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Special Reports |
1 From the Dept of Radiology, Univ of Southern California, Keck School of Medicine, USC University Hospital, 1500 San Pablo St, Los Angeles, CA 90033 (E.G.G.); Dept of Radiology, Brigham and Women’s Hosp, Harvard Med School, Boston, Mass (C.B.B., J.F.F.); Dept of Surgery, Oregon Health and Science Univ, Portland, Ore (G.L.M.); Cerebrovascular Ultrasound and Stroke Treatment Team, Univ of Texas Houston Med School (A.V.A.); Dept of Surgery, West Los Angeles VA Med Ctr, Calif (J.D.B.); Dept of Radiology, Ochsner Clinic, New Orleans, La (E.I.B.); Dept of Radiology, Duke Univ Med School, Durham, NC (B.A.C., B.S.H.); Dept of Biostatistics, Univ of Calgary, Alberta, Canada (M.E.); Midwest Heart Specialists Vascular Lab and La Grange Memorial Vascular Laboratory, Downers Grove, Ill (J.G.); Intersocietal Accreditation Commission, Columbia, Md (S.K.); Dept of Radiology, Thomas Jefferson Univ, Philadelphia, Pa (L.N.); Dept of Radiology, North Shore Univ Hosp, New York Univ School of Med, NY (J.P.); Dept of Radiology, Inova Alexandria Hosp, Va (K.S.R.); Dept of Surgery, Univ of Toronto, Ontario, Canada (D.L.W.); and Dept of Surgery, Univ of Washington Med School, Seattle (R.E.Z.). Received Apr 1, 2003; revision requested May 7; revision received May 21; accepted May 22. Address correspondence to E.G.G. (e-mail: edgrant@usc.edu).
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ABSTRACT |
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70% stenosis to near occlusion, near occlusion, and total occlusion. (c) ICA peak systolic velocity (PSV) and presence of plaque on gray-scale and/or color Doppler images are primarily used in diagnosis and grading of ICA stenosis; two additional parameters, ICA-to–common carotid artery PSV ratio and ICA end-diastolic velocity may also be used when clinical or technical factors raise concern that ICA PSV may not be representative of the extent of disease. (d) ICA should be diagnosed as (i) normal when ICA PSV is less than 125 cm/sec and no plaque or intimal thickening is visible; (ii) <50% stenosis when ICA PSV is less than 125 cm/sec and plaque or intimal thickening is visible; (iii) 50%–69% stenosis when ICA PSV is 125–230 cm/sec and plaque is visible; (iv) 70% stenosis to near occlusion when ICA PSV is greater than 230 cm/sec and visible plaque and lumen narrowing are seen; (v) near occlusion when there is a markedly narrowed lumen at color Doppler US; and (vi) total occlusion when there is no detectable patent lumen at gray-scale US and no flow at spectral, power, and color Doppler US. (e) The final report should discuss velocity measurements and gray-scale and color Doppler findings. Study limitations should be noted when they exist. The conclusion should state an estimated degree of ICA stenosis as reflected in the above categories. The panel also considered various technical aspects of carotid US and methods for quality assessment and identified several important unanswered questions meriting future research. © RSNA, 2003
Index terms: Carotid arteries, flow dynamics • Carotid arteries, stenosis or obstruction, 172.4311, 172.4312, 172.721 • Carotid arteries, US, 172.12981, 172.12983, 172.12984 • Special Reports
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INTRODUCTION |
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The performance of carotid US and the interpretation of US results vary considerablyfrom laboratory to laboratory (5). Accreditation of vascular laboratories has resulted in an increased degree of standardization of the carotid US examination, but a wide range of practice patterns still exist. The goal of the conference was to develop recommendations for the performance of Doppler US and interpretation of the results in the diagnosis of ICA stenosis. The panel limited its discussion to atherosclerotic stenosis of the ICA at or just beyond the carotid bifurcation and to vessels without prior intervention.
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METHODS AND CONFERENCE PREPARATIONS |
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The asymptomatic group includes patients who have not had a neurologic event. The seminal investigation in this population, the Asymptomatic Carotid Artery Study (2), included patients who, though they had not had a neurologic event, typically had clinical markers for diffuse atherosclerosis. Overall, the prevalence of significant (>50%) stenotic disease in symptomatic patients is stated as being in the range of 18%–20% (27,28), while the prevalence in asymptomatic patients referred for carotid imaging is 14% (29). The prevalence of ICA disease in the asymptomatic group, therefore, approaches that found in symptomatic patients.
Doppler US is by far the most common imaging examination performed worldwide to aid in the diagnosis of carotid disease. Given the prevalence of patients with carotid disease and the frequency with which patients are referred for carotid imaging, the number of carotid US examinations performed annually is considerable (22). This imaging modality is increasingly becoming the only examination performed before surgical intervention. It was estimated by the panelists that as many as 80% of patients in the United States undergo carotid endarterectomy after a US examination as the only preoperative imaging study. Therefore, it is of utmost importance that information provided by the US examination be reproducible and reliable.
Considerable gains have been made in the quality of US examinations of the carotid arteries over the past 2 decades. The technology has experienced great advances in equipment, ranging from continued improvements in gray-scale resolution to landmark advances in Doppler methods, including color Doppler imaging. The imaging community has gained expertise in performance of carotid US and interpretation of the results through widespread use of technology, research, and continuing medical education. In addition, various accrediting bodies have been established by groups such as the Intersocietal Commission for Accreditation of Vascular Laboratories, the American Institute of Ultrasound in Medicine, and the American College of Radiology in an attempt to improve and standardize the quality of vascular US examinations.
Despite improvements and advances, the consensus panel agreed that, overall, carotid US is often performed inconsistently within a given laboratory, and there is nonuniformity in practice from one laboratory to the next. In many settings, interpretive criteria for carotid stenosis are either indiscriminately applied or the interpreters are uncertain about exactly how to make the diagnosis of carotid stenosis.
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CONSENSUS CONFERENCE |
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Technical Considerations
Standardization
Issue.—The performance of carotid US examinations is not standardized from laboratory to laboratory. Even within a given laboratory, there is often a failure to follow a consistent protocol.
Recommendation.—Examinations of the ICA should be performed with gray-scale, color Doppler, and spectral Doppler US in a standardized fashion, according to a rigidly applied laboratory protocol, in accordance with the standards of one of the accrediting bodies. The panel encourages all sonographers performing carotid US to become credentialed as vascular technologists.
Positioning and Angulation
Issue.—Errors in positioning the Doppler gate and in accounting for the Doppler angle are common in current clinical practices. Since interpretative criteria for carotid stenosis are heavily based on Doppler velocities, errors in Doppler position and angle correction will lead to serious errors in diagnosis.
Recommendation.—The Doppler waveform should be obtained with an angle of insonation less than or equal to 60°, as measurements obtained with an angle of insonation greater than 60° are likely to be inaccurate, even with appropriate angle adjustment, because of the physical properties of Doppler.
Conflicting opinions.—Some believed that maintaining a constant angle of insonation of exactly 60° would provide greater consistency. Other panelists did not agree that a fixed angle of insonation for all carotid US examinations is required and instead expressed that it is necessary only to maintain an angle of less than or equal to 60°. It was thought that further investigation on this matter is warranted.
Sample Volume Position
Issue.—Other common technical shortcomings in ICA examinations include incorrect positioning of the sample volume, incomplete sampling through an area of stenosis, and failure to depict the distal end of a carotid plaque.
Recommendation.—Care should be taken to position the sample volume within the area of greatest stenosis. The ICA must be sampled through the region of stenosis completely until the distal end of the plaque is visualized, to ensure that the site of highest velocity has been located.
Patient Considerations
Issue.—Several errors may result from problems inherent to the patient, such as extensive plaque calcification, severe ICA tortuosity, and tandem lesions.
Recommendation.—It is important to recognize these patient conditions and understand that, in such cases, the examination may be limited.
Equipment
Issue.—There is substantial variability in equipment from machine to machine, from manufacturer to manufacturer, and between older and newer equipment (30–33). This variability in equipment may explain, in part, the lack of agreement and inconsistency in the literature concerning Doppler thresholds for the diagnosis of carotid stenosis.
Recommendation.—The panel encourages US equipment manufacturers to minimize equipment variability by establishing industry-wide standards for Doppler measurement and calibration and the development of a reliable Doppler phantom that can be made readily available to industry and to vascular laboratories.
Diagnostic Strata
Methods of Reporting
Issue.—Methods by which the degree of ICA stenosis is reported vary from laboratory to laboratory, as well as within some laboratories. Some report an estimate of the specific percentage of stenosis, others stratify their estimates into five or six diagnostic categories or gradations of stenosis.
Recommendation.—Doppler US cannot be used to predict a single percentage of stenosis. Therefore, the consensus panelists strongly recommend the use of defined diagnostic strata. Laboratories should establish protocols for stratifying the degree of ICA stenosis, and, once established, these criteria should be consistently applied.
Doppler Measurement Variability
Although investigators have confirmed that the average Doppler velocity rises in direct proportion to the degree of stenosis as determined with angiography (18,26), there are very wide ranges of Doppler values around those means, which makes it impossible to classify lesions into gradations as narrow as 10% (Figure) (18,34). Even in evaluations of the ability of Doppler US to help estimate the degree of stenosis by using more expanded strata (eg, <50%, 50%–69%, and 70% stenosis), the findings have been disappointing. US is most accurate when lesions are classified as being above or below a single level, such as 60% stenosis or 70% stenosis (18).
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Recommendation.—Because Doppler is inaccurate for subcategorizing stenoses less than 50%, these stenoses should be reported under a single category as 
<50% stenosis.
Subcategories for minor degrees of stenosis should not be used.
Stratification of Stenoses
Issue.—How should reporting of ICA stenosis be stratified?
Recommendation.—The consensus panel recommends stratification of the degree of stenosis on the basis of gray-scale and Doppler US results into the following strata: normal (no stenosis), <50% stenosis, 50%–69% stenosis, 70% stenosis but less than near occlusion, near occlusion, and total occlusion.
Discussion.—The threshold of 70% stenosis was chosen because it was believed to be the threshold currently used by most major vascular centers for surgical intervention. The panel agreed, however, that in some laboratories, there may be a compelling reason to choose a different stratification scheme. The diagnoses of near occlusion and total occlusion are usually not based primarily on the Doppler measurement of velocity but rather on gray-scale and color and/or power Doppler imaging.
Imaging and Doppler Parameters
Key Components of ICA Examination
Issue.—What are the key components of the US examination of the ICA?
Recommendation.—The ICA US examination should consist of gray-scale imaging, color Doppler imaging, and spectral Doppler velocity determination. Because stenosis is typically an area of narrowing caused by plaque, with a focal area of increased velocity and a poststenotic disturbed flow, the location and characteristics of plaque in the ICA should be determined. The color Doppler appearance of the lumen should also be assessed.
Primary US Parameters
Issue.—Numerous imaging and Doppler parameters are currently used at various laboratories for the evaluation of ICA stenosis, including ICA PSV, ICA EDV and ICA/CCA PSV ratio, CCA EDV, and ICA/CCA EDV ratio. The application of these parameters for diagnosis of ICA stenosis varies from laboratory to laboratory and sometimes within a given laboratory.
Recommendation.—The panel suggested that the ICA PSV and the presence of plaque on gray-scale and/or color Doppler US images are the parameters that should be used when diagnosing and grading ICA stenosis.
Discussion.—The ICA PSV is easy to obtain and has good reproducibility and should be used in conjunction with available gray-scale and color Doppler information to ensure concordance of diagnostic information. The degree of stenosis estimated by using ICA PSV and the degree of narrowing of the ICA lumen on gray-scale and color Doppler images should be similar.
Additional US Parameters
Issue.—Should other Doppler parameters be used and, if so, when?
Recommendation.—Two additional parameters, ICA/CCA PSV ratio and ICA EDV, are useful for internal checks or may be used when ICA PSV may not be representative of the extent of disease owing to technical or clinical factors such as in the presence of tandem lesions, contralateral high-grade stenosis, discrepancy between visual assessment of plaque and ICA PSV, elevated CCA velocity, hyperdynamic cardiac state, or low cardiac output. For example, in a patient with low cardiac output, the ICA PSV may be disproportionately low when compared with the ICA/CCA PSV ratio. This discrepancy should prompt the interpreter to consider all gray-scale and Doppler information when stratifying the degree of ICA stenosis. In particular in such cases, the interpretation should be based more heavily on the ICA/CCA PSV ratio than on absolute values such as the ICA PSV or ICA EDV. The panel believed that outlining the reasons for making diagnostic choices that are not in keeping with usual practice should be included in the final report.
Doppler Diagnostic Thresholds
Issue.—Published literature is replete with velocity thresholds for categorizing ICA stenosis (Table 1). Tremendous variation exists among these studies in the methods used to assess individual Doppler parameters and in the thresholds recommended for diagnosing ICA stenosis (7).
Recommendation.—The consensus panel developed recommendations for diagnosis and stratification of ICA stenosis (Table 3). These recommendations were derived from analysis of numerous studies and do not represent the results of any one laboratory or study. For a particular laboratory setting, internal validation is encouraged when possible. This may yield alternative diagnostic criteria that can be used successfully at that facility. However, each laboratory should have a single set of diagnostic criteria that is applied uniformly. The following points are included in Table 3 and should be considered in the diagnosis of ICA stenosis:
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2. A <50% ICA stenosis is diagnosed when ICA PSV is less than 125 cm/sec and plaque or intimal thickening is visible sonographically. Additional criteria include ICA/CCA PSV ratio < 2.0 and ICA EDV < 40 cm/sec.
3. A 50%–69% ICA stenosis is diagnosed when ICA PSV is 125–230 cm/sec and plaque is visible sonographically. Additional criteria include ICA/CCA PSV ratio of 2.0–4.0 and ICA EDV of 40–100 cm/sec.
4. A 70% ICA stenosis but less than near occlusion of the ICA is diagnosed when the ICA PSV is greater than 230 cm/sec and visible plaque and luminal narrowing are seen at gray-scale and color Doppler US. Additional criteria include ICA/CCA PSV ratio > 4 and ICA EDV > 100 cm/sec. The higher the Doppler parameter lies above the threshold of 230 cm/sec, the greater the likelihood of severe disease.
5. In cases of near occlusion of the ICA, the velocity parameters may not apply, since velocities may be high, low, or undetectable. This diagnosis is established primarily by demonstrating a markedly narrowed lumen at color or power Doppler US (35).
6. Total occlusion of the ICA should be suspected when there is no detectable patent lumen at gray-scale US and no flow with spectral, power, and color Doppler US. Magnetic resonance (MR) angiography, computed tomographic (CT) angiography, or conventional angiography may be used for confirmation in this setting (35).
Final Report of the Gray-Scale and Doppler US Examination
Issue.—The structure and content of final reports of carotid US examinations vary greatly from laboratory to laboratory, as well as within given laboratories.
Recommendation.—The final report of the gray-scale and Doppler US interpretation of the ICA examination should include the following:
Body of the report.—(a) Pertinent US findings, including velocity measurements and gray-scale findings (presence, location, and characteristics of ICA plaque), as well as color Doppler findings when appropriate; (b) comments about limitations of the study or deviations from usual interpretive criteria due to technical factors or hemodynamic considerations; and (c) comparison with results of prior studies.
Conclusion or impression.—Estimated degree of ICA stenosis, categorized by the laboratory’s established diagnostic criteria (modified, as appropriate, by technical factors or hemodynamic considerations).
Quality Assessment
Need for Quality Assessment
Issue.—Should every laboratory have a system for quality assessment?
Recommendation.—All laboratories should institute a program of quality assessment.
Internal Validation of Doppler Thresholds
Issue.—Development of internally validated Doppler thresholds may be difficult given the infrequency of correlative angiograms at most institutions.
Recommendation.—The panel agreed that it may not always be feasible to obtain angiographic or clinical correlation for quality assessment of US studies at each laboratory. For this reason, the consensus panel developed the table of recommended Doppler thresholds for diagnosis of ICA stenosis (Table 3), which can be applied at laboratories that cannot validate their own Doppler thresholds on the basis of correlative imaging or clinical information.
Discussion: Although angiography has historically been considered the gold standard for assessing Doppler thresholds for various degrees of ICA stenosis, few angiographic examinations are still performed. Those that are performed at a given institution are probably not representative cases, but rather those cases in which the US results were equivocal or otherwise problematic. The use of CT angiography and MR angiography for correlation has not, as yet, been fully validated (36).
Reference Standard
Issue.—When angiography is used as the reference standard for assessment of Doppler criteria for ICA stenosis, different techniques for measuring ICA stenosis have been used.
Recommendation.—The panel recommended that the NASCET method of carotid stenosis measurement should be employed when angiography is used to correlate the US findings.
Discussion.—In this method, the narrowest portion of the vascular lumen was compared with the normalized lumen distally (37). In the European Symptomatic Carotid Trial study and studies performed prior to the NASCET study, the degree of stenosis was determined by comparing the narrowest diameter of the residual lumen to an estimate of the original lumen in the same area. Because the original lumen cannot be depicted on the angiogram, exact measurement is impossible. While the NASCET method of measurement may not reflect the burden of atherosclerosis in the proximal ICA, it does minimize the amount of interobserver variability.
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OTHER CONSIDERATIONS |
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50% stenosis of the ICA who do not undergo carotid endarterectomy and who may be candidates for prophylactic carotid endarterectomy should be followed up at 6–12-month intervals, and high-risk patients with visible plaque and <50% stenosis should be evaluated every 1–2 years. Patients who have normal carotid US studies but marked risk factors might be evaluated every 3–5 years. In all cases of follow-up or surveillance, a complete examination should be performed. Follow-up studies should be compared with results from prior examinations.
Research Topics
The panel identified several important unanswered questions that merit future research.
1. What is the role of ICA plaque characterization in carotid disease?
2. What is the role of the ICA intimal-medial thickness? There are several ongoing large clinical trials in which the intimal-medial thickness is being evaluated as a marker of atherosclerotic disease, but there are not yet enough data to establish the role of this measurement in the assessment of carotid disease in individual patients.
3. At follow-up examination, how much of a change in estimated ICA stenosis or ICA PSV should be considered relevant?
4. What criteria should be used to assess patients after ICA surgery or stent placement?
5. Should US be used to screen for carotid disease?
Other issues that need to be addressed include the following:
1. There is considerable variation in Doppler measurements from machine to machine and manufacturer to manufacture. This should be rectified, because such variation leads to inconsistencies and inaccuracies in diagnosing ICA stenosis.
2. Phantoms for Doppler US need to be developed to facilitate calibration of Doppler US equipment.
3. Improved methods for calculating velocity with angle correction should be developed to eliminate or minimize the inconsistency in velocity measurements as the Doppler angle of insonation is changed.
4. Reliable quality assessment methods should be developed so that laboratories can assess their performance of the carotid US examination. This should lead to greater consistency in the performance of carotid US within each laboratory, as well as from laboratory to laboratory.
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M. Rubiera, M. Ribo, R. Delgado-Mederos, E. Santamarina, P. Delgado, J. Montaner, J. Alvarez-Sabin, and C. A. Molina Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion: An Independent Predictor of Poor Outcome After Systemic Thrombolysis Stroke, September 1, 2006; 37(9): 2301 - 2305. [Abstract] [Full Text] [PDF]
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M. Gerhard-Herman, J. M Gardin, M. Jaff, E. Mohler, M. Roman, and T. Z Naqvi Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology Vascular Medicine, August 1, 2006; 11(3): 183 - 200. [PDF]
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T. Scholbach Celiac artery compression syndrome in children, adolescents, and young adults: clinical and color duplex sonographic features in a series of 59 cases. J. Ultrasound Med., March 1, 2006; 25(3): 299 - 305. [Abstract] [Full Text] [PDF]
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R. Mikulik, A. V. Alexandrov, M. Ribo, Z. Garami, N. A. Porche, E. Fulep, J. C. Grotta, A. W. Wojner-Alexandrov, and J. Y. Choi Telemedicine-Guided Carotid and Transcranial Ultrasound: A Pilot Feasibility Study Stroke, January 1, 2006; 37(1): 229 - 230. [Abstract] [Full Text] [PDF]
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M. H. Heijenbrok-Kal, E. Buskens, P. J. Nederkoorn, Y. van der Graaf, and M. G. M. Hunink Optimal Peak Systolic Velocity Threshold at Duplex US for Determining the Need for Carotid Endarterectomy: A Decision Analytic Approach Radiology, December 21, 2005; (2005) 2381041078. [Abstract] [Full Text]
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M. H. Heijenbrok-Kal, P. J. Nederkoorn, E. Buskens, Y. van der Graaf, and M.G. Myriam Hunink Diagnostic Performance of Duplex Ultrasound in Patients Suspected of Carotid Artery Disease: The Ipsilateral Versus Contralateral Artery Stroke, October 1, 2005; 36(10): 2105 - 2109. [Abstract] [Full Text] [PDF]
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 H. Ota, K. Takase, H. Rikimaru, M. Tsuboi, T. Yamada, A. Sato, S. Higano, T. Ishibashi, and S. Takahashi Quantitative Vascular Measurements in Arterial Occlusive Disease RadioGraphics, September 1, 2005; 25(5): 1141 - 1158. [Abstract] [Full Text] [PDF]
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D. Gaitini and M. Soudack Diagnosing Carotid Stenosis by Doppler Sonography: State of the Art J. Ultrasound Med., August 1, 2005; 24(8): 1127 - 1136. [Abstract] [Full Text] [PDF]
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M. Schillinger, M. Exner, W. Mlekusch, S. Sabeti, J. Amighi, R. Nikowitsch, E. Timmel, B. Kickinger, C. Minar, M. Pones, et al. Inflammation and Carotid Artery--Risk for Atherosclerosis Study (ICARAS) Circulation, May 3, 2005; 111(17): 2203 - 2209. [Abstract] [Full Text] [PDF]
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 A. H. FRIEDLANDER, N. R. GARRETT, E. E. CHIN, and J. D. BAKER Ultrasonographic confirmation of carotid artery atheromas diagnosed via panoramic radiography J Am Dent Assoc, May 1, 2005; 136(5): 635 - 640. [Abstract] [Full Text] [PDF]
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Y. S. Kim, Z. Garami, R. Mikulik, C. A. Molina, A. V. Alexandrov, and for the CLOTBUST Collaborators Early Recanalization Rates and Clinical Outcomes in Patients With Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion and Isolated Middle Cerebral Artery Occlusion Stroke, April 1, 2005; 36(4): 869 - 871. [Abstract] [Full Text] [PDF]
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 R. E. Zierler Characterization of Carotid Artery Plaques Using Real-Time Compound B-Mode Ultrasound Perspectives in Vascular Surgery and Endovascular Therapy, March 1, 2005; 17(1): 59 - 60. [Abstract] [PDF]
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 F. B. Karassa, M. I. Matsagas, W. A. Schmidt, and J. P.A. Ioannidis Meta-Analysis: Test Performance of Ultrasonography for Giant-Cell Arteritis Ann Intern Med, March 1, 2005; 142(5): 359 - 369. [Abstract] [Full Text] [PDF]
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G. M. Hathout, J. R. Fink, S. M. El-Saden, and E. G. Grant Sonographic NASCET Index: A New Doppler Parameter for Assessment of Internal Carotid Artery Stenosis AJNR Am. J. Neuroradiol., January 1, 2005; 26(1): 68 - 75. [Abstract] [Full Text] [PDF]
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O. Y. Chernyshev, Z. Garami, S. Calleja, J. Song, M. S. Campbell, E. A. Noser, H. Shaltoni, C.-I Chen, Y. Iguchi, J. C. Grotta, et al. Yield and Accuracy of Urgent Combined Carotid/Transcranial Ultrasound Testing in Acute Cerebral Ischemia Stroke, January 1, 2005; 36(1): 32 - 37. [Abstract] [Full Text] [PDF]
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B. Unal, S. Bagcier, I. Simsir, Y. Bilgili, and S. Kara Evaluation of Differences Between Observers and Automatic-Manual Measurements in Calculation of Doppler Parameters J. Ultrasound Med., August 1, 2004; 23(8): 1041 - 1048. [Abstract] [Full Text] [PDF]
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S. Sabeti, M. Schillinger, W. Mlekusch, A. Willfort, M. Haumer, T. Nachtmann, M. Mullner, W. Lang, R. Ahmadi, and E. Minar Quantification of Internal Carotid Artery Stenosis with Duplex US: Comparative Analysis of Different Flow Velocity Criteria Radiology, August 1, 2004; 232(2): 431 - 439. [Abstract] [Full Text] [PDF]
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M. Nonent, J.-M. Serfaty, N. Nighoghossian, F. Rouhart, L. Derex, C. Rotaru, P. Chirossel, B. Guias, J.-F. Heautot, P. Gouny, et al. Concordance Rate Differences of 3 Noninvasive Imaging Techniques to Measure Carotid Stenosis in Clinical Routine Practice: Results of the CARMEDAS Multicenter Study Stroke, March 1, 2004; 35(3): 682 - 686. [Abstract] [Full Text] [PDF]
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