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Carotid Arteries: Contrast-enhanced US Angiography—Preliminary Clinical Experience¹

¹ From the Departments of Radiology (Y.K., S.P.P., C.B.S., B.G., W.W., R.F.M.) and Surgery (S.R.S.), University of California, San Diego Medical Center, 200 W Arbor Dr, Dept 8756, San Diego, CA 92103-8756. From the 1999 RSNA scientific assembly. Received April 1, 2002; revision requested June 13; final revision received March 4, 2003; accepted May 19. Address correspondence to Y.K. (e-mail: ykono@ucsd.edu).

View larger version (82K): [in a new window]   Figure 1a. Images in a 69-year-old male patient with a history of transischemic attack. (a) Precontrast US angiogram in right common carotid artery shows calcified (arrows) and noncalcified (arrowheads) plaque. (b) Postcontrast US angiogram obtained after injection of 0.5 mL of FS069 shows complete luminal enhancement. Soft plaque (arrowheads) along the posterior wall is well visualized. Also note the noncalcified component (arrows) of the calcified plaque along the anterior wall that was not detected in a. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (c) Conventional angiogram depicts the right common carotid artery (superior artery is on the left side, and inferior artery is on the right side). Gray scale is inverted to emphasize the similarity of this image and the contrast-enhanced US angiogram. This image was interpreted as showing focal kinking, which was actually intimal thickening.

View larger version (91K): [in a new window]   Figure 1b. Images in a 69-year-old male patient with a history of transischemic attack. (a) Precontrast US angiogram in right common carotid artery shows calcified (arrows) and noncalcified (arrowheads) plaque. (b) Postcontrast US angiogram obtained after injection of 0.5 mL of FS069 shows complete luminal enhancement. Soft plaque (arrowheads) along the posterior wall is well visualized. Also note the noncalcified component (arrows) of the calcified plaque along the anterior wall that was not detected in a. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (c) Conventional angiogram depicts the right common carotid artery (superior artery is on the left side, and inferior artery is on the right side). Gray scale is inverted to emphasize the similarity of this image and the contrast-enhanced US angiogram. This image was interpreted as showing focal kinking, which was actually intimal thickening.

View larger version (44K): [in a new window]   Figure 1c. Images in a 69-year-old male patient with a history of transischemic attack. (a) Precontrast US angiogram in right common carotid artery shows calcified (arrows) and noncalcified (arrowheads) plaque. (b) Postcontrast US angiogram obtained after injection of 0.5 mL of FS069 shows complete luminal enhancement. Soft plaque (arrowheads) along the posterior wall is well visualized. Also note the noncalcified component (arrows) of the calcified plaque along the anterior wall that was not detected in a. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (c) Conventional angiogram depicts the right common carotid artery (superior artery is on the left side, and inferior artery is on the right side). Gray scale is inverted to emphasize the similarity of this image and the contrast-enhanced US angiogram. This image was interpreted as showing focal kinking, which was actually intimal thickening.

View larger version (27K): [in a new window]   Figure 2. Bland-Altman plots of the percentage diameter stenosis measured on US angiograms and conventional (X-ray) angiograms. Most of the data points lie within the 95% CI, which indicates strong agreement between results with the two methods.

View larger version (106K): [in a new window]   Figure 3a. Images in a 79-year-old male patient with a history of cerebrovascular disease. (a-c) US angiograms show ulceration (arrow in a and c) in a thick soft plaque involving the anterior and posterior wall of the bulb that narrowed the origin of both the internal and external carotid arteries. (d) Conventional angiogram (superior artery is on the left side, and inferior artery is on the right side) shows ulceration (arrow). Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (109K): [in a new window]   Figure 3b. Images in a 79-year-old male patient with a history of cerebrovascular disease. (a-c) US angiograms show ulceration (arrow in a and c) in a thick soft plaque involving the anterior and posterior wall of the bulb that narrowed the origin of both the internal and external carotid arteries. (d) Conventional angiogram (superior artery is on the left side, and inferior artery is on the right side) shows ulceration (arrow). Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (107K): [in a new window]   Figure 3c. Images in a 79-year-old male patient with a history of cerebrovascular disease. (a-c) US angiograms show ulceration (arrow in a and c) in a thick soft plaque involving the anterior and posterior wall of the bulb that narrowed the origin of both the internal and external carotid arteries. (d) Conventional angiogram (superior artery is on the left side, and inferior artery is on the right side) shows ulceration (arrow). Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (107K): [in a new window]   Figure 3d. Images in a 79-year-old male patient with a history of cerebrovascular disease. (a-c) US angiograms show ulceration (arrow in a and c) in a thick soft plaque involving the anterior and posterior wall of the bulb that narrowed the origin of both the internal and external carotid arteries. (d) Conventional angiogram (superior artery is on the left side, and inferior artery is on the right side) shows ulceration (arrow). Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (113K): [in a new window]   Figure 4a. Images obtained in the right internal carotid artery in a 67-year-old male patient with a history of cerebrovascular disease. (a) US angiogram depicts a dissection as a thin channel of microbubbles (arrows) flowing parallel to the true lumen within the false lumen, which is probably thrombosed. (b) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom). Gray scale is inverted. Dissection (arrows) is depicted. Dissection was not detected on the duplex US image (not shown).

View larger version (111K): [in a new window]   Figure 4b. Images obtained in the right internal carotid artery in a 67-year-old male patient with a history of cerebrovascular disease. (a) US angiogram depicts a dissection as a thin channel of microbubbles (arrows) flowing parallel to the true lumen within the false lumen, which is probably thrombosed. (b) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom). Gray scale is inverted. Dissection (arrows) is depicted. Dissection was not detected on the duplex US image (not shown).

View larger version (133K): [in a new window]   Figure 5a. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (133K): [in a new window]   Figure 5b. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (136K): [in a new window]   Figure 5c. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (137K): [in a new window]   Figure 5d. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (135K): [in a new window]   Figure 5e. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (134K): [in a new window]   Figure 5f. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (83K): [in a new window]   Figure 5g. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (107K): [in a new window]   Figure 5h. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (145K): [in a new window]   Figure 5i. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (147K): [in a new window]   Figure 5j. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (140K): [in a new window]   Figure 5k. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (150K): [in a new window]   Figure 5l. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (142K): [in a new window]   Figure 5m. Transverse images in a 72-year-old male patient with intermittent symptoms of transient ischemic attack. (a-f) Serial US angiograms were obtained in the carotid artery from the common carotid artery (a) to the normal portion of the distal carotid artery (f). The carotid artery is depicted with a long noncalcified plaque (arrow in b-e) that causes eccentric stenosis of the internal carotid artery (arrowhead in b). (g) Conventional angiogram (superior artery is on top, and inferior artery is on the bottom) shows a severe stenosis (arrow) in the internal carotid artery. This two-dimensional projection along the long axis of the eccentric stenosis shows that the degree of stenosis is overestimated. Gray scale is inverted. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (h-m) Corresponding ex vivo high-spatial-resolution MR images depict the plaque seen in a-f. CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery.

View larger version (26K): [in a new window]   Figure 6. Bland-Altman plots of the percentage area stenosis determined at US angiography and ex vivo MR imaging of the plaque. Most of the data points lie within the 95% CI, which indicates strong agreement between findings with the two methods.