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The Current Role of Carotid Duplex Ultrasonography in the Management of Carotid Atherosclerosis: Foundations and Advances

DOI: 10.1155/2012/187872

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The management of atherosclerotic carotid occlusive disease for stroke prevention has entered a time of dramatic change. Improvements in medical management have begun to challenge traditional interventional approaches to asymptomatic carotid stenosis. Simultaneously, carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CE). Finally, multiple factors beyond degree of stenosis and symptom status now mitigate clinical decision making. These factors include brain perfusion, plaque morphology, and patency of intracranial collaterals (circle of Willis). With all of these changes, it seems prudent to review the role of carotid duplex ultrasonography in the management of atherosclerotic carotid occlusive disease for stroke prevention. Carotid duplex ultrasonography (CDU) for initial and serial imaging of the carotid bifurcation remains an essential component in the management of carotid bifurcation disease. However, correlative axial imaging modalities (computer tomographic angiography (CTA) and contrast-enhanced magnetic resonance angiography (CE-MRA)) increasingly aid in the assessment of individual stroke risk and are important in treatment decisions. The purpose of this paper is twofold: (1) to discuss foundations and advances in CDU and (2) to evaluate the current role of CDU, in light of other imaging modalities, in the clinical management of carotid atherosclerosis. 1. Introduction Carotid atherosclerosis is one of several etiological factors for stroke, an important health problem with a high burden of disease in the western world and in developing countries. Of all strokes, an estimated 88% are ischemic in nature [1–5]. Less than 20% of these are caused by atheroma in the carotid bifurcation [6–8]. While the percentage of strokes attributed to carotid disease is relatively low, the overall social and economic burden is high. It is, therefore, important to identify and manage carotid atherosclerosis with the aim of stroke prevention. The mortality rate for stroke in the United States has declined by nearly 70% since 1950 [9]. In December 2010, the Center for Disease Control and Prevention announced stroke was the fourth leading cause of death in the United States (down from its third place ranking which it held for decades) [10]. The identification of major risk factors through population-based studies [1, 11, 12] and randomized controlled trials (RCTs) of symptomatic [13–15] and asymptomatic [16, 17] patients has led to effective public health and clinic-based control strategies. These strategies include combining

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