Evaluation of the Utility of Carotid Duplex Ultrasonography (CDUS) in Acute Ischemic Stroke Patients Receiving Computed Tomography Angiography at Nassau University Medical Center Matthew Braiman, Larry Malkin, Lorin Berman, Megan E. Barber, Eli Q. Harris, Amgad N. Makaryus, and Roman Zeltser Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Nassau University Medical Center
Background ▪
▪
▪
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Results
Conclusions
Carotid stenosis is the etiology of only about 10% of all ischemic strokes
n=
126
Males (n, %)
74 (58.7%)
Carotid duplex ultrasonography (CDUS) is the gold standard for evaluation of carotid stenosis in acute ischemic event.
Females (n, %) 52 (41.3%0 DM2 (n, %)
40 (31.7%)
• Discrepancies were seen due to variability of radiology reports
A computed tomography angiogram (CTA) as an initial evaluation upon arrival to the emergency department is a standard of care for patients suspected of having an acute ischemic stroke
HTN (n, %)
93 (73.8%)
HLD (n, %)
44 (34.9%)
• Radiology is advised to standardize reports of CTA and include presence of any plaque even without obstruction in report
CAD (n, %)
22 (17.5%)
PAD (n, %)
25 (19.8%)
CKD (n, %)
3 (2.4%)
A. Fib (n, %)
16 (12.7%)
On AC (n, %)
19 (15.1%)
Some patients who arrive to the ER receive imaging tests in the evaluation of a possible thromboembolic stroke, which may include both CTA and CDUS.
Hypothesis Given evidence of a normal carotid arteries on CTA, the addition of a CDUS is of no utility in improving patient outcomes. We believe the addition of ultrasound to be an unnecessary imaging test associated with increased financial cost for the patient and hospital, as well as unnecessary exposure of patients to pathogens that increase the risk of causing or exacerbating illness.
• All patients with normal CTAs of carotid arteries had normal CDUS.
• It is probably safe in patients with normal CTAs not to order CDUS
Future Direction
Table 1. Baseline characteristics N
95
CTA neg
95
CDUS neg
93
Further analysis on correlation of severity of disease in CTA vs CDUS and outcomes will be done. We will also look if patients had other unnecessary imaging studies such as MRA, and whether changes in radiology reporting lead to changes in outcomes
Table 2. Results of patients with normal CTA Review of 2 discrepant cases showed CTA reports were incorrect.
Methods
Resources References:
A retrospective chart review of patients admitted between January 2015 - January 2019 for acute ischemic stroke or transient ischemic attack who received CTA followed by a carotid ultrasound. We examined rates of normal CTAs followed by CIDUS, and how many of those were abnormal.
Adams, B. C., Clark, R. M., Paap, C., & Goff, J. M. (2014). There is No Benefit to Universal Carotid Artery Duplex Screening before a Major Cardiac Surgical Procedure. Annals of Vascular Surgery, 28(1), 93-101. doi:10.1016/j.avsg.2013.06.018 Forjoe, T., & Rahi, M. A. (2019). Systematic review of preoperative carotid duplex ultrasound compared with computed tomography carotid angiography for carotid endarterectomy. The Annals of The Royal College of Surgeons of England, 101(3), 141-149. doi:10.1308/rcsann.2019.0010 Kristensen, T., Hovind, P., Iversen, H. K., & Andersen, U. B. (2017). Screening with doppler ultrasound for carotid artery stenosis in patients with stroke or transient ischaemic attack. Clinical Physiology and Functional Imaging, 38(4), 617-621. doi:10.1111/cpf.12456
B Figure 1. A. CTA with Internal Carotid Artery Stenosis. B. CIDUS with Internal Carotid Artery Stenosis