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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 4  |  Page : 1794-1798

Computed tomography angiography versus ultrasound in patients with ischemic stroke owing to carotid artery disease


Department of Neuropsychiatry, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission24-Aug-2022
Date of Decision06-Oct-2022
Date of Acceptance10-Oct-2022
Date of Web Publication04-Mar-2023

Correspondence Address:
Mohamed R Ahmed
Qweisna, Menoufia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_287_22

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  Abstract 


Objectives
This work aimed to assess the efficacy of computed tomography angiography (CTA) in comparison with ultrasound carotid duplex (USCD) to find out, assess, and evaluate carotid artery disease in patients with ischemic stroke.
Background
Stroke is the third most common cause of death worldwide. Strokes can be ischemic or hemorrhagic. Carotid artery stenosis is considered a major cause of ischemic stroke.
Patients and methods
A cross-sectional study was done on 50 patients with ischemic stroke to compare ultrasound duplex of the carotid system and CTA regarding stenosis percentage and degree and the plaque characteristics (site, dimensions, nature, number, and hemodynamic affection), including intima-media thickness. All of the study procedures were carried out and approved by the ethics committee of the Faculty of Medicine, Menoufia University, in June 2021.
Results
Regarding the degree of stenosis, USCD showed more stenosis percentage than CTA (47 vs. 43%, respectively, for first lesion, 60 vs. 40%, respectively, for second lesion, 55 vs. 45%, respectively, for third lesion, and 80 vs. 20%, respectively, for fourth lesion). Regarding the plaque nature, USCD showed almost close results to CTA (47% soft atheromatous plaques vs. 46% in CTA, and 50% calcified plaques in both).
Regarding the plaque number, USCD detects more plaques than CTA (20 cases have no plaques in CTA vs. nine in USCD).
Conclusion
The study recommends the combination of USCD and CTA in patients with ischemic stroke, as CTA is more sensitive regarding the degree of stenosis and USCD provides more descriptive data about the plaque characteristics.

Keywords: carotid artery disease, carotid duplex, carotid stenosis, computed tomography angiography, stroke


How to cite this article:
El-Sheikh WM, Melake MS, Lashin ME, Ahmed MR, Mounir AN. Computed tomography angiography versus ultrasound in patients with ischemic stroke owing to carotid artery disease. Menoufia Med J 2022;35:1794-8

How to cite this URL:
El-Sheikh WM, Melake MS, Lashin ME, Ahmed MR, Mounir AN. Computed tomography angiography versus ultrasound in patients with ischemic stroke owing to carotid artery disease. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1794-8. Available from: http://www.mmj.eg.net/text.asp?2022/35/4/1794/371018




  Introduction Top


Cerebrovascular stroke is the third leading cause of death worldwide and also a major reason for critical and permanent disability in adulthood [1].

Strokes can be ischemic or hemorrhagic [2]. Ischemic stroke constitutes ∼0% of all strokes [3].

According to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, ischemic stroke is subdivided into large artery atherosclerosis, small vessel occlusion, cardioembolic, stroke of other determined strokes, and stroke of undetermined cause [4].

Carotid artery stenosis is considered a major cause of ischemic stroke. It becomes more prevalent with advancing age. The evaluation of carotid artery stenosis in stroke can be done using ultrasound carotid duplex (USCD), computed tomography angiography (CTA), transcranial Doppler, and magnetic resonance arteriography. The evaluation includes many factors, where the degree of stenosis is the main one, and others include the characteristics of the plaques causing carotid artery stenosis and sites [5].

USCD is a cost-effective screening examination of the carotid artery and is devoid of the risk of exposure to either contrast or ionizing radiations [6].

This work aimed to assess the efficacy of CTA in comparison with USCD to evaluate carotid artery disease in patients with ischemic stroke.


  Patients and methods Top


This was a cross-sectional study that was carried out in Menoufia University Hospital on 50 patients of both sexes with ischemic cerebrovascular stroke. All of the study procedures were carried out and approved by the ethical committee of the Faculty of Medicine, Menoufia University, in June 2021.

All patients were diagnosed clinically and radiologically with ischemic stroke and had carotid artery disease suspected primarily by USCD. Pregnant women, patients with renal impairment, or those with hypersensitivity to the dye given during performing CTA were excluded from the study. The vascular risk factors, including hypertension, dyslipidemia, diabetes, obesity, and smoking, and neurological deficits, either asymptomatic, TIA, or hemiplegia, were also evaluated. CTA was done in patients with significant carotid stenosis who have more than 50% symptomatic carotid stenosis or more than 70% asymptomatic stenosis. CTA was also performed in patients in whom we could not perform a carotid duplex owing to obesity, short neck, and higher bifurcation of the carotid artery.

Carotid duplex ultrasound technique: evaluation was done by the same examiner using the GE Logiq P7 Ultrasound machine manufactured in South Korea after informed consent was taken from the patients. We assessed the patient lying in a supine position and exposing his neck completely. The actual way of examination differs; however, in most cases, teaching the patients to put their heads at 30° toward the contralateral side is more effective. The transducer is placed anterior or posterior to the sternomastoid muscle. Methods of measurement included the following: (a) plaque evaluation was done, such as presence or absence, size, thickness, number, surface (either ulcerated, smooth, or irregular), and echo density (either echogenic or echo lucent). We evaluate the carotid plaques by two methods: quantitative and qualitative. (b) Measurement of the degree of stenosis was done. There are two procedures: color-Doppler ultrasound, which detects the motion of the moving parts or fluid (blood) to assess the speed and other flow parameters, and B-mode (gray-scale) ultrasound, wherein images of the body parts/tissue architect, at rest, are generated from the reflected sound waves.

CTA technique: we did CTA of intracranial and extracranial vessels using GE Revolution device 128-slice manufactured in the USA. The evaluation was done by the same examiner, and patients gave written and informed consent about the side effects of the contrast. Patients were positioned supine and placed back on their heads. Patients were instructed to hold their breath. We injected the contrast in the cubital vein.

Measurement method: we used The NASCET trial criteria to assess the degree of carotid stenosis through measurement of the residual luminal surface at the stenosis and surface of the distal normal lumen where there is no stenosis [7].

Statistical analysis

Data were collected, tabulated, and statistically analyzed using an IBM-compatible personal computer with Statistical Package for the Social Sciences (SPSS), version 23 (SPSS Inc. Released 2015. IBM SPSS statistics for Windows, version 23.0; IBM Corp., Armonk, New York, USA). Two types of statistical analysis were performed: descriptive statistics, for example, qualitative data were expressed as number and percentage, whereas quantitative data were expressed as mean, SD, and range (minimum–maximum), and analytic statistics, for example, χ2 test was used to study the association between qualitative variables. Z test was used to compare two proportions in two groups. Wilcoxon test was used to compare two consecutive readings of non-normally distributed data in the same group. Significant test results were quoted as two-tailed probabilities. The significance of the obtained results was judged at the 5% level (P > 0.05).


  Results Top


In our study, 78% of patients (39 patients) were hypertensive, 52% (26 patients) were diabetic, 52% (26 patients) were dyslipidemic, 22% (11 patients) were cigarette smokers, and 16% (eight patients) had ischemic heart disease [Table 1].
Table 1: Sociodemographic characteristics and clinical history of the participants (n=50)

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Of 100 carotid arteries (CA) of 50 patients, USCD showed that 18% of patients had no plaques, 34% had only one plaque, 26% had two plaques, 10% had three plaques, and 12% had 4 plaques. Moreover, USCD showed that 46.4% (19 plaques) were soft atheromatous plaques, 4.9% (two plaques) were diffuse atheromatous plaques, and 48.7% (20 plaques) were calcified plaques [Table 2].
Table 2: The results of carotid duplex

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However, CTA found out that among them, 40% of patients had no plaques, 30% had only one plaque, 22% had two plaques, 4% had three plaques, and 4% had four plaques. Moreover, CTA showed that 43.3% were soft atheromatous plaques (13 plaques). Only 6.7% were diffuse atheromatous plaques (two plaques) and 50% were calcified plaques (15 plaques) [Table 3].
Table 3: Results of computed tomography angiography

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Moreover, regarding the degree of stenosis, CTA shows less percentage than the results of the USCD (43.43 ± 20.17% for the first lesion in CTA vs. 47.71 ± 22.93% in USCD; 40.47 ± 12.97% for the second lesion in CTA vs. 52.08 ± 20.59% in USCD; 49.0 ± 34.42% for the third lesion in CTA vs. 52.73 ± 19.74% in USCD; and 21.0 ± 1.41% for the fourth lesion in CTA vs. 50.17 ± 27.40% in USCD) s[Table 4] and [Figure 1].
Table 4: The role of computed tomography angiography in comparison with carotid duplex in diagnosis of plaques

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Figure 1: Comparison between CTA and carotid duplex regarding the number of plaques. CTA, computed tomography angiography.

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  Discussion Top


Stroke is considered one of the commonest leading causes of death and disability worldwide [1]. In our study, male sex represented 72% of the sample size, whereas 28% were females, with a male-to-female ratio of 2.5: 1, which was similar to the results of other studies like Barker-Collo et al. [8] and Jain et al. [9].

Regarding the lipid profile of the participants, 22 (44%) patients had total serum cholesterol level above 200 mg/dl and a mean cholesterol level was 204.50 ± 56.63 mg/dl. This result suggests a strong relationship between the increased total serum cholesterol level and stroke. It agrees with the study of Zhang et al. [10] and Goldstein et al. [11].

The degree of stenosis on CTA shows less percentage than the results of the USCD. This result was supported by Samarzija et al. [12] as they have confirmed that CTA (diameter)-based measurements significantly underestimated the degree of carotid stenosis. However, this result did not agree with Forjoe and Asad Rahi [13], as they found an agreement between the results of CTA and USCD regarding the degree of stenosis. Moreover, our study found out that CTA shows no significant value over USCD regarding the evaluation of the plaque nature. This finding was also supported by Patel et al. [14] and Abul-Kasim and Abul [15], whereas it was against Baradaran and Gupta [16], as they found out that routine CTA could provide detailed information about plaque morphology. Our study suggested that USCD is a better modality regarding the detection and quantification of carotid artery plaque characterization. The result was similar to Patel et al. [14] and was against the study done by Debernardi et al. [17], who suggested CTA is a better modality than USCD.


  Conclusion Top


The study recommends the combination of USCD and CTA in patients with ischemic stroke as CTA is more sensitive regarding the degree of stenosis and USCD provides more descriptive data about the plaque characteristics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation 2018; 137:e67–e492.  Back to cited text no. 1
    
2.
Lopez MF, Sarracino DA, Prakash A, Athanas M, Krastins B, Rezai T, et al. Discrimination of ischemic and hemorrhagic strokes using a multiplexed, mass spectrometry-based assay for serum apolipoproteins coupled to multi-marker ROC algorithm. Proteomics Clin Appl 2012; 6:190–200.  Back to cited text no. 2
    
3.
Musuka TD, Wilton SB, Traboulsi M, Hill MD. Diagnosis and management of acute ischemic stroke: speed is critical. CMAJ 2015; 187:887–893.  Back to cited text no. 3
    
4.
Adams Jr HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24:35–41.  Back to cited text no. 4
    
5.
Krawisz AK, Carroll BJ, Secemsky EA. Risk stratification and management of extracranial carotid artery disease. Cardiol Clin 2021; 39:539–549.  Back to cited text no. 5
    
6.
Steinke W, Kloetzsch C, Hennerici M. Carotid artery disease assessed by color Doppler flow imaging: correlation with standard Doppler sonography and angiography. Am J Roentgenol 1990; 154:1061–1068.  Back to cited text no. 6
    
7.
von Reutern GM, Goertler MW, Bornstein NM, Del Sette M, Evans DH, Hetzel A, et al. Neurosonology Research Group of the World Federation of Neurology. Grading carotid stenosis using ultrasonic methods. Stroke 2012; 43:916–921.  Back to cited text no. 7
    
8.
Barker-Collo S, Bennett DA, Krishnamurthi RV, Parmar P, Feigin VL, Naghavi M, et al. Sex differences in stroke incidence, prevalence, mortality and disability-adjusted life years: results from the Global Burden of Disease Study 2013. Neuroepidemiology 2015; 45:203–214.  Back to cited text no. 8
    
9.
Jain D, Chawala M, Paul BS, Mittal N, Jain A, Puri S. Profile of cerebrovascular accidents in subjects with or without type 2 diabetes mellitus in intensive care units of tertiary care centre. J Anaesthesiol Clin Pharmacol 2020; 36:251.  Back to cited text no. 9
  [Full text]  
10.
Zhang X, Patel A, Horibe H, Wu Z, Barzi F, Rodgers A, et al. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol 2003; 32:563–572.  Back to cited text no. 10
    
11.
Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42:517–584.  Back to cited text no. 11
    
12.
Samarzija K, Milosevic P, Jurjevic Z, Erdeljac E. Grading of carotid artery stenosis with computed tomography angiography: whether to use the narrowest diameter or the cross-sectional area. Insights Imaging 2018; 9:527–534.  Back to cited text no. 12
    
13.
Forjoe T, Asad Rahi M. Systematic review of preoperative carotid duplex ultrasound compared with computed tomography carotid angiography for carotid endarterectomy. Ann R Coll Surg Engl 2019; 101:141–149.  Back to cited text no. 13
    
14.
Patel M, Dave J, Dave A, Jagani J. Role of CT angiography in comparison to ultrasound for detection, characterization and quantification of carotid artery disease. Int J Contemp Med Surg Radiol 2019; 4:185–187.  Back to cited text no. 14
    
15.
Abul-Kasim K, Abul EM. CT-angiography and doppler ultrasonography in atherosclerotic carotid artery disease. A comparative study. New Iraqi J Med 2009; 5:35–40.  Back to cited text no. 15
    
16.
Baradaran H, Gupta A. Carotid vessel wall imaging on CTA. Am J Neuroradiol 2020; 41:380–386.  Back to cited text no. 16
    
17.
Debernardi S, Martincich L, Lazzaro D, Comelli S, Raso AM, Regge D. CT angiography in the assessment of carotid atherosclerotic disease: results of more than two years' experience. Radiol Med (Torino) 2004; 108:116–127.  Back to cited text no. 17
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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