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The Limitations of Carotid Sonography

Interpretive and Technology-Related Errors

Mindy M. Horrow1, John Stassi1, Andrew Shurman1, Joshua D. Brody1, Cheryl L. Kirby1 and Henrietta Kotlus Rosenberg1

1 Department of Radiology, Albert Einstein Medical Center, 5501 Old York Rd., Philadelphia PA 19141-3098



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  		Fig. 1. —Contingency table of angiographic and sonographic results for discrepant pairs. Angiographic interpretations are in columns and sonographic interpretations are in rows. Entries above shaded blocks represent false-negative sonographic interpretations; those below shaded blocks are false-positive. Entry in shaded box indicates case of correct severity of stenosis in incorrect location.

 


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  		Fig. 2. —65-year-old man with right carotid bruit undergoing treatment with intraaortic balloon pump. Image represents false-positive error in sonographic interpretation.

A, Duplex Doppler sonogram obtained only during pump-assisted cycles shows elevated velocities. Because first systolic peak (arrow) was slightly higher than 250 cm/sec, stenosis was interpreted as critical.

 


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  		Fig. 2. —65-year-old man with right carotid bruit undergoing treatment with intraaortic balloon pump. Image represents false-positive error in sonographic interpretation.

B, Color Doppler sonogram of right internal carotid artery (straight arrows) shows turbulence in tortuous vessel. Note plaque and no area of narrowing that would be consistent with critical stenosis. Because of tortuosity, angle of insonation may be inaccurate, and velocity should be interpreted with caution (vessel in blue is jugular vein). Also note focal area of flow reversal (curved arrow) that corresponds to posterior ulcer seen in C.

 


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  		Fig. 2. —65-year-old man with right carotid bruit undergoing treatment with intraaortic balloon pump. Image represents false-positive error in sonographic interpretation.

C, Lateral digital subtraction angiogram obtained during selective right common carotid artery injection shows only 50% stenosis (straight arrow) of proximal right internal carotid artery. Note large posterior ulcer (curved arrow).

 


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  		Fig. 3. —77-year-old woman with unexplained dizziness. Her case represents false-positive error with accurate sonographic interpretation but discrepant angiographic results.

A, Color duplex Doppler sonogram of left internal carotid artery shows proximal stenosis (arrow) with peak systolic and diastolic velocities of 388 and 198 cm/sec, respectively. Internal carotid artery/common carotid artery velocity ratio was 6:4. Both color and duplex Doppler data were consistent with critical (80-99%) stenosis. Color and duplex Doppler sonogram of right side show complete internal carotid artery occlusion.

 


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  		Fig. 3. —77-year-old woman with unexplained dizziness. Her case represents false-positive error with accurate sonographic interpretation but discrepant angiographic results.

B, Lateral digital subtraction angiogram obtained during selective left common carotid artery injection shows severe (60-79%) stenosis of left internal carotid artery (arrow).

 


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  		Fig. 4. —68-year-old man with transient ischemic attacks. Image represents false-negative error with accurate sonographic interpretation but discrepant angiographic results.

A, Color Doppler sonogram of left internal carotid artery shows area of turbulence (arrow).

 


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  		Fig. 4. —68-year-old man with transient ischemic attacks. Image represents false-negative error with accurate sonographic interpretation but discrepant angiographic results.

B, Duplex Doppler sonogram shows velocities of 160 and 45 cm/sec. Peak systole and end diastole indicate moderate (40-59%) stenosis consistent with A.

 


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  		Fig. 4. —68-year-old man with transient ischemic attacks. Image represents false-negative error with accurate sonographic interpretation but discrepant angiographic results.

C, Lateral digital subtraction angiogram obtained during selective left common carotid artery injection shows 60% stenosis (straight arrow) of left internal carotid artery with large posterior ulcer (curved arrow).

 


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  		Fig. 4. —68-year-old man with transient ischemic attacks. Image represents false-negative error with accurate sonographic interpretation but discrepant angiographic results.

D, Anterioposterior digital subtraction angiogram obtained during left common carotid artery injection shows ulcer en face (arrows) and left internal carotid artery does not appear to be narrow. Presumably, color Doppler image was obtained with ulcer en face. In retrospect, ulcer corresponds to area of turbulence.

 

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