Selection of patients for carotid endarterectomy: The role of ultrasound

Stroke is the third leading cause of death in the western world and the maj or cause of disability among the middle aged and elderly populations. Carot id artery stenosis is the single most important risk factor for stroke. The North American Symptomatic Carotid Endarterectomy Trial and the European C arotid Surgery Trial have demonstrated that the risk of stroke is reduced b y surgery in patients with high grade stenosis. Carotid plaque morphology a lso plays an important role; plaques which are ulcerated and echolucent are associated with a higher risk of stroke. Arteriography has long been regar ded as the gold standard diagnostic tool for evaluation of carotid artery d isease, but it is an invasive and costly technique which carries the risk o f potentially serious complications. Doppler ultrasound can provide functio nal and anatomical information on vessel stenosis and plaque morphology at sub-millimetric resolutions and is an inexpensive and noninvasive tool. Col or and Spectral Doppler ultrasound are now recognized as the best screening tests for carotid artery stenosis. The evidence for its use as the sole di agnostic imaging modality prior to carotid endarterectomy is examined. The recent availability of ultrasound contrast agents helps to distinguish betw een pseudo- and true occlusions, improves ultrasound images and should help to reduce operator variability.