Del Brutto Victor J, Gornik Heather L, Rundek Tatjana
Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA.
Department of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH, USA.
Ann Transl Med. 2020 Oct;8(19):1270. doi: 10.21037/atm-20-1188a.
The risk of new or recurrent stroke is high among patients with extracranial carotid artery stenosis and the benefit of carotid revascularization is associated to the degree of luminal stenosis. Catheter-based digital subtraction angiography (DSA) as the diagnostic gold-standard for carotid stenosis (CS) has been replaced by non-invasive techniques including duplex ultrasound, computed-tomography angiography, and magnetic resonance angiography (MRA). Duplex ultrasound is the primary noninvasive diagnostic tool for detecting, grading and monitoring of carotid artery stenosis due to its low cost, high resolution, and widespread availability. However, as discussed in this review, there is a wide range of practice patterns in use of ultrasound diagnostic criteria for carotid artery stenosis. To date, there is no internationally accepted standard for the gradation of CS. Discrepancies in ultrasound criteria may result in clinically relevant misclassification of disease severity leading to inappropriate referral, or lack of it, to revascularization procedures, and potential for consequential adverse outcome. The Society of Radiologists in Ultrasound (SRU), either as originally outlined or in a modified form, are the most common criteria applied. However, such criteria have received criticism for relying primarily on peak systolic velocities, a parameter that when used in isolation could be misleading. Recent proposals rely on a multiparametric approach in which the hemodynamic consequences of carotid narrowing beyond velocity augmentation are considered for an accurate stenosis classification. Consensus criteria would provide standardized parameters for the diagnosis of CS and considerably improve quality of care. Accrediting bodies around the world have called for consensus on unified criteria for diagnosis of CS. A healthy debate between professionals caring for patients with CS regarding optimal CS criteria still continues.
颅外颈动脉狭窄患者发生新发或复发性卒中的风险很高，而颈动脉血运重建的益处与管腔狭窄程度相关。基于导管的数字减影血管造影（DSA）作为颈动脉狭窄（CS）的诊断金标准，已被包括双功超声、计算机断层血管造影和磁共振血管造影（MRA）在内的非侵入性技术所取代。双功超声因其成本低、分辨率高且广泛可用，是检测、分级和监测颈动脉狭窄的主要非侵入性诊断工具。然而，正如本综述所讨论的，在使用颈动脉狭窄的超声诊断标准方面存在广泛的实践模式。迄今为止，尚无国际公认的CS分级标准。超声标准的差异可能导致疾病严重程度在临床上出现相关的错误分类，从而导致不适当的转诊或未能转诊至血运重建手术，并可能产生相应的不良后果。超声放射学会（SRU）的标准，无论是最初概述的还是修改后的，都是最常用的标准。然而，这些标准因主要依赖收缩期峰值流速而受到批评，该参数单独使用时可能会产生误导。最近的提议依赖于多参数方法，其中考虑了除流速增加之外颈动脉狭窄的血流动力学后果，以进行准确的狭窄分类。共识标准将为CS的诊断提供标准化参数，并显著提高医疗质量。世界各地的认证机构呼吁就CS诊断的统一标准达成共识。在照顾CS患者的专业人员之间，关于最佳CS标准的健康辩论仍在继续。
