICA) stenosis were investigated primarily by computed tomography angiography (CTA). Digital subtraction angiography (DSA), Doppler ultrasonography (DUS) and magnetic resonance angiography (MRA) were performed as well. Atherosclerotic plaque specimens were transversally cut into smaller segments and histologically processed. The slides were scanned and specimens showing maximal stenosis were determined; the minimal diameter and the diameter of the whole plaque were measured. High quality histological specimen and histological measurement was considered to be the prerequisite for inclusion into the analysis. The preoperative findings were compared with histological measurement.

CTA and histological measurements were obtained from 152 patients. DSA measurements were available in 138 of these cases, MRA in 107 and DUS in 88. A comparison between preoperative and histological findings was performed. In addition, correlation coefficients were computed and tested.

Results

A significant correlation was found for each of the diagnostic procedures. The strongest correlation coefficient and the best allocation of stenosis into clinical significant groups (<50 %, 50–69 %, ≥70 %) was observed for CTA. Mean differences in the whole cohort between preoperative and histological measurements were as follows: CTA underestimated histological measurement by 2.4 % (based on European Carotid Surgery Trial [ECST] methodology) and 11.9 % (based on North American Symptomatic Carotid Endarterectomy Trial [NASCET] methodology). DSA underestimated the histological measurement by 7 % (ECST) and 12.2 % (NASCET). MRA overestimated the histological measurement by 2.6 % (ECST) and underestimated by 0.6 % (NASCET). DUS overestimated the stenosis by 1.8 %.

Conclusions

CTA yields the best accuracy in detection of carotid stenosis, provided that all axial slices of the stenosis are checked and carefully analysed. DSA underestimates moderate and mild ICA stenosis, whereas DUS overestimates high-grade ICA stenosis. For MRA, a relatively low correlation coefficient was observed with histological findings. We conclude that CTA-ecst technique is the most reliable technique for carotid stenosis measurement.

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Acknowledgments

We are indebted to Lenka Bernardová and Ondřej Krahula for technical support.

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Authors and Affiliations

  1. Department of Neurosurgery, 1st Faculty of Medicine, Central Military Hospital, Charles University, U vojenské nemocnice 1200, 169 02, Prague 6, Czech Republic

    David Netuka, Lucie Coufalová, Ondřej Bradáč, Svatopluk Ostrý & Vladimír Beneš

  2. Radiodiagnostic Unit, Central Military Hospital, U vojenské nemocnice 1200, 169 02, Prague 6, Czech Republic

    Tomáš Belšán, František Charvát & Josef Malík

  3. Department of Internal Medicine, 1st Faculty of Medicine, Central Military Hospital, U vojenské nemocnice 1200, 169 02, Prague 6, Czech Republic

    Karolina Broulíková

  4. Institute of Pathology, 3rd Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Šrobárova 50, 100 34, Prague 10, Czech Republic

    Václav Mandys

  5. Unit of Neurology, České Budějovice Hospital, B. Němcové 54, 370 01, České Budějovice, Czech Republic

    Svatopluk Ostrý

Authors
  1. David Netuka
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  2. Tomáš Belšán
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  9. Svatopluk Ostrý
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  10. Vladimír Beneš
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Corresponding author

Correspondence to Vladimír Beneš.

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Funding

The Ministry of Health of the Czech Republic provided financial support in the form grant IGA MZ NT 13627. The sponsor had no role in the design or conduct of this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Comments

The community of cerebrovascular surgeons continues to search for the safest and most accurate alternative imaging modality to reduce the need for catheter angiography in the evaluation of carotid stenosis and for surgical planning purposes. Catheter angiography has been held forth as the gold standard always, but concerns about contrast allergy (common), poor renal function precluding contrast administration (occasional), and angiographic-related stroke (rare), must always be considered.

From years of experience, we have learned that DUS is unreliable and generates values that are highly operator-dependent, and that MRA is unable to demonstrate the extent of distal disease needed to plan surgery, nor to discern between tight stenosis and complete occlusion (a critical distinction). We have learned to embrace CTA as a reasonable alternative to DSA, and can plan surgery in some cases with CTA alone, but we have admonished the reader in our own publications that in the presence of extensive carotid bulb calcification (all too common), CTA underestimates the degree of carotid stenosis, and may not be reliable. In this article our experiential intuition regarding carotid imaging is confirmed, for the most part. The authors compare histological specimens to the different types of carotid imaging done preoperatively, and find, somewhat contrary to what we might have predicted, that CTA is actually best, showing the greatest correlation with histological specimens, and that DSA slightly underestimates the degree of stenosis, with MRA and DUS being less useful or accurate. The authors are experienced, the methodology is sound, and the conclusions are appropriate. We congratulate them for scientific study of issues that we embraced previously only through our own intuitive knowledge, and for this most worthwhile contribution to cerebrovascular thought. It seems that carotid bulb calcification is less of an issue for these authors than it has been for me, and I look forward to a personal discussion of this discrepancy with these good professional friends at our next meeting.

Christopher M. Loftus

Maywood, IL, USA

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Netuka, D., Belšán, T., Broulíková, K. et al. Detection of carotid artery stenosis using histological specimens: a comparison of CT angiography, magnetic resonance angiography, digital subtraction angiography and Doppler ultrasonography. Acta Neurochir 158, 1505–1514 (2016). https://doi.org/10.1007/s00701-016-2842-0

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